HESI Medical-Surgical

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.

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. Rationale: 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 need immediate attention.

A client is prescribed codeine USP 60 mg every 4 hours. The available medication is codeine USP 30 mg/tablet. How many tablets should the practical nurse administer? Fill in the blank.

2 Rationale: Desired dose/available dose × mg/dose of available drug = mg to administer(60 mg/30 mg) × 1 tablet = 2 tabletsRatio and proportion:30 mg : 1 tab::60 mg : x tabs; 30 mg/1 tab = 60 mg/x tabs = 2 tablets

A client is admitted to the hospital for a Crohn's disease flare up and severe dehydration. Which findings should the practical nurse report to the registered nurse and/or health care provider immediately?

a. A rigid hard abdomen and elevated white blood cell count Rationale: A hard, rigid abdomen and elevated white blood cell (WBC) count are indicative of peritonitis, which is a medical emergency and should be reported to the RN and health care provider immediately.

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. Rationale: 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.

The practical nurse is reinforcing osteoporosis prevention education to a group of senior citizens. The nurse realizes teaching has been effective if the senior citizens select which life style choices will help decrease the risk of developing osteoporosis? (Select all that apply.)

a. Alcohol in moderation and smoking cessation c. Regular weight-bearing exercises e. Consumption of a diet rich in calcium and vitamin D Rationale: 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.

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. 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.

A client diagnosed with chronic obstructive pulmonary disease complains to the practical nurse of extreme fatigue after coughing. Which self-care measures can help minimize the client's dyspnea? (Select all that apply.)

a. Assume a sitting position with shoulders relaxed and knees flexed. b. Support forearms with a pillow and place both feet flat on the floor. c. Slightly drop the head, bend forward, and slowly exhale with pursed lips. d. Resume sitting up straight, using diaphragmatic breathing to inhale slowly and deeply. Rationale: Effective coughing can help the client to cough secretions, therefore improving gas exchange and minimize fatigue. The client should assume the sitting position with shoulders relaxed and knees flexed. Their forearms should be supported with a pillow and both feet place flat on the floor. The client should slightly drop their head, bent forward, and slowly exhale through pursed lips using slow and deep diaphragmatic breathing to help facilitate effective coughing. The client should repeat the previous steps two or three times. The client should initiate the cough reflex, not wait for it. The client should also take a deep abdominal breath before initiating a cough.

The nurse is reinforcing instructions regarding risk factor reduction for a client with angina. The nurse should focus instructions to reduce the risk of cardiovascular disease by which risk factors? (Select all that apply.)

a. Blood pressure c. Blood sugar e. Stressful lifestyle Rationale: The nurse should focus instructions on risk factors that can be modified are blood pressure, blood sugar, and stressful lifestyle. The client cannot change age, gender, or family history.

A client diagnosed with bacterial meningitis is admitted to the unit and is prescribed neuro checks every 2 hours. Which manifestation would the practical nurse monitor for that would provide the first indication of altered neurological function?

a. Change in level of consciousness Rationale: A decrease or change in the level of consciousness is usually the first indication of neurological deterioration.

A client underwent a colon resection 48 hours ago. Which finding requires the most immediate intervention by the practical nurse (PN)?

a. Fever of 102° F (38.9° C) and chills Rationale: A sudden increase in temperature is an indicator of peritonitis and chills, along with abdominal pain and tenderness. The PN should immediately notify the charge nurse, who should notify the health care provider.

Which foods should the practical nurse encourage a client to eat to increase their potassium intake? (Select all that apply.)

a. Green beans d. Milk e. Flounder f. Sweet potatoes g. Cantaloupe Rationale: Flounder, sweet potatoes, milk, green beans, and cantaloupe are all potassium-rich foods.

The nurse is assisting with planning care for a client who is undergoing chemotherapy to treat breast cancer. Which elements should be included in the client's education on ways to prevent contracting pneumonia? (Select all that apply.)

a. Maintain a healthy diet with protein, fruits, and vegetables. b. Ask your health care provider about receiving the flu and pneumonia vaccine. d. Try to do your grocery shopping when your local grocery store is the least crowded. Rationale: Adequate nutrition reduces the risk of contracting pneumonia. The client should receive all recommended flu and pneumonia vaccines. The client should go in public places when those places are the last crowded to avoid contact with large number of microorganisms. The client should stop smoking, not simply cut back. Adequate rest periods during the day can improve the client's ability to resist infection.

A client has a serum potassium level of 3 mEq/L. Which findings should the practical nurse report to the charge nurse? (Select all that apply.)

a. Muscle cramps e. Abnormal heart rhythms Rationale: A normal potassium level ranges from 3.5 to 5 mEq/L (mmol/L). Signs and symptoms of low potassium include muscle cramps and dysrhythmias.

A client diagnosed with rheumatoid arthritis is prescribed splints for night time use. Which statement by the client demonstrates to the practical nurse (PN) an accurate understanding of the use of the splints?

a. Prevention of deformities Rationale: Splints may be used at night by clients with rheumatoid arthritis to prevent deformities caused by muscle spasms and contractures.

The nurse is assisting with data collection for an older adult who is visiting the health care provider today. Which signs and symptoms should the nurse report to the health care provider as possible signs associated with colon cancer? (Select all that apply.)

a. Rectal bleeding c. Abdominal distention d. Sensation that bowels are not evacuating completely Rationale: Some signs and symptoms associated with colon cancer include rectal bleeding, abdominal distention, and a sensation the bowels are not evacuating completely. A diet high in cauliflower, cabbage, and kale is associated with a reduced, not increased, risk of colon cancer. A client who has colon cancer is more likely to have a weight loss rather than weight gain.

A client has had a permanent pacemaker implanted. Which aspect should the nurse include when reinforcing instructions for care upon discharge?

a. Stand 4 feet away from radar detectors in use. Rationale: The client should be educated to stay 4 to 5 feet away from electromagnetic sources, such as radar detectors. It is not necessary to avoid microwaves. The client should be taught the pacemaker rate settings, and it is important to report a pulse lower than the settings, as that would indicate the pacemaker is not functioning. Clients should inform airport security of the presence of a pacemaker; handheld wand screening should NOT be used over the pacemaker site.

A client is diagnosed with fluid volume deficit. Which findings would the practical nurse document consistent with fluid volume deficit? (Select all that apply.)

a. Tachycardia c. Cool skin e. Decreased urine output f. Increased thirst Rationale: Fluid volume deficit causes tachycardia because the body tries to compensate and pump blood efficiently. Cool skin is consistent with fluid volume deficit. Decreased urine output results from reduced fluid volume perfusing the kidneys. Thirst will be stimulated by the hypothalamus because of decreased fluid volume.

A client diagnosed with ulcerative colitis (UC) asks the practical nurse why a low-fiber diet has been prescribed. Which is the most appropriate response?

a. To reduce the amount and frequency of stool Rationale: The purpose of a low-fiber diet is to reduce the amount and frequency of stooling to promote healing of the bowels by consuming foods that do not irritate the intestinal lining and prolong intestinal transit time to encourage optimal absorption of nutrients.

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. e. Postcard reminders for clients to get papanicolaou (Pap) smears and mammograms. Rationale: Secondary prevention deals with early diagnosis to treat disease in the beginning of its development. Breast self-examinations, testicular self-examinations, mammograms, and Pap smears are considered secondary prevention methods.

An older adult client diagnosed with dementia was admitted from a long-term facility to the hospital 2 days ago. The client's children express concern that their parent's confusion has gotten worse since being admitted. How should the practical nurse (PN) respond?

b. "Confusion in an older person is expected with a relocation to new surroundings." Rationale: Relocation often results in confusion among older adult clients and is stressful for clients of all ages.

A practical nurse (PN) reinforced client teaching regarding the transmission of the HIV virus. Which statement by the client demonstrates an understanding of the reinforced teaching?

b. "I may still contract HIV even though I am 62 years old." Rationale: More than 10% of all AIDS cases in the United States are among those older than 50 years of age.

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?

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.

A client with chronic obstructive pulmonary disease (COPD) tells the nurse "I get so tired when I eat; I'm just about ready to stop eating altogether". Which nursing intervention is most appropriate for this client?

b. Advise the client to take smaller, but more frequent meals. Rationale: Having a full stomach can cause difficulty breathing, and the client is advised to take frequent small meals and take most of their fluids between meals. Using an oxygen mask during meals would not be practical, as it would have to be removed with every bite of food.

A client asks the practical nurse what type of food is the best to eat reduce their chances of getting colon cancer. Which type of foods should the PN suggest to the client? (Select all that apply.)

b. Fruits and vegetables d. Whole grains Rationale: According to the American Cancer Society, "studies suggest that fiber in the diet, especially from whole grains, may lower colorectal cancer risk."

The nurse is caring for a 70-year-old female client who experienced a myocardial infarction. During review of the client's medical records, which signs and symptoms did the client most likely experience? (Select all that apply.)

b. Shortness of breath c. Fatigue e. Sleep disturbances Rationale: A female client is more likely to experience dyspnea, fatigue, and sleep disturbances. Hot dry skin and extreme hunger are more likely associated with an elevated blood sugar. Melena is blood in the stools.

A client has undergone craniotomy to remove a brain tumor. The client spent several days in the intensive care unit, and is now on the post-surgical unit. The nurse has urgently contact the surgeon to report signs of increasing intracranial pressure (ICP). Which was the most likely EARLY sign that the client was experiencing increased ICP?

b. The client became more confused than he was upon transfer to the post-surgical unit. Rationale: A change in the level of consciousness is most likely the earliest symptom of increased ICP. Vital sign changes can also occur, with a widening pulse pressure and bradycardia. Neither of these are indicated by data in the options. Sanguineous drainage does not indicate increased ICP.

The Centers for Disease Control and Prevention (CDC) has issued guidelines for health care workers in relation to protection from HIV. The practical nurse (PN) who suspects they may be pregnant is assigned a client who is HIV+. What action should the PN implement?

b. Wear gloves when coming in contact with the blood or body fluids of a client. Rationale: The CDC guidelines for standard precautions recommend that health care workers use gloves when coming in contact with blood or body fluids from any client because HIV is infectious before the client becomes aware of symptoms. Pregnancy of a nurse should not inhibit the nurse for taking care of a HIV+ client as long as standard precautions are observed.

A client diagnosed with status asthmaticus is admitted to the unit. Which breath sounds would the practical nurse anticipate to hear when auscultating the client's lungs?

b. Wheezes Rationale: Wheezes are continuous, high-pitched musical or squeaking-type sounds. They are reflective of the narrowing of the airways as a result of the inflammation from the asthma. Wheezes are generally heard with expiration, but can be heard with inspiration in severe cases of asthma.

The nurse is caring for a client who has an ileostomy and has reinforced instructions regarding ileostomy care. The nurse realizes the client needs additional instructions if the client makes which statement?

c. "I will need to set a time every day when I can irrigate the ostomy." Rationale: The client will not be able to set a time to irrigate the ostomy because the ileostomy drains all the time. A client who has had an ostomy placed on the descending colon will most likely need to irrigate the ostomy at the same time each day. High-fiber foods will cause diarrhea. The client will need to empty the ostomy pouch when it is one-third to one-half full. Water and a simple squirt bottle can be used to remove effluence from the pouch and reduce odors.

A client diagnosed with a fracture of the left radius has a plaster cast applied. The nurse has reinforced instructions for drying the cast over the next 24 hours. Which statement by the client indicates the teaching was effective?

c. "I will not cover it; instead I'll keep the cast surfaces exposed to circulating air." Rationale: The nurse should instruct the client to keep the cast exposed to circulating air and avoid covering it with material that might keep it moist.

The nurse is teaching concerned family members of a client who experienced a cardiac arrest prior to admission in the technique of cardiopulmonary resuscitation. The nurse recognizes the family members are performing the technique correctly if they use which depth of manual chest compression on the manikin?

c. 2 inches (5 cm) to 2.4 inches (6 cm) Rationale: According to the American Heart Association 2015 guidelines, the depth of compressions on an adult during CPR should be at least 2 inches (5 cm) to 2.4 inches (6 cm).

The health care provider informed a client diagnosed with stage 4 liver cancer that the cancer has spread to their spine. The client states to the practical nurse, "I have a cancer, but it is not malignant." What is the best initial nursing action?

c. Ask the client to explain his understanding of the term malignancy. Rationale: The best initial action is to assess the client's knowledge of the term malignancy when used to describe cancer. The client appears to have inaccurate knowledge. Stage 4 cancer means the cancer has spread (metastasized) from where it has started to another body part.

A client diagnosed with viral influenza is prescribed vitamin C 1000 mg PO daily and acetaminophen 650 mg PO every 4 hours prn. The client complains to the practical nurse of abdominal cramping and increasing episodes of diarrhea. Which prescription change should the nurse anticipate?

c. Decrease the dose of vitamin C. Rationale: Diarrhea is an adverse effect of high doses of vitamin C, so the nurse should anticipate a reduction in the dose of vitamin C.

A client who has undergone closed-appendectomy is prescribed to begin ambulation the next day. The next day when the practical nurse (PN) goes to assist the client with ambulation, the client yells they are watching the television and they do not feel like getting out of bed. Which response should the PN provide?

d. "I'll be back in 30 minutes to help you get out of bed and walk around the room." Rationale: Returning within 30 minutes provides a "cooling off" period, is firm, direct, and nonthreatening, and avoids arguing with the client.

A client who had an abdominal hysterectomy 48 hours ago suddenly complains of chest pain and becomes short of breath, pale, and diaphoretic. The practical nurse (PN) immediately assesses the client's vital signs and obtains 100/80 mm Hg blood pressure, 110 beats/min heart rate, and 36 breaths/min respiratory rate. What nursing action should the PN to do next?

d. Apply oxygen at 2 L per nasal cannula. Rationale: The PN should immediately provide oxygen while performing further assessment. Pulmonary embolism and pneumothorax are risks associated with major surgery.

A client has visited the health care provider and has been diagnosed with type 2 diabetes mellitus. Which symptom most likely prompted the client to seek medical attention?

d. Frequent vaginal infections Rationale: Symptoms of type 2 diabetes arise more slowly and are less dramatic. The client may learn then have type 2 diabetes when being treated for frequent infections, a change in vision and impotence. Extreme thirst, hunger, and a large urine output are more likely to be noticed with type 1 diabetes. Fruity odor to the breath is associated with diabetic ketoacidosis (DKA). Type 2 diabetes is less likely to cause DKA.

A client diagnosed with osteoarthritis. Which intervention should the practical nurse implement to help relieve joint pain and stiffness?

d. Instruct the client to take an analgesic before walking daily. Rationale: Adequate pain management is important for the success of an exercise program. Keeping the joints active decreases pain, so taking an analgesic and walking daily is likely to help decrease joint pain and stiffness.

A client residing in a memory care nursing facility with a diagnosis of diabetes approaches the nurse crying, saying "I just do not feel good." What action should the practical nurse take first?

d. Obtain a fingerstick blood glucose test. Rationale: An early sign of hypoglycemia increases confusion and/or irritability, sometimes described as "feeling bad." Based on the history of diabetes, the PN should first obtain objective data of a fingerstick blood glucose level to provide information to guide further nursing actions.