HESI PN MED SURG II QUESTIONS AND CORRECT
DETAILED ANSWERS AGRADE
Three days after surgery, a male client suddenly grabs his right chest and becomes
short of breath, pale, and diaphoretic. The practical nurse (PN) immediately assesses
his vital signs and obtains 100/80 mm Hg blood pressure, 110 beats/min heart rate,
and 36 breaths/min respiratory rate. What action is most important for the PN to
take next? - ANSWER: Apply oxygen at 2 liters per nasal cannula.
An elderly female client with dementia is transferred from a long-term care unit to
an acute care unit. The client's children express concern that their mother's
confusion is worsening. How should the practical nurse (PN) respond? - ANSWER:
Confusion in an older person often follows relocation to new surroundings."
A client with chronic obstructive pulmonary disease complains of extreme fatigue
after coughing. Which self-care measures should the practical nurse (PN) suggest to
minimize dyspnea? (Select all that apply.) - ANSWER: 1.Assume a sitting position with
shoulders relaxed and knees flexed.
2.Support forearms with a pillow and place both feet flat on the floor.
3.Slightly drop the head, bend forward, and slowly exhale with pursed lips.
4.Resume sitting up straight, using diaphragmatic breathing to inhale slowly and
deeply
A practical nurse (PN) is monitoring a client with diabetes. The nurse recognizes
which of the following symptoms as possible signs of diabetic ketoacidosis (DKA)?
(Select all that apply.) - ANSWER: Fruity breath odor
Rapid, weak pulse
Extreme thirst
Urinary frequency
The practical nurse (PN) recognizes which of the following characteristics considered
high-risk factors for developing type 2 diabetes? (Select all that apply.) - ANSWER:
Age 40 years or older
African American
Obesity
Hispanic
The women's health nurse practitioner and the clinic practical nurse (PN) are
developing a plan of care for a 56-year-old female client who has been diagnosed
with osteopenia. The plan is focused on preventing further bone resorption and
increasing bone mass. Which outcome statement should be included in the plan of
care? - ANSWER: The client will decrease the number of cigarettes smoked by 50%
within 2 weeks.
, A practical nurse (PN) has reinforced teaching a client with asthma to use a metered-
dose inhaler (MDI). Which of the following actions determines that the client
understands the correct procedure? (Select all that apply.) - ANSWER: Sit or stand.
Shake the inhaler.
Attach the canister of medication to the mouthpiece.
Use a spacer attachment and place the mouthpiece in the mouth.
Close the lips around the mouthpiece.
After inhaling the medication, hold the breath 10 seconds.
Three days following surgery, a male client observes his colostomy for the first time.
He becomes quite upset and tells the practical nurse (PN) that it is much bigger than
he expected. What is the best response by the PN? - ANSWER: Inform the client that
the stoma will become smaller when the initial swelling diminishes.
A client has a seizure disorder that has been managed with phenobarbital (Luminal
Nembutal) for several years. Lately, the client has become more difficult to arouse
and frequently wants to take a nap. What intervention should the nurse implement?
- ANSWER: Hold the medication and notify the health care provider
A client's infusion of normal saline infiltrated earlier today, and approximately 500
mL of saline infused into the subcutaneous tissue. The client is now complaining of
excruciating arm pain and demanding "stronger pain medications." What initial
action is most important for the practical nurse (PN) to take? - ANSWER: Measure
the pulse volume and capillary refill distal to the infiltration.
The practical nurse is caring for a client with a serum potassium level of 3 mEq/L.
Which findings should the nurse report to the charge nurse? (Select all that apply.) -
ANSWER: Abnormal heart rhythms
Muscle cramps
A practical nurse (PN) prepares to administer 5 units of Regular insulin and 15 units
of NPH insulin to a diabetic client. In which order should the actions be implemented
when preparing the injection? (Arrange from first on top to last on bottom). -
ANSWER: 1.Perform hand hygiene according to facility policy.
2.Inspect insulin vials for type and expiration dates.
3.Inject 15 units of air into NPH insulin vial.
4.Inject 5 units of air into Regular insulin vial.
5.Withdraw 5 units of Regular insulin from vial.
6.Withdraw 15 units of NPH insulin from vial.
Which action by the nurse is consistent with culturally competent care? - ANSWER:
Understanding one's own world views in addition to the client's
The practical nurse receives a shift report that the client is experiencing fluid volume
deficit. Which findings that are consistent with fluid volume deficit should the nurse
document? (Select all that apply.) - ANSWER: Tachycardia
Cool skin
DETAILED ANSWERS AGRADE
Three days after surgery, a male client suddenly grabs his right chest and becomes
short of breath, pale, and diaphoretic. The practical nurse (PN) immediately assesses
his vital signs and obtains 100/80 mm Hg blood pressure, 110 beats/min heart rate,
and 36 breaths/min respiratory rate. What action is most important for the PN to
take next? - ANSWER: Apply oxygen at 2 liters per nasal cannula.
An elderly female client with dementia is transferred from a long-term care unit to
an acute care unit. The client's children express concern that their mother's
confusion is worsening. How should the practical nurse (PN) respond? - ANSWER:
Confusion in an older person often follows relocation to new surroundings."
A client with chronic obstructive pulmonary disease complains of extreme fatigue
after coughing. Which self-care measures should the practical nurse (PN) suggest to
minimize dyspnea? (Select all that apply.) - ANSWER: 1.Assume a sitting position with
shoulders relaxed and knees flexed.
2.Support forearms with a pillow and place both feet flat on the floor.
3.Slightly drop the head, bend forward, and slowly exhale with pursed lips.
4.Resume sitting up straight, using diaphragmatic breathing to inhale slowly and
deeply
A practical nurse (PN) is monitoring a client with diabetes. The nurse recognizes
which of the following symptoms as possible signs of diabetic ketoacidosis (DKA)?
(Select all that apply.) - ANSWER: Fruity breath odor
Rapid, weak pulse
Extreme thirst
Urinary frequency
The practical nurse (PN) recognizes which of the following characteristics considered
high-risk factors for developing type 2 diabetes? (Select all that apply.) - ANSWER:
Age 40 years or older
African American
Obesity
Hispanic
The women's health nurse practitioner and the clinic practical nurse (PN) are
developing a plan of care for a 56-year-old female client who has been diagnosed
with osteopenia. The plan is focused on preventing further bone resorption and
increasing bone mass. Which outcome statement should be included in the plan of
care? - ANSWER: The client will decrease the number of cigarettes smoked by 50%
within 2 weeks.
, A practical nurse (PN) has reinforced teaching a client with asthma to use a metered-
dose inhaler (MDI). Which of the following actions determines that the client
understands the correct procedure? (Select all that apply.) - ANSWER: Sit or stand.
Shake the inhaler.
Attach the canister of medication to the mouthpiece.
Use a spacer attachment and place the mouthpiece in the mouth.
Close the lips around the mouthpiece.
After inhaling the medication, hold the breath 10 seconds.
Three days following surgery, a male client observes his colostomy for the first time.
He becomes quite upset and tells the practical nurse (PN) that it is much bigger than
he expected. What is the best response by the PN? - ANSWER: Inform the client that
the stoma will become smaller when the initial swelling diminishes.
A client has a seizure disorder that has been managed with phenobarbital (Luminal
Nembutal) for several years. Lately, the client has become more difficult to arouse
and frequently wants to take a nap. What intervention should the nurse implement?
- ANSWER: Hold the medication and notify the health care provider
A client's infusion of normal saline infiltrated earlier today, and approximately 500
mL of saline infused into the subcutaneous tissue. The client is now complaining of
excruciating arm pain and demanding "stronger pain medications." What initial
action is most important for the practical nurse (PN) to take? - ANSWER: Measure
the pulse volume and capillary refill distal to the infiltration.
The practical nurse is caring for a client with a serum potassium level of 3 mEq/L.
Which findings should the nurse report to the charge nurse? (Select all that apply.) -
ANSWER: Abnormal heart rhythms
Muscle cramps
A practical nurse (PN) prepares to administer 5 units of Regular insulin and 15 units
of NPH insulin to a diabetic client. In which order should the actions be implemented
when preparing the injection? (Arrange from first on top to last on bottom). -
ANSWER: 1.Perform hand hygiene according to facility policy.
2.Inspect insulin vials for type and expiration dates.
3.Inject 15 units of air into NPH insulin vial.
4.Inject 5 units of air into Regular insulin vial.
5.Withdraw 5 units of Regular insulin from vial.
6.Withdraw 15 units of NPH insulin from vial.
Which action by the nurse is consistent with culturally competent care? - ANSWER:
Understanding one's own world views in addition to the client's
The practical nurse receives a shift report that the client is experiencing fluid volume
deficit. Which findings that are consistent with fluid volume deficit should the nurse
document? (Select all that apply.) - ANSWER: Tachycardia
Cool skin
