2024 HESI PN MED SURGE /MED SURGE PN
HESI EXIT EXAM TEST BANK NEWEST 2024-2025
ACTUAL EXAM 70 QUESTIONS AND CORRECT
DETAILED ANSWERS
Terms in this set (75)
A 70-year-old client status a. Braden Scale
post hip replacement is
transferred to a The Braden Scale is made up of six subscales: sensory
rehabilitation facility. perception, moisture, activity, mobility, nutrition, and
Which scale should the friction and shear. A hospitalized adult with a score 16
practical nurse (PN) or below or an older adult with a score of 18 or below
identify as the best tool to is at an increased risk for skin breakdown.
predict the client's risk for
developing skin
breakdown?
a. Braden Scale
b. Morse Scale
c. Aldrete Scale
d. Wong-Baker Face Scale
,An adult client is admitted a. Remove all the client's clothing, shoes, and jewelry.
to the emergency Rationale:
department with partial- Interventions for moderate to severe burns of deep
thickness and full- partial-thickness and full-thickness, once an airway
thickness burns over 40% and circulation is established, then the next thing is to
of the body surface area remove all the victims clothing, shoes, and jewelry
resulting from a car before the edema sets in and they become
collision fire. After the constricting, also it is possible to cause more severe
health care provider and burns by leaving clothing on.
nurse have intubated the
client, which intervention
should the practical nurse
(PN) do first?
a. Remove all the client's
clothing, shoes, and
jewelry.
b. Insert indwelling urinary
foley.
c. Initiate an intravenous
catheter line.
d. Obtain blood work and
urine sample
,The Centers for Disease b. Wear gloves when coming in contact with the
Control and Prevention blood or body fluids of a client.
(CDC) has issued Rationale:
guidelines for health care The CDC guidelines for standard precautions
workers in relation to recommend that health care workers use gloves when
protection from HIV. The coming in contact with blood or body fluids from any
practical nurse (PN) who client because HIV is infectious before the client
suspects they may be becomes aware of symptoms. Pregnancy of a nurse
pregnant is assigned a should not inhibit the nurse for taking care of a HIV+
client who is HIV+. What client as long as standard precautions are observed.
action should the PN
implement?
a. Make the suspected
pregnancy known and
request a different client
assignment.
b. Wear gloves when
coming in contact with the
blood or body fluids of a
client.
c. Limit contact and
interaction with the client
and have another nurse
bathe the client.
d. Put on all the PPE to
include gown and mask
when entering the client's
room.
, A client comes to the a. Ask the client if they have had unprotected sex.
clinic and reports the Rationale:
presence of a painful These are typical signs and symptoms of herpes
lesion in the genital area; simplex virus 2 (HSV2), a sexually transmitted disease
they described it as a (STD), so the PN should ask the client if they had
blister 2 days earlier that is unprotected sex and if the client has exposed others
now crusty. Which to the disease.
intervention should the
practical nurse (PN)
implement first?
a. Ask the client if they
have had unprotected sex.
b. Prepare the client for a
culture and sensitivity test
of the lesion.
c. Inform the client this
occurrence will have to be
reported to the public
health department.
d. Prepare to administer
penicillin intramuscularly
into the dorsogluteal area.
A client demonstrated b. Record the finding on the assessment notes.
pupillary constriction
when a pen light was Pupillary constriction to light is a normal finding and
shined in their eyes. Which should be documented in the assessment notes.
nursing action should the
practical nurse perform?
a. Report the finding to
the health care provider.
b. Record the finding on
the assessment notes.
c. Assess blood pressure
to rule out hypertension.
d. Record that the client
has poor vision.
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