HESI PN LPN Medical Surgical -EXAM PACK | 200+ Verified Q&A Best revision for latest exams

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? a. Encourage the client to attend a cancer education program. b. Perform a complete history and physical assessment. c. Ask the client to explain his understanding of the term malignancy. d. Offer the client emotional support to deal with the diagnosis. 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 with severe Parkinson disease diagnosed with anorexia, dysphagia, drooling, generalized weakness, and slurred speech is admitted to the unit. Which nursing action should the practical nurse implement first for this client? a. Provide the client with a word board. b. Set up a suction and Yankauer at client's bedside. c. Encourage passive and active range-of-motion exercises. d. Offer client nutritional milkshakes every 2 hours. b. Set up a suction and Yankauer at client's bedside. Rationale: Dysphagia and drooling predispose this client to aspiration. A suction machine and Yankauer should be set up and near the client to be used to help prevent aspiration pneumonia. Aspiration is the primary concern in this situation. A client diagnosed with epilepsy is admitted to the unit. What intervention should the practical nurse (PN) implement if the client experiences a seizure? a. Observe the length and activity of the seizure. b. Insert an oral airway. c. Gently restrain the client to prevent harm. d. Call the code team. a. Observe the length and activity of the seizure. Rationale: The PN should observe the client as they have their seizure. The length of time and movement by the client needs to be observed and then documented once the client is stable. The client should be placed on their side to help prevent aspiration. A client diagnosed with a brain tumor is receiving radiation beam treatments to the right frontal area. The practical nurse (PN) should observe this client for which problem during the early post-therapy days? a. Hemiplegia b. Headache c. Hearing loss d. Dysphagia b. Headache Rationale: Radiotherapy is a local treatment, and most side effects are site-specific, such as inflammation of surrounding brain tissue, swelling, headache, and fatigue. 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 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. The nurse is assigned the care of a client whose spiritual beliefs are vastly different from the nurse's background. What action should the nurse take? a. Tell the client "I am uncomfortable with some of the religious items in your room." b. Tell the client "I will leave you alone most of the day so you can pray uninterrupted." c. Ask the client "Do you have any spiritual needs or concerns related to your health?" d. Tell the client "We only have regular food here, but your family can bring you food." c. Ask the client "Do you have any spiritual needs or concerns related to your health?" Rationale: During time of illness, spiritual practices may be a source of comfort to the client. The nurse should ask clients if there are any spiritual needs or concerns related to their health that need to be addressed. It is inappropriate for the nurse to mention discomfort with religious items in the client's room. The nurse should not leave the client alone for most of the day, but should ask if there are particular times the client would like to pray or meditate. The nurse can then plan care around those times whenever possible. Referring to facility food as "regular food" insinuates that the client's foods are abnormal. In addition, depending on the client's prescribed diet, the family may or may not be able to bring in additional foods. A client with a history of emphysema is hospitalized for an exacerbation of the disease. The nurse expects to see which aspect emphasized in the plan of care? a. Oxygen administered at 6 L/m via nasal cannula. b. Fluids to be restricted to less than 1500 mL/day. c. Supine or low Fowler's position while resting in bed. d. Information on smoking cessation classes and support. d. Information on smoking cessation classes and support. Rationale: The client should have information provided on smoking cessation classes and support while quitting. Oxygen is given at a low flow rate to prevent respiratory depression due to suppression of the stimulus to breathe. Fluids are encouraged to 3000 mL unless contraindicated. The client should be positioned sitting upright and bending slightly forward to promote breathing. 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? a. "I will wrap the cast in plastic wrap for 24 hours." b. "I will support the cast on a firm surface during the night." c. "I will not cover it; instead I'll keep the cast surfaces exposed to circulating air." d. "I can use a blow dryer on medium setting until the plaster cast feels dry to the touch." 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. A client is diagnosed with acute myocardial infarction (MI). Which diagnostic laboratory value should the practical nurse (PN) anticipate to be the first to elevate to establish a diagnosis of an acute myocardial infarction (MI)? a. Elevated troponin b. Elevated creatine kinase-MB (CK-MB) level c. Prolonged prothrombin time (PT) d. Elevated serum blood urea nitrogen (BUN) and creatinine a. Elevated troponin Rationale: Tissue damage in the myocardium causes the release of cardiac enzymes into the blood system. According to the American College of Cardiology (ACS) and the European Society of cardiology (ESC), an elevation of the troponin will occur within 2 to 3 hours of an MI and is used to establish the diagnosis. It takes the CK-MB level 6 to 9 hours or longer to elevate. A plan of care for a 56-year-old client who has been diagnosed with osteopenia has been developed. The plan is focused on preventing further bone resorption and increasing bone mass. Which outcome statement should be included in the plan of care? a. The nurse practitioner will instruct the client on the use of alendronate. b. The client will decrease the number of cigarettes smoked by 50% within 2 weeks. c. The client will swim for 30 minutes three to four times per week for the next 2 months. d. The practical nurse will provide the client with a list of foods that are high in calcium b. The client will decrease the number of cigarettes smoked by 50% within 2 weeks. Rationale: A desired outcome statement should be client-centered with a measurable outcome, and the client decreasing the number of cigarettes smoked by 50% within 2 weeks is both client-centered and measurable. Cigarette smoking has a negative effect on bone resorption, so the client should be advised to stop smoking. In order to provide culturally competent care to a group of clien