MED-SURG HESI PN EXIT EXAM (QUESTIONS AND ANSWERS) LATEST UPDATED

1. The client with aphasia and right hemiplegia who is scheduled for gastrostomy tube (GT) placement today. 2. The client who has chronic renal disease is scheduled for hemodialysis today and three times weekly. 3. The client who has had GI bleeding but had a negative guaiac test for the last three stools. 4. The client who is recovering from a left total knee replacement and who ambulates with a walker. The client with aphasia should be seen first because this client has safety risks related to limited mobility and communication and requires assessment before the GT is placed. The client with chronic renal disease should be seen next to evaluate the impact of fluid balance and potassium on cardiac function between dialysis treatments. The client with GI bleeding is stable and should be seen third to evaluate resolution of bleeding. The ambulatory client is progressing toward independence and is the least likely to - The practical nurse (PN) received report on their assignment of clients. In which order should the PN assess these clients? Arrange the sequence options in the correct order by assigning each option a number. The client who has had GI bleeding but had a negative guaiac test for the last three stools. The client who is recovering from a left total knee replacement and who ambulates with a walker. The client who has chronic renal disease is scheduled for hemodialysis today and three times weekly. The client with aphasia and right hemiplegia who is scheduled for gastrostomy tube (GT) placement today. a. "If I feel the need to void while the catheter is still in, I should try to void around the catheter." c. "I should only have intercourse twice weekly once I return home after surgery." Rationale: After prostatectomy, the client should not try to void around the catheter. It is common to feel pressure inside the bladder while the irrigating catheter is still in the bladder. The client should not have intercourse immediately after surgery. The client should drink 12 to 14 glasses of fluid once the catheter is removed. Urine that is lightly blood tinged is common; bright red blood in the urine should be reported to the surgeon. - The nurse has reinforced teaching regarding postoperative care for a client who has had a prostatectomy. Which statements indicate the need for further instructions? (Select all that apply.) a. "If I feel the need to void while the catheter is still in, I should try to void around the catheter." b. "I should drink about 12 glasses of water a day, once the indwelling catheter is removed." c. "I should only have intercourse twice weekly once I return home after surgery." d. "I should report bright red blood and large clots in my urine to my surgeon." e. "I can expect to have urine that is lightly tinged with blood when I get home." a. Administer 0.5 mL of tetanus toxoid IM. Prevention of infection from Clostridium tetani by administering tetanus toxoid has the highest priority for care of a client in the acute phase of burn care. - A client sustained a burn injury greater than 25% of total body surface with majority of it lower extremities during a house fire. During the acute phase of care, which intervention is most important for the practical nurse to implement? a. Administer 0.5 mL of tetanus toxoid IM. b. Offer high-protein supplemental feedings. c. Perform active range-of-motion exercises. d. Application of compression stockings and ambulation a. Administer a nitroglycerine tablet sublingually. Rationale: The first action is to administer nitroglycerine sublingually, in order to dilate the coronary arteries so that more oxygenated blood can be provided to the myocardium. It is not necessary to notify EMS unless the angina pain is unrelieved by three nitroglycerine tablets. The client should rest immediately, not walk back to the room. It is not a priority to determine whether or not the attack occurred at the same time as yesterday's. - A client is walking in the hallway and begins experiencing an acute angina attack. Which is the first action for the nurse to take? a. Administer a nitroglycerine tablet sublingually. b. Notify the local emergency medical services. (EMS). c. Assist the client to walk back to the client's room. d. Ask the client if this attack occurred at the same time as yesterday's. a. Alcohol in moderation and smoking cessation c. Regular weight-bearing exercises e. Consumption of a diet rich in calcium and vitamin D Alcohol in moderation and smoking cessation, regular weight-bearing exercises at least 30 minutes a day, and consumption of a diet rich in calcium and vitamin D are life style choices that decrease the risk for developing osteoporosis. - The practical nurse is reinforcing osteoporosis prevention education to a group of senior citizens. The nurse