HESI PN MED SURG EXIT EXAM / MED
SURG HESI PN
A 70-yr-antique purchaser fame put up hip replacement is transferred to a rehabilitation facility.
Which scale ought to the realistic nurse (PN) discover because the pleasant device to predict
the purchaser's risk for growing 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, pastime, mobility,
nutrition, and friction and shear. A hospitalized person with a score sixteen or underneath or an
older person with a score of 18 or below is at an multiplied chance for skin breakdown.
A consumer comes to the health center and reviews the presence of a painful lesion in the
genital place; they described it as a blister 2 days earlier this is now crusty. Which intervention
should the practical nurse (PN) enforce first?
A. Ask the purchaser in the event that they have had unprotected sex.
B. Prepare the client for a tradition and sensitivity check of the lesion.
C. Inform the consumer this occurrence will ought to be reported to the general public health
department.
D. Prepare to administer penicillin intramuscularly into the dorsogluteal location. - ANS-a. Ask
the customer if they have had unprotected sex.
Rationale:
These are normal symptoms and signs and symptoms of herpes simplex virus 2 (HSV2), a
sexually transmitted disorder (STD), so the PN should ask the consumer in the event that they
had unprotected sex and if the customer has exposed others to the disease.
A client established pupillary constriction while a pen light become shined of their eyes. Which
nursing motion ought to the practical nurse perform?
A. Report the finding to the fitness care company.
B. Record the locating on the evaluation notes.
C. Assess blood stress to rule out hypertension.
D. Record that the consumer has poor imaginative and prescient. - ANS-b. Record the locating
on the evaluation notes.
,Pupillary constriction to mild is a everyday locating and ought to be documented within the
assessment notes.
A purchaser diagnosed with a mind tumor is receiving radiation beam remedies to the right
frontal location. The practical nurse (PN) should take a look at this patron for which hassle at
some point of the early submit-remedy days?
A. Hemiplegia
b. Headache
c. Hearing loss
d. Dysphagia - ANS-b. Headache
Rationale:
Radiotherapy is a neighborhood treatment, and most side outcomes are website online-unique,
inclusive of infection of surrounding mind tissue, swelling, headache, and fatigue.
A client recognized with a fracture of the left radius has a plaster cast implemented. The nurse
has bolstered instructions for drying the cast over the following 24 hours. Which statement
through the consumer suggests the coaching turned into powerful?
A. "I will wrap the solid in plastic wrap for 24 hours."
b. "I will assist the cast on a company surface at some stage in the night time."
c. "I will no longer cowl it; alternatively I'll keep the forged surfaces exposed 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 not cowl it; alternatively I'll keep the forged surfaces uncovered to circulating air."
Rationale:
The nurse ought to teach the purchaser to maintain the forged exposed to circulating air and
keep away from overlaying it with cloth that could keep it moist.
A consumer recognized with a fracture of the left radius has a plaster cast carried out. The
nurse has strengthened commands for drying the cast over the following 24 hours. Which
announcement by way of the consumer suggests the teaching become powerful?
A. "I will wrap the solid in plastic wrap for 24 hours."
b. "I will support the solid on a corporation floor in the course of the night time."
c. "I will not cowl it; as an alternative I'll preserve the solid surfaces uncovered to circulating air."
d. "I can use a blow dryer on medium setting until the plaster solid feels dry to the touch." -
ANS-c. "I will now not cover it; rather I'll maintain the solid surfaces exposed to circulating air."
Rationale:
The nurse ought to educate the purchaser to keep the forged exposed to circulating air and
keep away from overlaying it with fabric that would maintain it moist.
,A consumer identified with a skull hematoma and fractured left (L) clavicle following a six foot
fall from a ladder is admitted to the unit. Which sign have to the practical nurse (PN) report at
once?
A. Spontaneously opens eyes.
B. Obeys instructions in motion and grip.
C. Answers questions, but is careworn.
D. Has atypical flexion or extension of (L) arm. - ANS-c. Answers questions, however is
burdened.
Rationale:
Confusion following a head damage is commonly the first sign of improved intracranial strain.
A purchaser identified with bacterial meningitis is admitted to the unit and is prescribed neuro
checks each 2 hours. Which manifestation would the realistic nurse screen for that could
provide the first indication of altered neurological function?
A. Change in stage of attention
b. Increasing muscular weak spot
c. Changes in scholar length bilaterally
d. Progressive nuchal pressure - ANS-a. Change in level of cognizance
A lower or alternate within the stage of awareness is usually the primary indication of
neurological deterioration.
A patron diagnosed with continual obstructive pulmonary disease complains to the realistic
nurse of severe fatigue after coughing. Which self-care measures can help limit the client's
dyspnea? (Select all that apply.)
a. Assume a sitting position with shoulders comfortable and knees flexed.
B. Support forearms with a pillow and vicinity each ft flat at the floor.
C. Slightly drop the head, bend ahead, and slowly exhale with pursed lips.
D. Resume sitting up instantly, the usage of diaphragmatic breathing to inhale slowly and
deeply.
E. Repeat breathing in deeply and slowly with pursed lips while bending ahead handiest once.
F. Repeat exhaling and watch for the cough reflex to facilitate movement of the secretions.
G. After coughing, inhale deeply from abdomen and cough 3 or four times even as exhaling. -
ANS-a. Assume a sitting function with shoulders relaxed and knees flexed.
B. Support forearms with a pillow and area each toes flat at the floor.
C. Slightly drop the top, bend forward, and slowly exhale with pursed lips.
D. Resume sitting up straight, using diaphragmatic breathing to inhale slowly and deeply.
Effective coughing can help the client to cough secretions, consequently enhancing fuel
exchange and decrease fatigue. The patron have to count on the sitting function with shoulders
relaxed and knees flexed. Their forearms have to be supported with a pillow and both toes place
, flat on the floor. The consumer need to barely drop their head, bent ahead, and slowly exhale
via pursed lips using sluggish and deep diaphragmatic breathing to help facilitate powerful
coughing. The patron must repeat the previous steps or 3 instances. The customer ought to
provoke the cough reflex, now not look forward to it. The purchaser need to additionally take a
deep stomach breath before initiating a cough.
A consumer diagnosed with congestive coronary heart failure has evolved growing pedal edema
and pulmonary edema. What nutritional amendment is maximum crucial for the sensible nurse
(PN) to boost with this purchaser?
A. Avoid excessive carbohydrate foods.
B. Decrease consumption of fats-soluble nutrients.
C. Decrease caloric consumption.
D. Restrict salt and fluid consumption. - ANS-d. Restrict salt and fluid intake.
Rationale:
Salt and fluid restrictions are the first nutritional changes for a client who is preserving fluid as
manifested via edema and pulmonary edema.
A consumer identified with diabetes has a prescription of 5 gadgets of ordinary insulin and 15
units of NPH insulin. In which order ought to the realistic nurse prepare to administer the
insulin?List so as the nursing moves to be carried out.
Arrange the sequence options in the best order by way of assigning every choice various.
Perform hand hygiene in line with facility policy.
Inject five devices of air into ordinary insulin vial.
Inspect insulin vials for type and expiration dates.
Inject 15 devices of air into NPH insulin vial.
Withdraw 15 units of NPH insulin from vial.
Withdraw five devices of normal insulin from vial. - ANS-1. Perform hand hygiene according to
facility policy.
2. Inspect insulin vials for kind and expiration dates.
Three. Inject 15 devices of air into NPH insulin vial.
4. Inject 5 gadgets of air into ordinary insulin vial.
Five. Withdraw 5 devices of everyday insulin from vial.
6. Withdraw 15 gadgets of NPH insulin from vial.
Rationale:
The first nursing motion is to perform hand hygiene. The subsequent motion is to look into vials
for kind and expiration dates after which add 15 gadgets of air to NPH insulin vial. Next add five
units of air into normal insulin vial, then withdraw 5 gadgets of everyday insulin from vial, and
withdraw 15 gadgets of NPH insulin from vial. Note that it's miles important to fill the syringe with
normal insulin (shorter appearing insulin) first to prevent infection of the NPH insulin
(intermediate-appearing insulin).
SURG HESI PN
A 70-yr-antique purchaser fame put up hip replacement is transferred to a rehabilitation facility.
Which scale ought to the realistic nurse (PN) discover because the pleasant device to predict
the purchaser's risk for growing 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, pastime, mobility,
nutrition, and friction and shear. A hospitalized person with a score sixteen or underneath or an
older person with a score of 18 or below is at an multiplied chance for skin breakdown.
A consumer comes to the health center and reviews the presence of a painful lesion in the
genital place; they described it as a blister 2 days earlier this is now crusty. Which intervention
should the practical nurse (PN) enforce first?
A. Ask the purchaser in the event that they have had unprotected sex.
B. Prepare the client for a tradition and sensitivity check of the lesion.
C. Inform the consumer this occurrence will ought to be reported to the general public health
department.
D. Prepare to administer penicillin intramuscularly into the dorsogluteal location. - ANS-a. Ask
the customer if they have had unprotected sex.
Rationale:
These are normal symptoms and signs and symptoms of herpes simplex virus 2 (HSV2), a
sexually transmitted disorder (STD), so the PN should ask the consumer in the event that they
had unprotected sex and if the customer has exposed others to the disease.
A client established pupillary constriction while a pen light become shined of their eyes. Which
nursing motion ought to the practical nurse perform?
A. Report the finding to the fitness care company.
B. Record the locating on the evaluation notes.
C. Assess blood stress to rule out hypertension.
D. Record that the consumer has poor imaginative and prescient. - ANS-b. Record the locating
on the evaluation notes.
,Pupillary constriction to mild is a everyday locating and ought to be documented within the
assessment notes.
A purchaser diagnosed with a mind tumor is receiving radiation beam remedies to the right
frontal location. The practical nurse (PN) should take a look at this patron for which hassle at
some point of the early submit-remedy days?
A. Hemiplegia
b. Headache
c. Hearing loss
d. Dysphagia - ANS-b. Headache
Rationale:
Radiotherapy is a neighborhood treatment, and most side outcomes are website online-unique,
inclusive of infection of surrounding mind tissue, swelling, headache, and fatigue.
A client recognized with a fracture of the left radius has a plaster cast implemented. The nurse
has bolstered instructions for drying the cast over the following 24 hours. Which statement
through the consumer suggests the coaching turned into powerful?
A. "I will wrap the solid in plastic wrap for 24 hours."
b. "I will assist the cast on a company surface at some stage in the night time."
c. "I will no longer cowl it; alternatively I'll keep the forged surfaces exposed 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 not cowl it; alternatively I'll keep the forged surfaces uncovered to circulating air."
Rationale:
The nurse ought to teach the purchaser to maintain the forged exposed to circulating air and
keep away from overlaying it with cloth that could keep it moist.
A consumer recognized with a fracture of the left radius has a plaster cast carried out. The
nurse has strengthened commands for drying the cast over the following 24 hours. Which
announcement by way of the consumer suggests the teaching become powerful?
A. "I will wrap the solid in plastic wrap for 24 hours."
b. "I will support the solid on a corporation floor in the course of the night time."
c. "I will not cowl it; as an alternative I'll preserve the solid surfaces uncovered to circulating air."
d. "I can use a blow dryer on medium setting until the plaster solid feels dry to the touch." -
ANS-c. "I will now not cover it; rather I'll maintain the solid surfaces exposed to circulating air."
Rationale:
The nurse ought to educate the purchaser to keep the forged exposed to circulating air and
keep away from overlaying it with fabric that would maintain it moist.
,A consumer identified with a skull hematoma and fractured left (L) clavicle following a six foot
fall from a ladder is admitted to the unit. Which sign have to the practical nurse (PN) report at
once?
A. Spontaneously opens eyes.
B. Obeys instructions in motion and grip.
C. Answers questions, but is careworn.
D. Has atypical flexion or extension of (L) arm. - ANS-c. Answers questions, however is
burdened.
Rationale:
Confusion following a head damage is commonly the first sign of improved intracranial strain.
A purchaser identified with bacterial meningitis is admitted to the unit and is prescribed neuro
checks each 2 hours. Which manifestation would the realistic nurse screen for that could
provide the first indication of altered neurological function?
A. Change in stage of attention
b. Increasing muscular weak spot
c. Changes in scholar length bilaterally
d. Progressive nuchal pressure - ANS-a. Change in level of cognizance
A lower or alternate within the stage of awareness is usually the primary indication of
neurological deterioration.
A patron diagnosed with continual obstructive pulmonary disease complains to the realistic
nurse of severe fatigue after coughing. Which self-care measures can help limit the client's
dyspnea? (Select all that apply.)
a. Assume a sitting position with shoulders comfortable and knees flexed.
B. Support forearms with a pillow and vicinity each ft flat at the floor.
C. Slightly drop the head, bend ahead, and slowly exhale with pursed lips.
D. Resume sitting up instantly, the usage of diaphragmatic breathing to inhale slowly and
deeply.
E. Repeat breathing in deeply and slowly with pursed lips while bending ahead handiest once.
F. Repeat exhaling and watch for the cough reflex to facilitate movement of the secretions.
G. After coughing, inhale deeply from abdomen and cough 3 or four times even as exhaling. -
ANS-a. Assume a sitting function with shoulders relaxed and knees flexed.
B. Support forearms with a pillow and area each toes flat at the floor.
C. Slightly drop the top, bend forward, and slowly exhale with pursed lips.
D. Resume sitting up straight, using diaphragmatic breathing to inhale slowly and deeply.
Effective coughing can help the client to cough secretions, consequently enhancing fuel
exchange and decrease fatigue. The patron have to count on the sitting function with shoulders
relaxed and knees flexed. Their forearms have to be supported with a pillow and both toes place
, flat on the floor. The consumer need to barely drop their head, bent ahead, and slowly exhale
via pursed lips using sluggish and deep diaphragmatic breathing to help facilitate powerful
coughing. The patron must repeat the previous steps or 3 instances. The customer ought to
provoke the cough reflex, now not look forward to it. The purchaser need to additionally take a
deep stomach breath before initiating a cough.
A consumer diagnosed with congestive coronary heart failure has evolved growing pedal edema
and pulmonary edema. What nutritional amendment is maximum crucial for the sensible nurse
(PN) to boost with this purchaser?
A. Avoid excessive carbohydrate foods.
B. Decrease consumption of fats-soluble nutrients.
C. Decrease caloric consumption.
D. Restrict salt and fluid consumption. - ANS-d. Restrict salt and fluid intake.
Rationale:
Salt and fluid restrictions are the first nutritional changes for a client who is preserving fluid as
manifested via edema and pulmonary edema.
A consumer identified with diabetes has a prescription of 5 gadgets of ordinary insulin and 15
units of NPH insulin. In which order ought to the realistic nurse prepare to administer the
insulin?List so as the nursing moves to be carried out.
Arrange the sequence options in the best order by way of assigning every choice various.
Perform hand hygiene in line with facility policy.
Inject five devices of air into ordinary insulin vial.
Inspect insulin vials for type and expiration dates.
Inject 15 devices of air into NPH insulin vial.
Withdraw 15 units of NPH insulin from vial.
Withdraw five devices of normal insulin from vial. - ANS-1. Perform hand hygiene according to
facility policy.
2. Inspect insulin vials for kind and expiration dates.
Three. Inject 15 devices of air into NPH insulin vial.
4. Inject 5 gadgets of air into ordinary insulin vial.
Five. Withdraw 5 devices of everyday insulin from vial.
6. Withdraw 15 gadgets of NPH insulin from vial.
Rationale:
The first nursing motion is to perform hand hygiene. The subsequent motion is to look into vials
for kind and expiration dates after which add 15 gadgets of air to NPH insulin vial. Next add five
units of air into normal insulin vial, then withdraw 5 gadgets of everyday insulin from vial, and
withdraw 15 gadgets of NPH insulin from vial. Note that it's miles important to fill the syringe with
normal insulin (shorter appearing insulin) first to prevent infection of the NPH insulin
(intermediate-appearing insulin).
