HESI PN Comprehensive Exam 1 t t t t
A client with deep partial-thickness and full-
t t t t t t
thickness burns of the face and chestis receiving wound care using the open method. Th
t t t t t t t t t t t t t t t
e plan of care includes the NsgDx, "Risk for infection R/T impaired tissue integrity." B
t t t t t t t t t t t t t t t
ased on the expected outcome, "Client remains free of infections," which nursing inter
t t t t t t t t t t t t
ventions should the PN implement? t t t t
A. Wear gown, cap, mask, and gloves during direct client care.
t t t t t t t t t
B. Restrict visitors in order to prevent wound contamination. t t t t t t t
C. Use sterile water for debridement in the hydrotherapy tank.
t t t t t t t t
D. Apply sterile dressings after debridement of burn wounds.
t t t t t t t
(ANS - A. Wear gown, cap, mask, and gloves during direct client care.
t t t t t t t t t t t t
No dressing is used for burn wound care using the open method. The burn area isexpos
t t t t t t t t t t t t t t t t
ed and an aseptic environment is needed to prevent contamination and infection. Prot
t t t t t t t t t t t t
ective isolation precautions should be implemented during direct client care and wou
t t t t t t t t t t t
nd care, which should include wearing gown, cap, mask, and gloves.
t t t t t t t t t t
What action should the PN implement to facilitate speech for a client who has afenestrate
t t t t t t t t t t t t t t t
d tracheostomy tube?
t t
A. Show the client how to use a tracheostomy plug. t t t t t t t t
B. Determine the client's ability to swallow. t t t t t
C. Remove the inner cannula. t t t
D. Give oxygen at 6 L/minute via tracheostomy collar.(A
t t t t t t t t
NS - B. Determine the client's ability to swallow.
t t t t t t t t
A fenestrated tracheostomy has an opening or hole on the posterior aspect of the outer ca
t t t t t t t t t t t t t t t
nnula that allows airflow over the vocal cords and speech in a client who isspontaneously
t t t t t t t t t t t t t t t t
breathing. It does not have a cuff, so the client's risk for aspiration should be determined.
t t t t t t t t t t t t t t t
,A male client scheduled for a total laryngectomy and radical neck dissection for cancer
t t t t t t t t t t t t t t
of the larynx asks the PN if he will ever be able to speak. Which response isbets for the P
t t t t t t t t t t t t t t t t t t t t
N to provide?
t t
A. Breathing occurs through a permanent neck opening which prevents normalspe t t t t t t t t t t
ech.
B. Permanent removal of the voice box requires rehabilitation for esophagealspe t t t t t t t t t t
ech.
C. Due to removal of the vocal cords, communication requires the use of signlang
t t t t t t t t t t t t t
uage.
D. Once the breathing hole in the neck heals, the ability to speak requires a device.(AN
t t t t t t t t t t t t t t t
S- t
B. Permanent removal of the voice box requires rehabilitation for esophageal speech.
t t t t t t t t t t t t
A total laryngectomy includes removal of the larynx and pre-
t t t t t t t t t
epiglottis region resulting in a permanent tracheostomy and loss of normal speech abilit
t t t t t t t t t t t t
ies. Rehab isrequired to learn to speak using a prosthesis, esophageal speech, or an electr
t t t t t t t t t t t t t t t
olarynx.
A client is wearing a continuous 24-
t t t t t t
hour Holter monitor for elevation of heartrhythm disturbances. What info should t
t t t t t t t t t t t t
he PN reinforce with this client?
t t t t t
A. Remove the electrodes to shower or bathe t t t t t t
B. Keep a diary of activities as long as the monitor is worn. t t t t t t t t t t t
C. Exercise as much as possible while the monitor is in place. t t t t t t t t t t
D. Call the assigned number if an episode of irregular heartbeats occurs.(A
t t t t t t t t t t t
NS - B. Keep a diary of activities as long as the monitor is worn.
t t t t t t t t t t t t t t
Nursing care for a client with a Holter monitor includes preparation of the skin, place
t t t t t t t t t t t t t t
ment of the electrodes and leads, and activities of daily living, so the clientshould be i
t t t t t t t t t t t t t t t t
nformed of the importance of keeping an accurate record of activitiesand symptoms
t t t t t t t t t t t t
,The PN is caring for a client who is receiving a therapeutic dose of warfarin (Coumadin).
t t t t t t t t t t t t t t t t
The client asks the PN to explain the effect of eating green leafyvegetables. What info sho
t t t t t t t t t t t t t t t t
uld the PN provide?
t t t
A. The high content of vitamin K in green leafy vegetables decreases Coumadin'sacti
t t t t t t t t t t t t
on.
B. Green vegetables are high in fiber and cellulose that decrease the absorption ofCou
t t t t t t t t t t t t t
madin.
C. These foods have a natural anticoagulant effect that potentiates the effect ofCou
t t t t t t t t t t t t
madin.
D. Dietary intake of green leafy vegetables alters the bowel bacteria's production ofvita
t t t t t t t t t t t t
min K. t
(ANS - t
A. The high content of vitamin K in green leafy vegetables decreasesCoumadin's action.
t t t t t t t t t t t t t t
Coumadin works as an anticoagulant by blocking hepatic utilization of vitamin Kin the
t t t t t t t t t t t t t t
production of prothrombin, which is a component of the blood clotting cascade. Green
t t t t t t t t t t t t t
leafy vegetables are high in vitamin K, which counteracts the anticoagulant effect of C
t t t t t t t t t t t t t
oumadin.
The PN is reviewing the effects of NSAIDs (nonsteroidal anti-
t t t t t t t t t
inflammatory drugs)with a client who has acute gastritis. What info is correct about the
t t t t t t t t t t t t t t t
action of NSAIDs? t t
A. Causes histamine receptor stimulation that increases the release of hydrochloricaci
t t t t t t t t t t
d.
B. Inhibits the synthesis of prostaglandins that normally protect the stomach lining.
t t t t t t t t t t
C. Activates an inflammatory response which increases the drug's absorption.C.
t t t t t t t t t
D. Stimulates parietal cells to release pepsin leading to digestion of ingested foods.(AN
t t t t t t t t t t t t
S - B. Inhibits the synthesis of prostaglandins that normally protect the stomach lining
t t t t t t t t t t t t t
NSAIDs inhibit the synthesis of prostaglandins which protect the stomach lining.
t t t t t t t t t t
, After undergoing exploratory laparotomy and bowel resection, a client with an NGtube
t t t t t t t t t t t t
to suction complains of nausea and stomach distention. The PN irrigates the tube, but th
t t t t t t t t t t t t t t t
e irrigating fluid does not return. What action should the PN implement?
t t t t t t t t t t t
A. Notify the healthcare provider. t t t
B. Auscultate for bowel sounds. t t t
C. Reposition the tube and check for placement. t t t t t t
D. Remove the tube and replace it with a new one. (ANS - t t t t t t t t t t t
C. Reposition the tube and check for placement.
t t t t t t t t
Patency and position of a NGT are checked frequently to evaluate for dislodgement or
t t t t t t t t t t t t t t
NGT obstruction with mucous, sediment, or blood clots. The placement should be verif
t t t t t t t t t t t t
ied and repositioned in the stomach to obtain a return ofthe normal saline used to irrigat
t t t t t t t t t t t t t t t t
e the NGT.
t t
A client with advanced cirrhosis is prescribed lactulose (Cephulac) 30 ml QID. Theclient
t t t t t t t t t t t t t
complains that the medicine is causing diarrhea. Which therapeutic response of the medi
t t t t t t t t t t t t t
cation should the PN provide the client? t t t t t t
A. Promotes fluid loss. t t
B. Prevents constipation. t
C. Excretes ammonia to improve cerebral function. t t t t t
D. Reduces the risk for gastrointestinal bleeding. t t t t t
(ANS - C. Excretes ammonia to improve cerebral function.
t t t t t t t t
To treat portal- t t
systemic encephalopathy, lactulose causes the movement of serumammonia, which a
t t t t t t t t t t
ccumulates due to hepatic dysfunction in cirrhosis, into the gutand results in diarrhea t t t t t t t t t t t t t t
due to the osmotic movement of water.
t t t t t t
The PN is reinforcing the discharge instructions for a female client with cystitis.Whic
t t t t t t t t t t t t t
h statement indicates to the PN that the client understands measures to prevent urinary
t t t t t t t t t t t t t
tract infections (UTI)?
t t t
A client with deep partial-thickness and full-
t t t t t t
thickness burns of the face and chestis receiving wound care using the open method. Th
t t t t t t t t t t t t t t t
e plan of care includes the NsgDx, "Risk for infection R/T impaired tissue integrity." B
t t t t t t t t t t t t t t t
ased on the expected outcome, "Client remains free of infections," which nursing inter
t t t t t t t t t t t t
ventions should the PN implement? t t t t
A. Wear gown, cap, mask, and gloves during direct client care.
t t t t t t t t t
B. Restrict visitors in order to prevent wound contamination. t t t t t t t
C. Use sterile water for debridement in the hydrotherapy tank.
t t t t t t t t
D. Apply sterile dressings after debridement of burn wounds.
t t t t t t t
(ANS - A. Wear gown, cap, mask, and gloves during direct client care.
t t t t t t t t t t t t
No dressing is used for burn wound care using the open method. The burn area isexpos
t t t t t t t t t t t t t t t t
ed and an aseptic environment is needed to prevent contamination and infection. Prot
t t t t t t t t t t t t
ective isolation precautions should be implemented during direct client care and wou
t t t t t t t t t t t
nd care, which should include wearing gown, cap, mask, and gloves.
t t t t t t t t t t
What action should the PN implement to facilitate speech for a client who has afenestrate
t t t t t t t t t t t t t t t
d tracheostomy tube?
t t
A. Show the client how to use a tracheostomy plug. t t t t t t t t
B. Determine the client's ability to swallow. t t t t t
C. Remove the inner cannula. t t t
D. Give oxygen at 6 L/minute via tracheostomy collar.(A
t t t t t t t t
NS - B. Determine the client's ability to swallow.
t t t t t t t t
A fenestrated tracheostomy has an opening or hole on the posterior aspect of the outer ca
t t t t t t t t t t t t t t t
nnula that allows airflow over the vocal cords and speech in a client who isspontaneously
t t t t t t t t t t t t t t t t
breathing. It does not have a cuff, so the client's risk for aspiration should be determined.
t t t t t t t t t t t t t t t
,A male client scheduled for a total laryngectomy and radical neck dissection for cancer
t t t t t t t t t t t t t t
of the larynx asks the PN if he will ever be able to speak. Which response isbets for the P
t t t t t t t t t t t t t t t t t t t t
N to provide?
t t
A. Breathing occurs through a permanent neck opening which prevents normalspe t t t t t t t t t t
ech.
B. Permanent removal of the voice box requires rehabilitation for esophagealspe t t t t t t t t t t
ech.
C. Due to removal of the vocal cords, communication requires the use of signlang
t t t t t t t t t t t t t
uage.
D. Once the breathing hole in the neck heals, the ability to speak requires a device.(AN
t t t t t t t t t t t t t t t
S- t
B. Permanent removal of the voice box requires rehabilitation for esophageal speech.
t t t t t t t t t t t t
A total laryngectomy includes removal of the larynx and pre-
t t t t t t t t t
epiglottis region resulting in a permanent tracheostomy and loss of normal speech abilit
t t t t t t t t t t t t
ies. Rehab isrequired to learn to speak using a prosthesis, esophageal speech, or an electr
t t t t t t t t t t t t t t t
olarynx.
A client is wearing a continuous 24-
t t t t t t
hour Holter monitor for elevation of heartrhythm disturbances. What info should t
t t t t t t t t t t t t
he PN reinforce with this client?
t t t t t
A. Remove the electrodes to shower or bathe t t t t t t
B. Keep a diary of activities as long as the monitor is worn. t t t t t t t t t t t
C. Exercise as much as possible while the monitor is in place. t t t t t t t t t t
D. Call the assigned number if an episode of irregular heartbeats occurs.(A
t t t t t t t t t t t
NS - B. Keep a diary of activities as long as the monitor is worn.
t t t t t t t t t t t t t t
Nursing care for a client with a Holter monitor includes preparation of the skin, place
t t t t t t t t t t t t t t
ment of the electrodes and leads, and activities of daily living, so the clientshould be i
t t t t t t t t t t t t t t t t
nformed of the importance of keeping an accurate record of activitiesand symptoms
t t t t t t t t t t t t
,The PN is caring for a client who is receiving a therapeutic dose of warfarin (Coumadin).
t t t t t t t t t t t t t t t t
The client asks the PN to explain the effect of eating green leafyvegetables. What info sho
t t t t t t t t t t t t t t t t
uld the PN provide?
t t t
A. The high content of vitamin K in green leafy vegetables decreases Coumadin'sacti
t t t t t t t t t t t t
on.
B. Green vegetables are high in fiber and cellulose that decrease the absorption ofCou
t t t t t t t t t t t t t
madin.
C. These foods have a natural anticoagulant effect that potentiates the effect ofCou
t t t t t t t t t t t t
madin.
D. Dietary intake of green leafy vegetables alters the bowel bacteria's production ofvita
t t t t t t t t t t t t
min K. t
(ANS - t
A. The high content of vitamin K in green leafy vegetables decreasesCoumadin's action.
t t t t t t t t t t t t t t
Coumadin works as an anticoagulant by blocking hepatic utilization of vitamin Kin the
t t t t t t t t t t t t t t
production of prothrombin, which is a component of the blood clotting cascade. Green
t t t t t t t t t t t t t
leafy vegetables are high in vitamin K, which counteracts the anticoagulant effect of C
t t t t t t t t t t t t t
oumadin.
The PN is reviewing the effects of NSAIDs (nonsteroidal anti-
t t t t t t t t t
inflammatory drugs)with a client who has acute gastritis. What info is correct about the
t t t t t t t t t t t t t t t
action of NSAIDs? t t
A. Causes histamine receptor stimulation that increases the release of hydrochloricaci
t t t t t t t t t t
d.
B. Inhibits the synthesis of prostaglandins that normally protect the stomach lining.
t t t t t t t t t t
C. Activates an inflammatory response which increases the drug's absorption.C.
t t t t t t t t t
D. Stimulates parietal cells to release pepsin leading to digestion of ingested foods.(AN
t t t t t t t t t t t t
S - B. Inhibits the synthesis of prostaglandins that normally protect the stomach lining
t t t t t t t t t t t t t
NSAIDs inhibit the synthesis of prostaglandins which protect the stomach lining.
t t t t t t t t t t
, After undergoing exploratory laparotomy and bowel resection, a client with an NGtube
t t t t t t t t t t t t
to suction complains of nausea and stomach distention. The PN irrigates the tube, but th
t t t t t t t t t t t t t t t
e irrigating fluid does not return. What action should the PN implement?
t t t t t t t t t t t
A. Notify the healthcare provider. t t t
B. Auscultate for bowel sounds. t t t
C. Reposition the tube and check for placement. t t t t t t
D. Remove the tube and replace it with a new one. (ANS - t t t t t t t t t t t
C. Reposition the tube and check for placement.
t t t t t t t t
Patency and position of a NGT are checked frequently to evaluate for dislodgement or
t t t t t t t t t t t t t t
NGT obstruction with mucous, sediment, or blood clots. The placement should be verif
t t t t t t t t t t t t
ied and repositioned in the stomach to obtain a return ofthe normal saline used to irrigat
t t t t t t t t t t t t t t t t
e the NGT.
t t
A client with advanced cirrhosis is prescribed lactulose (Cephulac) 30 ml QID. Theclient
t t t t t t t t t t t t t
complains that the medicine is causing diarrhea. Which therapeutic response of the medi
t t t t t t t t t t t t t
cation should the PN provide the client? t t t t t t
A. Promotes fluid loss. t t
B. Prevents constipation. t
C. Excretes ammonia to improve cerebral function. t t t t t
D. Reduces the risk for gastrointestinal bleeding. t t t t t
(ANS - C. Excretes ammonia to improve cerebral function.
t t t t t t t t
To treat portal- t t
systemic encephalopathy, lactulose causes the movement of serumammonia, which a
t t t t t t t t t t
ccumulates due to hepatic dysfunction in cirrhosis, into the gutand results in diarrhea t t t t t t t t t t t t t t
due to the osmotic movement of water.
t t t t t t
The PN is reinforcing the discharge instructions for a female client with cystitis.Whic
t t t t t t t t t t t t t
h statement indicates to the PN that the client understands measures to prevent urinary
t t t t t t t t t t t t t
tract infections (UTI)?
t t t
