HESI PN MED SURG EXIT EXAM / MED
SURG HESI PN
A 70-year-antique customer popularity submit hip substitute is transferred to a rehabilitation
facility. Which scale should the realistic nurse (PN) pick out because the exceptional device to
expect the patron's threat for developing skin breakdown?
A. Braden Scale
b. Morse Scale
c. Aldrete Scale
d. Wong-Baker Face Scale - ANS-a. Braden Scale
The Braden Scale is made from six subscales: sensory perception, moisture, activity, mobility,
nutrition, and friction and shear. A hospitalized grownup with a score sixteen or underneath or
an older grownup with a rating of 18 or below is at an improved chance for skin breakdown.
A patron involves the medical institution and reviews the presence of a painful lesion inside the
genital area; they defined it as a blister 2 days earlier that is now crusty. Which intervention
need to the realistic nurse (PN) put in force first?
A. Ask the customer if they have had unprotected sex.
B. Prepare the purchaser for a subculture and sensitivity take a look at of the lesion.
C. Inform the consumer this prevalence will have to be mentioned to the general public health
department.
D. Prepare to administer penicillin intramuscularly into the dorsogluteal place. - ANS-a. Ask the
consumer in the event that they have had unprotected intercourse.
Rationale:
These are ordinary signs and symptoms of herpes simplex virus 2 (HSV2), a sexually
transmitted ailment (STD), so the PN have to ask the purchaser in the event that they had
unprotected sex and if the customer has exposed others to the disorder.
A consumer validated pupillary constriction when a pen light changed into shined in their eyes.
Which nursing motion need to the sensible nurse carry out?
A. Report the locating to the health care issuer.
B. Record the finding at the evaluation notes.
C. Assess blood strain to rule out high blood pressure.
D. Record that the consumer has poor vision. - ANS-b. Record the locating at the evaluation
notes.
,Pupillary constriction to mild is a regular finding and ought to be documented inside the
assessment notes.
A purchaser identified with a brain tumor is receiving radiation beam treatments to the right
frontal location. The realistic nurse (PN) must take a look at this patron for which hassle all
through the early submit-remedy days?
A. Hemiplegia
b. Headache
c. Hearing loss
d. Dysphagia - ANS-b. Headache
Rationale:
Radiotherapy is a local treatment, and most facet results are web page-unique, including
irritation of surrounding mind tissue, swelling, headache, and fatigue.
A customer diagnosed with a fracture of the left radius has a plaster cast carried out. The nurse
has bolstered commands for drying the forged over the following 24 hours. Which declaration by
means of the consumer shows the teaching turned into powerful?
A. "I will wrap the forged in plastic wrap for 24 hours."
b. "I will aid the solid on a firm surface during the night time."
c. "I will now not cover it; as an alternative I'll maintain the cast surfaces uncovered to circulating
air."
d. "I can use a blow dryer on medium placing until the plaster solid feels dry to the touch." -
ANS-c. "I will now not cover it; rather I'll maintain the forged surfaces uncovered to circulating
air."
Rationale:
The nurse must educate the customer to keep the solid uncovered to circulating air and avoid
covering it with cloth that would hold it moist.
A patron identified with a fracture of the left radius has a plaster forged implemented. The nurse
has reinforced commands for drying the solid over the subsequent 24 hours. Which declaration
by using the client shows the coaching became powerful?
A. "I will wrap the cast in plastic wrap for 24 hours."
b. "I will guide the cast on a corporation floor at some point of the night."
c. "I will no longer cowl it; rather I'll preserve the cast surfaces exposed to circulating air."
d. "I can use a blow dryer on medium setting until the plaster forged feels dry to the touch." -
ANS-c. "I will not cowl it; as a substitute I'll maintain the cast surfaces exposed to circulating air."
Rationale:
,The nurse must train the consumer to hold the cast exposed to circulating air and avoid masking
it with cloth that might keep it wet.
A client identified with a cranium hematoma and fractured left (L) clavicle following a six foot fall
from a ladder is admitted to the unit. Which signal should the sensible nurse (PN) file
immediately?
A. Spontaneously opens eyes.
B. Obeys instructions in motion and grip.
C. Answers questions, however is stressed.
D. Has odd flexion or extension of (L) arm. - ANS-c. Answers questions, however is burdened.
Rationale:
Confusion following a head injury is typically the primary signal of improved intracranial strain.
A purchaser diagnosed with bacterial meningitis is admitted to the unit and is prescribed neuro
tests every 2 hours. Which manifestation might the realistic nurse display for that might provide
the primary indication of altered neurological function?
A. Change in stage of recognition
b. Increasing muscular weak spot
c. Changes in pupil size bilaterally
d. Progressive nuchal stress - ANS-a. Change in level of recognition
A decrease or change within the level of recognition is typically the first indication of
neurological deterioration.
A client identified with chronic obstructive pulmonary disorder complains to the practical nurse of
extreme fatigue after coughing. Which self-care measures can help limit the customer's
dyspnea? (Select all that observe.)
a. Assume a sitting position with shoulders relaxed and knees flexed.
B. Support forearms with a pillow and vicinity both ft flat at the ground.
C. Slightly drop the head, bend ahead, and slowly exhale with pursed lips.
D. Resume sitting up straight, the usage of diaphragmatic respiration to inhale slowly and
deeply.
E. Repeat breathing in deeply and slowly with pursed lips at the same time as bending forward
only once.
F. Repeat exhaling and await the cough reflex to facilitate motion of the secretions.
G. After coughing, inhale deeply from abdomen and cough three or 4 times even as exhaling. -
ANS-a. Assume a sitting function with shoulders comfortable and knees flexed.
B. Support forearms with a pillow and location both toes flat on the floor.
C. Slightly drop the head, bend forward, and slowly exhale with pursed lips.
D. Resume sitting up instantly, using diaphragmatic respiratory to inhale slowly and deeply.
, Effective coughing can help the consumer to cough secretions, therefore improving fuel trade
and decrease fatigue. The client need to expect the sitting function with shoulders comfortable
and knees flexed. Their forearms ought to be supported with a pillow and each feet region flat at
the ground. The patron must barely drop their head, bent ahead, and slowly exhale via pursed
lips using sluggish and deep diaphragmatic respiratory to help facilitate effective coughing. The
purchaser must repeat the preceding steps two or three times. The consumer need to provoke
the cough reflex, no longer await it. The customer ought to also take a deep belly breath before
beginning a cough.
A patron identified with congestive coronary heart failure has evolved increasing pedal edema
and pulmonary edema. What dietary modification is maximum vital for the realistic nurse (PN) to
enhance with this patron?
A. Avoid high carbohydrate ingredients.
B. Decrease consumption of fat-soluble nutrients.
C. Decrease caloric intake.
D. Restrict salt and fluid intake. - ANS-d. Restrict salt and fluid consumption.
Rationale:
Salt and fluid restrictions are the first dietary adjustments for a purchaser who's retaining fluid as
manifested by using edema and pulmonary edema.
A client recognized with diabetes has a prescription of five units of everyday insulin and 15
gadgets of NPH insulin. In which order should the practical nurse put together to manage the
insulin?List in order the nursing moves to be accomplished.
Arrange the series options in the perfect order by means of assigning each choice a number.
Perform hand hygiene in line with facility policy.
Inject five units of air into regular insulin vial.
Inspect insulin vials for kind and expiration dates.
Inject 15 gadgets of air into NPH insulin vial.
Withdraw 15 units of NPH insulin from vial.
Withdraw 5 units of everyday insulin from vial. - ANS-1. Perform hand hygiene consistent with
facility policy.
2. Inspect insulin vials for type and expiration dates.
3. Inject 15 units of air into NPH insulin vial.
Four. Inject five gadgets of air into regular insulin vial.
5. Withdraw 5 devices of everyday insulin from vial.
6. Withdraw 15 units of NPH insulin from vial.
Rationale:
The first nursing motion is to perform hand hygiene. The subsequent movement is to investigate
vials for kind and expiration dates and then add 15 units of air to NPH insulin vial. Next add five
units of air into everyday insulin vial, then withdraw five units of regular insulin from vial, and
SURG HESI PN
A 70-year-antique customer popularity submit hip substitute is transferred to a rehabilitation
facility. Which scale should the realistic nurse (PN) pick out because the exceptional device to
expect the patron's threat for developing skin breakdown?
A. Braden Scale
b. Morse Scale
c. Aldrete Scale
d. Wong-Baker Face Scale - ANS-a. Braden Scale
The Braden Scale is made from six subscales: sensory perception, moisture, activity, mobility,
nutrition, and friction and shear. A hospitalized grownup with a score sixteen or underneath or
an older grownup with a rating of 18 or below is at an improved chance for skin breakdown.
A patron involves the medical institution and reviews the presence of a painful lesion inside the
genital area; they defined it as a blister 2 days earlier that is now crusty. Which intervention
need to the realistic nurse (PN) put in force first?
A. Ask the customer if they have had unprotected sex.
B. Prepare the purchaser for a subculture and sensitivity take a look at of the lesion.
C. Inform the consumer this prevalence will have to be mentioned to the general public health
department.
D. Prepare to administer penicillin intramuscularly into the dorsogluteal place. - ANS-a. Ask the
consumer in the event that they have had unprotected intercourse.
Rationale:
These are ordinary signs and symptoms of herpes simplex virus 2 (HSV2), a sexually
transmitted ailment (STD), so the PN have to ask the purchaser in the event that they had
unprotected sex and if the customer has exposed others to the disorder.
A consumer validated pupillary constriction when a pen light changed into shined in their eyes.
Which nursing motion need to the sensible nurse carry out?
A. Report the locating to the health care issuer.
B. Record the finding at the evaluation notes.
C. Assess blood strain to rule out high blood pressure.
D. Record that the consumer has poor vision. - ANS-b. Record the locating at the evaluation
notes.
,Pupillary constriction to mild is a regular finding and ought to be documented inside the
assessment notes.
A purchaser identified with a brain tumor is receiving radiation beam treatments to the right
frontal location. The realistic nurse (PN) must take a look at this patron for which hassle all
through the early submit-remedy days?
A. Hemiplegia
b. Headache
c. Hearing loss
d. Dysphagia - ANS-b. Headache
Rationale:
Radiotherapy is a local treatment, and most facet results are web page-unique, including
irritation of surrounding mind tissue, swelling, headache, and fatigue.
A customer diagnosed with a fracture of the left radius has a plaster cast carried out. The nurse
has bolstered commands for drying the forged over the following 24 hours. Which declaration by
means of the consumer shows the teaching turned into powerful?
A. "I will wrap the forged in plastic wrap for 24 hours."
b. "I will aid the solid on a firm surface during the night time."
c. "I will now not cover it; as an alternative I'll maintain the cast surfaces uncovered to circulating
air."
d. "I can use a blow dryer on medium placing until the plaster solid feels dry to the touch." -
ANS-c. "I will now not cover it; rather I'll maintain the forged surfaces uncovered to circulating
air."
Rationale:
The nurse must educate the customer to keep the solid uncovered to circulating air and avoid
covering it with cloth that would hold it moist.
A patron identified with a fracture of the left radius has a plaster forged implemented. The nurse
has reinforced commands for drying the solid over the subsequent 24 hours. Which declaration
by using the client shows the coaching became powerful?
A. "I will wrap the cast in plastic wrap for 24 hours."
b. "I will guide the cast on a corporation floor at some point of the night."
c. "I will no longer cowl it; rather I'll preserve the cast surfaces exposed to circulating air."
d. "I can use a blow dryer on medium setting until the plaster forged feels dry to the touch." -
ANS-c. "I will not cowl it; as a substitute I'll maintain the cast surfaces exposed to circulating air."
Rationale:
,The nurse must train the consumer to hold the cast exposed to circulating air and avoid masking
it with cloth that might keep it wet.
A client identified with a cranium hematoma and fractured left (L) clavicle following a six foot fall
from a ladder is admitted to the unit. Which signal should the sensible nurse (PN) file
immediately?
A. Spontaneously opens eyes.
B. Obeys instructions in motion and grip.
C. Answers questions, however is stressed.
D. Has odd flexion or extension of (L) arm. - ANS-c. Answers questions, however is burdened.
Rationale:
Confusion following a head injury is typically the primary signal of improved intracranial strain.
A purchaser diagnosed with bacterial meningitis is admitted to the unit and is prescribed neuro
tests every 2 hours. Which manifestation might the realistic nurse display for that might provide
the primary indication of altered neurological function?
A. Change in stage of recognition
b. Increasing muscular weak spot
c. Changes in pupil size bilaterally
d. Progressive nuchal stress - ANS-a. Change in level of recognition
A decrease or change within the level of recognition is typically the first indication of
neurological deterioration.
A client identified with chronic obstructive pulmonary disorder complains to the practical nurse of
extreme fatigue after coughing. Which self-care measures can help limit the customer's
dyspnea? (Select all that observe.)
a. Assume a sitting position with shoulders relaxed and knees flexed.
B. Support forearms with a pillow and vicinity both ft flat at the ground.
C. Slightly drop the head, bend ahead, and slowly exhale with pursed lips.
D. Resume sitting up straight, the usage of diaphragmatic respiration to inhale slowly and
deeply.
E. Repeat breathing in deeply and slowly with pursed lips at the same time as bending forward
only once.
F. Repeat exhaling and await the cough reflex to facilitate motion of the secretions.
G. After coughing, inhale deeply from abdomen and cough three or 4 times even as exhaling. -
ANS-a. Assume a sitting function with shoulders comfortable and knees flexed.
B. Support forearms with a pillow and location both toes flat on the floor.
C. Slightly drop the head, bend forward, and slowly exhale with pursed lips.
D. Resume sitting up instantly, using diaphragmatic respiratory to inhale slowly and deeply.
, Effective coughing can help the consumer to cough secretions, therefore improving fuel trade
and decrease fatigue. The client need to expect the sitting function with shoulders comfortable
and knees flexed. Their forearms ought to be supported with a pillow and each feet region flat at
the ground. The patron must barely drop their head, bent ahead, and slowly exhale via pursed
lips using sluggish and deep diaphragmatic respiratory to help facilitate effective coughing. The
purchaser must repeat the preceding steps two or three times. The consumer need to provoke
the cough reflex, no longer await it. The customer ought to also take a deep belly breath before
beginning a cough.
A patron identified with congestive coronary heart failure has evolved increasing pedal edema
and pulmonary edema. What dietary modification is maximum vital for the realistic nurse (PN) to
enhance with this patron?
A. Avoid high carbohydrate ingredients.
B. Decrease consumption of fat-soluble nutrients.
C. Decrease caloric intake.
D. Restrict salt and fluid intake. - ANS-d. Restrict salt and fluid consumption.
Rationale:
Salt and fluid restrictions are the first dietary adjustments for a purchaser who's retaining fluid as
manifested by using edema and pulmonary edema.
A client recognized with diabetes has a prescription of five units of everyday insulin and 15
gadgets of NPH insulin. In which order should the practical nurse put together to manage the
insulin?List in order the nursing moves to be accomplished.
Arrange the series options in the perfect order by means of assigning each choice a number.
Perform hand hygiene in line with facility policy.
Inject five units of air into regular insulin vial.
Inspect insulin vials for kind and expiration dates.
Inject 15 gadgets of air into NPH insulin vial.
Withdraw 15 units of NPH insulin from vial.
Withdraw 5 units of everyday insulin from vial. - ANS-1. Perform hand hygiene consistent with
facility policy.
2. Inspect insulin vials for type and expiration dates.
3. Inject 15 units of air into NPH insulin vial.
Four. Inject five gadgets of air into regular insulin vial.
5. Withdraw 5 devices of everyday insulin from vial.
6. Withdraw 15 units of NPH insulin from vial.
Rationale:
The first nursing motion is to perform hand hygiene. The subsequent movement is to investigate
vials for kind and expiration dates and then add 15 units of air to NPH insulin vial. Next add five
units of air into everyday insulin vial, then withdraw five units of regular insulin from vial, and
