HESI PN Medical Surgical Exam

A male client with diabetes mellitus calls the clinic to report left calf pain after walking around the block. Which additional information should the PN report to the healthcare provider? Muscle cramps occur at night when sleeping. Muscles are deconditioned from lack of regular exercise. Shooting pain occurs down the back of one leg when walking. The pain is immediately relieved when he sits down. The pain is immediately relieved when he sits down. Rationale Atherosclerosis secondary to diabetes mellitus increases the client's risk for peripheral arterial disease, which is manifested by pain precipitated by walking. The pain is immediately relieved when the clients sits down to rest(intermittent claudication) (D) and should be reported. (A, B, and C) occur from different problems. The practical nurse (PN) is reviewing preoperative instructions with a male client who is having surgery today. What question should the PN ask the client to best evaluate his understanding of the surgery? Do you understand why you are having surgery? Have you undergone this type of surgery in the past? What do you know about the surgery you are having? What symptoms brought you to the hospital for surgery? What do you know about the surgery you are having? Rationale Although it is the surgeon's responsibility to explain the surgery to the client, it is a nursing responsibility to determine whether the client understands what he has been told about his surgery. Asking open-ended questions is an important step in eliciting what the client understands (C). (A and B) are closed end questions and will elicit one word responses. (D) asks the client to explain the admission related to his need for surgery, but not his understanding about the procedure. Which finding is most important for the practical nurse (PN) to explore further for a client who had a total abdominal hysterectomy and bilateral oophorectomy yesterday? Right calf is 24 cm and the left calf is 21 cm. No bowel sounds or gurgles auscultated in the abdomen. No urine output 3 hours after the catheter is removed. Dried blood 3 cm in size noted on the abdominal dressing. Right calf is 24 cm and the left calf is 21 cm. Rationale A client with major abdominal surgery is at risk for the complication of deep vein thrombosis (DVT) due to immobility, dehydration, and manipulation of major vessels. Unilateral leg swelling (A) is a classic sign of a DVT. Not having bowel sounds one day postoperatively (B) after a major abdominal surgery is an expected finding. (C) is not unexpected 3 hours after removal of a urinary catheter, and the PN should encourage the client to void 6 to 8 hours after the removal of a catheter before taking more aggressive actions. A small amount of dried blood is an expected finding (D). Which finding for a client who is 1-day postoperative for a partial thyroidectomy requires immediate follow-up by the practical nurse (PN)? Which finding for a client who is 1-day postoperative for a partial thyroidectomy requires immediate follow-up by the practical nurse (PN)? High pitched expiratory sound. Throat pain rated "9." Voice is hoarse. Capillary refill is 4 seconds. High pitched expiratory sound. Rationale Stridor indicates airway obstruction, which is a postoperative complication after thyroidectomy (A). (B, C, and D) should be addressed after preparing for interventions related to airway obstruction. The practical nurse (PN) is evaluating the self-care of a client who is recovering at home after a laryngectomy. Which finding indicates to the PN that the client needs additional information? A cool mist humidifier is at the bedside. The salt water solution is dated 3 days ago. A Medic Alert bracelet is on the client's wrist. The client's stoma is covered with a crocheted scarf. The salt water solution is dated 3 days ago. Rationale Salt water solution (B) should be changed daily to prevent bacterial growth. (A, C, and D) are within accepted parameters for care. Which information should the practical nurse (PN) offer a female client who is at risk for recurrent urinary tract infection (UTI)? (Select all that apply.) Select all that apply Use vinegar solution douche regularly. Avoid wearing tight-fitting jeans. Limit caffeine and alcohol. Void before and after intercourse. Wipe the perineum from front to back. Avoid wearing tight-fitting jeans. Limit caffeine and alcohol. Void before and after intercourse. Wipe the perineum from front to back. Rationale Correct selections are (B, C, D, and E). Voiding before and after intercourse (D), avoiding caffeine and alcohol (C), and not wearing tight jeans (B), as well as wiping the perineal area from front to back (E), reduce UTI risk. Frequent douching (A) does not reduce a client's risk for frequent UTIs. The practical nurse is caring for a client who is admitted with signs of possible acute brain attack (stroke) three hours ago. The client's blood pressure is 170/96, regular radial pulse 76 beats/minute, respirations are nonlabored at 11 breaths/minute, and a SpO2 of 99%. What action is most important for the PN to implement? Call healthcare provider for antihypertensive. Assess the client for Brudzinski's sign. Continue to monitor client's blood pressure. Monitor client's IV fluid intake and urine output. Continue to monitor client's blood pressure. Rationale The goals for management of a client with a suspected stroke is continuous monitor of blood pressure (C) and neurological deterioration to determine eligibility for reperfusion therapy. Antihypertensives are indicated if the systolic is 180- 230 or diastolic is 105-140, so (A) is not indicated at this time. (B) is most likely associated with meningeal irritation related to meningitis. Although (D) is a basic component of client care, the priority is monitoring the client's blood pressure. A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the practical nurse to report to the healthcare provider? Pain radiating to the right shoulder. Clay-colored stool. Hard, rigid abdomen. Vomiting bile-stained emesis. Hard, rigid abdomen. Rationale As bile accumulates due to obstruction of the common bile duct, the gallbladder distends and can perforate, which is manifested by a distended, hard, rigid abdomen (C) that should be reported immediately to the healthcare provider. Radiating pain (A) and clay-colored stool (B) are manifestations associated with obstructive jaundice due to cholelithiasis. (D) indicates the obstruction of the common bile duct is reduced. Which findings should the practical nurse identify in a client with anemia due to a vitamin B 12 deficiency? Select all that apply Gradual weight gain. Smooth, beefy-red oral cavity. Macrocytic red blood cells (RBC). Paresthesia of hands and feet. Leukopenia. Smooth, beefy-red oral cavity. Paresthesia of hands and feet. Rationale Correct choices are (B and D). Vitamin B 12 deficiency anemia is due to a dietary deficiency or failure to absorb vitamin B12 from the intestinal tract as a result of partial gastrectomy or pernicious anemia. Manifestations of pernicious anemia include glossitis (a smooth, beefy-red tongue) (B), fatigue, paresthesia (D), pallor and jaundice, and weight loss, not (A). The results of a complete blood count (CBC) that show macrocytic anemia (C), leukopenia (E) and thrombocytopenia are indicative of bone marrow failure, not vitamin B12 deficiency. An older client with presbyopia receives a prescription for corrective lenses. Which information should the practical nurse provide that explains the expected results of the corrective lenses? Helps to sharpen distance vision. Improves both near and distance vision. Corrects vision for reading and close work. Assists with bilateral accommodation. Corrects vision for reading and close work. Rationale Due to aging of the lenses and loss of elasticity, presbyopic changes reduce the lenses' ability to accommodate, which makes close vision blurry. Corrective lenses improve visual acuity for reading and in close work (C). (A, B, and D) are inaccurate. A client with epilepsy is having bilateral rhythmic jerking movements of all extremities. After calling for help, which action should the practical nurse (PN) do next? (Arrange the interventions from first to last.) 1. Maintain the client's airway. 2. Observe the client for incontinence. 3. Apply pads to the bedside rails. 4. Avoid stimulation during post-ictal phase. 1. Maintain the client's airway. 2. Apply pads to the bedside rails. 3. Observe the client for incontinence. 4. Avoid stimulation during post-ictal phase. Rationale During a tonic-clonic seizure (grand mal), the PN should maintain the client's airway. Next, the client should be protected from injury by padding the side rails. Observation of the client's behaviors, such as incontinence, should be noted during a seizure. Minimal stimulation should be maintained during the post-ictal phase to prevent precipitation of subsequent seizures. A male client is having an intraocular pressure (IOP) measurement using a tonometer for the first time. The client is fearful that the test hurts and may damage his vision. Which explanation should the practical nurse provide? Eyedrops will be prescribed for abnormal IOP readings. A topical anesthetic will be used on the eye surface. The test is quick and does not cause injury or blindness. Reassure the client that the procedure does not hurt. A topical anesthetic will be used on the eye surface. Rationale Pain sensation is eliminated by the use of a topical ophthalmic anesthetic (B) placed in the conjunctival sac prior to the placement of a tonometer when measuring IOP for glaucoma, which is a common cause of blindness if early treatment is not implemented. (A, C, and D) do not provide the client with specific measures taken to prevent discomfort during the procedure. An older female client with osteoporosis asks the practical nurse (PN) to explain why she is now 2 inches shorter than when she was younger. What information is best for the practical nurse (PN) to provide? Loss of calcium in the bones causes the change. Bones get shorter with age due to wear and tear. Less fluid in each of the disks between the vertebrae occurs with degeneration. It is a combination of wear and tear and calcium loss that causes the change. It is a combination of wear and tear and calcium loss that causes the change. Rationale A biological theory of aging includes the wear-and-tear theory, which explains that after repeated use and damage, body structures and functions wear out because of stress. A normal spine at 40 years of age and osteoporotic changes at 60 and 70 years of age can cause a loss of as much as 6 inches in height. Small losses in the thickness of each of the intervertebral disks, which results from changes in disk consistency, erosion, and osteoporosis, can lead to significant changes in height (D). Calcium changes (A) and wear and tear (B and C) alone do not support significant height loss in aging, but a basic explanation of disk degeneration that combines several factors provides the client with the best information. An older client who has had a cataract in the right eye for several years tells the practical nurse (PN), "Now I have lost the sight in my right eye because I waited too long for treatment." What information should the PN provide? Prompt treatment can save the sight in both of eyes. Nothing can be done once sight is lost in the affected eye. Surgery can restore vision with corrective lens implants or glasses. Explain that surgery cannot provide optimal results immediately. Surgery can restore vision with corrective lens implants or glasses. Rationale Removal of a cataract results in restoration of vision with corrective lenses based on the client's underlying error of refraction and retinal integrity. (A and D) are vague and do not focus on the client's fear and specific treatment. (B) is incorrect. A client with major burns is receiving cimetidine (Tagamet). Which finding should the practical nurse (PN) obtain to best evaluate the effectiveness of the medication? Soft, non-tender abdomen. Change in stool frequency. Hyperactive bowel sounds. Absence of blood in the stool. Absence of blood in the stool. Rationale In burns, Curling's ulcer, a type of gastroduodenal stress ulcer, is caused by a generalized stress response resulting in decreased production of mucus and increased gastric acid secretion, which can cause epigastric pain, gastric ulceration, and bleeding. Cimetidine (Tagamet), a histamine blocker, reduces gastric acid secretion and is used for prevention of Curling's ulcers associated with severe trauma, such as major burns. Absence of blood in the stool (D) or the occurrence of black, tarry stool indicates the medication is effective. Although abdominal findings (A), change in stool frequency (B) or bowel sounds (C) provides information about the effectiveness of therapy, the best evaluation of the prevention of GI distress and ulceration is the absence of blood in the stool. A client who was hit in the head with a baseball is admitted to the hospital for observation. Which finding requires the practical nurse (PN) to follow-up with further assessment? A negative Babinski reflex. Pupils respond to light equally. Headache rated "8" on a scale of 0-10. Reports the hospital room is an office. Reports the hospital room is an office. Rationale The client's confusion about the hospital surroundings is an early sign of a change in mental status, which is consistent with findings associated with an increased intracranial pressure (D). (A and B) are normal findings. A headache is an expected finding due to trauma (C) and is not an indication of intracranial pathology. While completing preoperative preparation for a client admitted for same-day surgery, what evaluation statement should the practical nurse identify as an important outcome? Reports optimal rest in the hours before surgery. Asks questions regarding the surgical experience. Leaves the nursing unit for the surgical department on time. Reads all surgical literature before the operation takes place. Asks questions regarding the surgical experience. Rationale Preoperative preparation should be planned to allow the client and family time to ask questions and receive appropriate feedback (B). (A, C, and D) are not the most important client outcomes of preoperative care. A male client with peptic ulcer disease complains of feeling weak and dizzy. The practical nurse (PN) observes that the client is diaphoretic, has a firm abdomen, thready pulse at 104 beats/minute, and blood pressure of 90/50. Which action should the PN implement? Place the client in a left side-lying position. Obtain vital signs every 2 hours. Increase the client's oral fluid intake. Notify the healthcare provider. Notify the healthcare provider. Rationale Peptic ulcer perforation can cause hemorrhage. The client is manifesting signs of hypovolemic shock, a life-threatening emergency that requires intervention, so the healthcare provider should be notified immediately (D). (A, B, and C) delay obtaining life-saving prescriptions. A client who is 2-days postoperative for abdominal surgery has a nasogastric tube (NGT) to low continuous suction. The client tells the practical nurse (PN) his mouth is so dry that he has been drinking water to quench his thirst. Which potential imbalance should the PN monitor for development in the client? Fluid volume excess. Metabolic alkalosis. Hyperkalemia. Hypercalcemia. Metabolic alkalosis. Rationale The continuous gastric suction and the fluids the client drank increase the washing out gastric hydrochloric acid, which places the client at risk for metabolic alkalosis (B). (A, C, and D) are unlikely with gastric suction. Which client should the practical nurse consider at greatest risk for bacterial cystitis? A middle-aged female who has never been pregnant. An older female who does not use estrogen replacement. An older male with heart failure. A male who uses sildenafil (Viagra). An older female who does not use estrogen replacement. Rationale Postmenopausal women who do not use hormone replacement therapy are at an increased risk for bacterial cystitis because of changes in the cells of the urethra and vagina (B). (A and C) are not relevant. Urinary tract infections (UTI) are reported in 3% of men on sildenafil (Viagra) (D) compared to the incidence of UTI in postmenopausal women. Which finding prompts the practical nurse (PN) to check the nasogastric tube (NGT) placement? The client has vomited. The pH of aspirated fluid is 6.5. The fluid has a grassy green appearance. The abdomen is distended. The client has vomited. Rationale A NGT can become displaced with vomiting (A) and NGT placement should be verified. The pH of fluid aspirated from the stomach should be 5 or lower, but does not impact placement (B). Fluid aspirated from the stomach can have a grassy green, brown, or clear, mucoid-flecked appearance (C). (D) is not an uncommon finding for a client with a NGT. A client with heart failure (HF) takes a daily tablet of furosemide (Lasix) and lisinopril (Zestril). Which finding during the clinic visit should indicate to the practical nurse that the client's condition is worsening? Dizziness when changing position. Reports urgency with urination. Sharp chest pain with arm movement. Sleeps with two additional pillows. Sleeps with two additional pillows. Rationale Clients with worsening HF often require additional pillows to sleep comfortably at night (D) resulting from a deceased cardiac output that causes fluid backup into the alveoli when supine. Since ACE inhibitors can cause postural hypotension, clients should be advised to change positions slowly (A). Lasix can cause urinary urgency (B) when the bladder fills as a result of diuresis. (C) is likely related to muscle strain because the pain is movement-induced and not related to cardiac hypoxia. A male client is admitted with lower right abdominal pain for the past two days. During the focused assessment, the practical nurse (PN) observes that the client's abdomen is rigid with tense positioning. Which action should the PN implement? Withhold opioid use that contributes to constipation. Ask the client if he recently ate any gluten products. Determine if the client has biliary colic pain. Keep the client NPO for possible surgery. Keep the client NPO for possible surgery. Rationale The client's symptoms of prolonged lower right abdominal pain accompanied by tenseness and guarding are indicative of possible appendix perforation and peritonitis. The client is should be NPO and prepared for possible surgery (D). (A, B, and C) are not indicated. An adult client with otitis media has thick, yellow drainage from the right ear canal. What additional findings should the practical nurse (PN) expect to identify? Pain relief after ear drainage begins. Periauricle skin excoriation. Increased sensitivity to sound. Increased pain with movement of the pinna. Pain relief after ear drainage begins. Rationale Otitis media is an infection of the middle ear that creates an increased pressure behind the tympanic membrane, which can rupture and drain purulent exudate. Acute ear pain (A) that lessens when ear drainage occurs is a sign of a ruptured tympanic membrane. (B, C, and D) are not expected findings with otitis media and acute tympanic membrane rupture. A client with type 2 diabetes mellius (DM) presents in the clinic with a leg laceration that has not healed in two weeks. Which client data is most important for the practical nurse to collect? Serum electrolyte results. Use of vitamin C supplements. Daily administration of insulin. Fingerstick glucose level. Finger stick glucose level. Rationale Poor wound healing is often a sign of uncontrolled diabetes mellitus, so a fingerstick glucose level should be obtained first (D). Although (A) should be monitored during diabetic ketoacidosis, the priority is to determine the client's glucose level in response to poor wound healing and possible infection. Vitamin C (B) intake can influence wound healing, but managing the client glucose level is the priority. Type 2 DM is usually managed with oral antidiabetic agents, and (C) maybe indicated to promote healing based on the client's serum glucose. Which instructions should the practical nurse (PN) reinforce with a client who is preparing for discharge after placement of a permanent pacemaker implant? (Select all that apply.) Select all that apply Request the use of special hand scanning at airports. Avoid using cellular phones for long periods of time. Do not lean against the car while the engine is running. Keep the regularly scheduled follow-up appointments. Ingest a consistent amount of leafy green vegetables. Request the use of special hand scanning at airports. Do not lean against the car while the engine is running. Keep the regularly scheduled follow-up appointments. Rationale A client who has a permanent pacemaker should receive reinforcement of instructions that prevent malfunction of the pacemaker (A and C). The client should implement (D) to ensure that no complications have occurred with the pacemaker. (B and E) are not indicated for a client with a pacemaker implant. The practical nurse (PN) is reviewing the plan of care for a client scheduled for a surgical amputation of the left lower leg. Which nursing diagnosis should the PN use as the highest priority for this client after the surgery? Impaired walking. Impaired adjustment. Disturbed body image. Ineffective health maintenance. Disturbed body image. Rationale The psychological impact of the removal of a limb results in a "Disturbed body image" (C), which is the highest priority after surgery that affects the client's ability to cope with walking, adjustment, and health maintenance. The client's perception of alterations in body image influences how the client achieves outcomes related to impaired walking (A), impaired adjustment (B), and ineffective health maintenance (D). The practical nurse (PN) receives a report on a group of clients assigned for the day. Which priority assessment should the PN implement? Check the pulse oximeter for a client with myasthenia gravis. Assess a client with multiple sclerosis for bowel incontinence. Determine the presence of nuchal rigidity in a client with resolving meningitis. Perform Glasgow Coma Scale (GCS) assessment for a client with a concussion. Check the pulse oximeter for a client with myasthenia gravis. Rationale Myasthenia gravis results in weakness of the upper body muscles, including the muscles involved in swallowing and respirations, so assessing the client for adequate oxygenation is essential (A). Bowel and bladder incontinence are anticipated symptoms of multiple sclerosis and are not urgent assessments (B). (C) and (D) are important assessments, but checking the oxygenation level of a patient with the possibility of respiratory compromise is most important. The practical nurse (PN) is reviewing the side effects associated with chlopromazine (Thorazine) rectal suppository for a client with nausea and vomiting. Which information should the PN review with the client? Limit fresh fruit and dietary roughage intake. Report any signs of urinary frequency. Minimize exposure to sunlight during therapy. Eat a balance diet to minimize weight loss. Minimize exposure to sunlight during therapy. Rationale The most common adverse effects of chlorpromazine (Thorazine) are sedation, orthostatic hypotension, and anticholinergic effects, such as dry mouth, blurred