HESI PN COMPREHENSIVE EXAM 1 2023 \2024REAL EXAM LATEST UPDATE APRIL 2023 A client with deep partial -thickness and full -thickness burns of the face and chest is receiving wound care using the open method. The plan of care includes the Nsg Dx, "Risk for infection R/T impaired tissue integrity." Based on the expected outcome, "Cli ent remains free of infections," which nursing interventions should the PN implement? A. Wear gown, cap, mask, and gloves during direct client care. B. Restrict visitors in order to prevent wound contamination. C. Use sterile water for debridement in the hydrotherapy tank. D. Apply sterile dressings after debridement of burn wounds . ANSWER>>>A. Wear gown, cap, mask, and gloves during direct client care. No dressing is used for burn wound care using the open method. The burn area is exposed and an aseptic environment is needed to prevent contamination and infection. Protective isolation precautions should be implemented during direct client care and wound care, which should include wearing gown, cap, mask, and gloves. What action should the PN implement t o facilitate speech for a client who has a fenestrated tracheostomy tube? A. Show the client how to use a tracheostomy plug. B. Determine the client's ability to swallow. C. Remove the inner cannula. D. Give oxygen at 6 L/minute via tracheostomy collar. ANSWER>>>B. Determine the client's ability to swallow. A fenestrated tracheostomy has an opening or hole on the posterior aspect of the outer cannula that allows airflow over the vocal cords and speech in a client who is spontaneously breathing. It does not have a cuff, so the client's risk for aspiration should be determined. A male client scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the PN if he will ever be able to speak. Which response is bets for the P N to provide? A. Breathing occurs through a permanent neck opening which prevents normal speech. B. Permanent removal of the voice box requires rehabilitation for esophageal speech. C. Due to removal of the vocal cords, communication requires the use of sign language. D. Once the breathing hole in the neck heals, the ability to speak requires a device. ANSWER>>>B. Permanent removal of the voice box requires rehabilitation for esophageal speech. A total laryngectomy includes removal of the larynx and pre -epiglottis region resulting in a permanent tracheostomy and loss of normal speech abilities. Rehab is required to learn to speak using a prosthesis, esophageal speech, or an electrolarynx. A client is wearing a continuous 24 -hour Holter monitor for eleva tion of heart rhythm disturbances. What info should the PN reinforce with this client? A. Remove the electrodes to shower or bathe B. Keep a diary of activities as long as the monitor is worn. C. Exercise as much as possible while the monitor is in place . D. Call the assigned number if an episode of irregular heartbeats occurs. ANSWER>>>B. Keep a diary of activities as long as the monitor is worn. Nursing care for a client with a Holter monitor includes preparation of the skin, placement of the electrod es and leads, and activities of daily living, so the client should be informed of the importance of keeping an accurate record of activities and symptoms The PN is caring for a client who is receiving a therapeutic dose of warfarin (Coumadin). The client asks the PN to explain the effect of eating green leafy vegetables. What info should the PN provide? A. The high content of vitamin K in green leafy vegetables decreases Coumadin's action. B. Green vegetables are high in fiber and cellulose that decrease the absorption of Coumadin. C. These foods have a natural anticoagulant effect that potentiates the effect of Coumadin. D. Dietary intake of green leafy vegetables alters the bowel bacteria's production of vitamin K .ANSWER>>>A. The high content of vitami n K in green leafy vegetables decreases Coumadin's action. Coumadin works as an anticoagulant by blocking hepatic utilization of vitamin K in the production of prothrombin, which is a component of the blood clotting cascade. Green leafy vegetables are hi gh in vitamin K, which counteracts the anticoagulant effect of Coumadin. The PN is reviewing the effects of NSAIDs (nonsteroidal anti -inflammatory drugs) with a client who has acute gastritis. What info is correct about the action of NSAIDs? A. Causes hi stamine receptor stimulation that increases the release of hydrochloric acid. B. Inhibits the synthesis of prostaglandins that normally protect the stomach lining. C. Activates an inflammatory response which increases the drug's absorption. C. D. Stimula tes parietal cells to release pepsin leading to digestion of ingested foods. ANSWER>>>B. Inhibits the synthesis of prostaglandins that normally protect the stomach lining NSAIDs inhibit the synthesis of prostaglandins which protect the stomach lining. After undergoing exploratory laparotomy and bowel resection, a client with an NG tube to suction complains of nausea and stomach distention. The PN irrigates the tube, but the irrigating fluid does not return. What action should the PN implement? A. Notify the healthcare provider. B. Auscultate for bowel sounds. C. Reposition the tube and check for placement. D. Remove the tube and replace it with a new one. ANSWER>>>C. Reposition the tube and check for placement. Patency and position of a NGT are checked frequently to evaluate for dislodgement or NGT obstruction with mucous, sediment, or blood clots. The placement should be verified and repositioned in the stomach to obtain a return of the normal saline used to irrigate the NGT. A client with advanced ci rrhosis is prescribed lactulose (Cephulac) 30 ml QID. The client complains that the medicine is causing diarrhea. Which therapeutic response of the medication should the PN provide the client? A. Promotes fluid loss. B. Prevents constipation. C. Excretes ammonia to improve cerebral function. D. Reduces the risk for gastrointestinal bleeding. ANSWER>>>C. Excretes ammonia to improve cerebral function. To treat portal -systemic encephalopathy, lactulose causes the movement of serum ammonia, which accumulate s due to hepatic dysfunction in cirrhosis, into the gut and results in diarrhea due to the osmotic movement of water.
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