2023 HESI PN MED SURGE /MED SURGE PN HESI EXIT
EXAM TEST BANK NEWEST 2023-2024 ACTUAL EXAM
500 QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES (ALL POSSIBLE QUESTIONS)
|AGRADE
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?
a. “Your health care provider has prescribed ambulation on the first postoperative
day.”
b. “You must ambulate to avoid serious complications that are much more painful.”
c. “I know how you feel—you’re angry about having to do this, but it is required.”
d. “I’ll be back in 30 minutes to help you get out of bed and walk around the
room.” – ANSWER- 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 diagnosed with duodenal ulcers is admitted to the hospital. The client was
administered ranitidine hydrochloride 150 mg PO at bedtime. Which finding would
indicate a therapeutic response of the medication?
a. Gastric secretions pH level below 3.
b. Hemoccult testing is positive on two different occasions.
c. No difficulty falling asleep reported.
d. No complaints of abdominal pain or heartburn verbalized. – ANSWER- d. No
complaints of abdominal pain or heartburn verbalized.
Rationale:
Lack of abdominal pain within 4 hours after meals indicates decreased duodenal
irritation, a positive outcome in the treatment of duodenal ulcer.
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. – ANSWER- 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. – ANSWER- 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. – ANSWER- 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 – ANSWER- 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. – ANSWER- 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.” –
ANSWER- 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. –
ANSWER- 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.