Hesi PN Med-Surg Exam Actual 2025
Questions and Answers ()(Verified
Answers)
The practical nurse (PN) is assigned a client diagnosed with a hemothorax who
had a chest tube inserted 36 hours ago; upon entering the room, the PN
observes the client resting comfortably in the semi-Fowler position; respirations
appear even and unlabored; the water in the suction chamber is bubbling; and
there is serous drainage noted in the collection chamber. What is the best initial
action for the PN to take?
a. Measure and document in the drainage in the chamber.
b. Clamp the chest tube while assessing for air leaks.
c. "Milk" the tube to remove any excessive blood clot buildup.
d. Decrease the bubbling in the suction chamber.
d. Decrease the bubbling in the suction chamber.
Rationale:
Follow the ABC's (airway, breathing, and circulation) to determine that the airway
and breathing are stable, and the next step is to evaluate the extent of the
bleeding. It is not necessary to change the amount of bubbling in the suction
chamber.
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. "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.
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. 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 has had a gastrectomy to treat stomach cancer. The nurse has
reinforced instructions on ways to prevent "dumping syndrome." Which client
statement indicates the need for further instruction?
,a. "My meals need to be mostly protein."
b. "I should walk around after each meal."
c. "I should eat fewer carbohydrates."
d. "I should eat smaller, more frequent meals."
b. "I should walk around after each meal."
Rationale:
The client should lie down after meals to avoid syncope. The client should eat
more protein and less carbohydrates, and smaller more frequent meals
An adult client is admitted to the emergency department with partial-thickness
and full-thickness burns over 40% of the body surface area resulting from a car
collision fire. After the health care provider and nurse have intubated the client,
which intervention should the practical nurse (PN) do first?
a. Remove all the client's clothing, shoes, and jewelry.
b. Insert indwelling urinary foley.
c. Initiate an intravenous catheter line.
d. Obtain blood work and urine sample
a. Remove all the client's clothing, shoes, and jewelry.
Rationale:
Interventions for moderate to severe burns of deep partial-thickness and full-
thickness, once an airway and circulation is established, then the next thing is to
remove all the victims clothing, shoes, and jewelry before the edema sets in and
they become constricting, also it is possible to cause more severe burns by leaving
clothing on.
The practical nurse (PN) is assigned a client with a medical history of diabetes
and gangrene who had a right below the knee amputation. At the time of
rewrapping and inspecting the stump, the client refuses to look at their stump.
The practical nurse (PN) tells the client that the incision is healing well, but the
client refuses to talk about it. What is the best response to this client's silence?
a. "It is normal to feel angry and depressed, but the sooner you deal with this
surgery, the better you will feel."
b. "Looking at your incision can be frightening, but facing this fear is a necessary
part of your recovery."
c. "It is okay if you do not want to talk about your surgery. I will be available
, when you are ready."
d. "I will ask another person who has had an amputation to come by and share
their experiences with you."
c. "It is okay if you do not want to talk about your surgery. I will be available when
you are ready."
Rationale:
Informing the client that it is okay they do not want to talk about their surgery
and stating that the PN is available when they need them, displays sensitivity and
understanding without judging the client.
A client comes to the clinic and reports the presence of a painful lesion in the
genital area; they described it as a blister 2 days earlier that is now crusty.
Which intervention should the practical nurse (PN) implement first?
a. Ask the client if they have had unprotected sex.
b. Prepare the client for a culture and sensitivity test of the lesion.
c. Inform the client this occurrence will have to be reported to the public health
department.
d. Prepare to administer penicillin intramuscularly into the dorsogluteal area.
a. Ask the client if they have had unprotected sex.
Rationale:
These are typical signs and symptoms of herpes simplex virus 2 (HSV2), a sexually
transmitted disease (STD), so the PN should ask the client if they had unprotected
sex and if the client has exposed others to the disease.
Which educational materials should the practical nurse select for reinforcement
of teaching for secondary prevention? (Select all that apply.)
a. Video that teaches client to do breast self-examinations.
b. Pamphlets describing how to do testicular self-examinations.
c. Chart that emphasizes childhood immunization schedule.
d. Chart that emphasizes childhood immunization schedule.
e. Postcard reminders for clients to get papanicolaou (Pap) smears and
mammograms.
a. Video that teaches client to do breast self-examinations.
b. Pamphlets describing how to do testicular self-examinations.
e. Postcard reminders for clients to get papanicolaou (Pap) smears and
Questions and Answers ()(Verified
Answers)
The practical nurse (PN) is assigned a client diagnosed with a hemothorax who
had a chest tube inserted 36 hours ago; upon entering the room, the PN
observes the client resting comfortably in the semi-Fowler position; respirations
appear even and unlabored; the water in the suction chamber is bubbling; and
there is serous drainage noted in the collection chamber. What is the best initial
action for the PN to take?
a. Measure and document in the drainage in the chamber.
b. Clamp the chest tube while assessing for air leaks.
c. "Milk" the tube to remove any excessive blood clot buildup.
d. Decrease the bubbling in the suction chamber.
d. Decrease the bubbling in the suction chamber.
Rationale:
Follow the ABC's (airway, breathing, and circulation) to determine that the airway
and breathing are stable, and the next step is to evaluate the extent of the
bleeding. It is not necessary to change the amount of bubbling in the suction
chamber.
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. "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.
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. 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 has had a gastrectomy to treat stomach cancer. The nurse has
reinforced instructions on ways to prevent "dumping syndrome." Which client
statement indicates the need for further instruction?
,a. "My meals need to be mostly protein."
b. "I should walk around after each meal."
c. "I should eat fewer carbohydrates."
d. "I should eat smaller, more frequent meals."
b. "I should walk around after each meal."
Rationale:
The client should lie down after meals to avoid syncope. The client should eat
more protein and less carbohydrates, and smaller more frequent meals
An adult client is admitted to the emergency department with partial-thickness
and full-thickness burns over 40% of the body surface area resulting from a car
collision fire. After the health care provider and nurse have intubated the client,
which intervention should the practical nurse (PN) do first?
a. Remove all the client's clothing, shoes, and jewelry.
b. Insert indwelling urinary foley.
c. Initiate an intravenous catheter line.
d. Obtain blood work and urine sample
a. Remove all the client's clothing, shoes, and jewelry.
Rationale:
Interventions for moderate to severe burns of deep partial-thickness and full-
thickness, once an airway and circulation is established, then the next thing is to
remove all the victims clothing, shoes, and jewelry before the edema sets in and
they become constricting, also it is possible to cause more severe burns by leaving
clothing on.
The practical nurse (PN) is assigned a client with a medical history of diabetes
and gangrene who had a right below the knee amputation. At the time of
rewrapping and inspecting the stump, the client refuses to look at their stump.
The practical nurse (PN) tells the client that the incision is healing well, but the
client refuses to talk about it. What is the best response to this client's silence?
a. "It is normal to feel angry and depressed, but the sooner you deal with this
surgery, the better you will feel."
b. "Looking at your incision can be frightening, but facing this fear is a necessary
part of your recovery."
c. "It is okay if you do not want to talk about your surgery. I will be available
, when you are ready."
d. "I will ask another person who has had an amputation to come by and share
their experiences with you."
c. "It is okay if you do not want to talk about your surgery. I will be available when
you are ready."
Rationale:
Informing the client that it is okay they do not want to talk about their surgery
and stating that the PN is available when they need them, displays sensitivity and
understanding without judging the client.
A client comes to the clinic and reports the presence of a painful lesion in the
genital area; they described it as a blister 2 days earlier that is now crusty.
Which intervention should the practical nurse (PN) implement first?
a. Ask the client if they have had unprotected sex.
b. Prepare the client for a culture and sensitivity test of the lesion.
c. Inform the client this occurrence will have to be reported to the public health
department.
d. Prepare to administer penicillin intramuscularly into the dorsogluteal area.
a. Ask the client if they have had unprotected sex.
Rationale:
These are typical signs and symptoms of herpes simplex virus 2 (HSV2), a sexually
transmitted disease (STD), so the PN should ask the client if they had unprotected
sex and if the client has exposed others to the disease.
Which educational materials should the practical nurse select for reinforcement
of teaching for secondary prevention? (Select all that apply.)
a. Video that teaches client to do breast self-examinations.
b. Pamphlets describing how to do testicular self-examinations.
c. Chart that emphasizes childhood immunization schedule.
d. Chart that emphasizes childhood immunization schedule.
e. Postcard reminders for clients to get papanicolaou (Pap) smears and
mammograms.
a. Video that teaches client to do breast self-examinations.
b. Pamphlets describing how to do testicular self-examinations.
e. Postcard reminders for clients to get papanicolaou (Pap) smears and
