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Med-Surg Hesi PN_Questions with accurate answers + Rationale

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Med-Surg Hesi PN*++, Questions with accurate answers. Rated A. 2022/2023 During a clinic visit, a client reports to the practical nurse (PN) that they felt a solid mass in their breast during sel... f-examination, but it was not painful. What instruction should the PN reinforce with the client? A. Continue to monitor the mass until the next scheduled annual exam. B. Notify the PCP if the mass becomes soft or painful or starts to drain. C. Schedule an appointment with the PCP for evaluation D. Breast masses are usually insignificant if they feel soft or are easily moveable. - ✔✔c. Schedule an appointment with the health care provider for evaluation. A painless breast mass is an abnormal finding, and the PN should instruct the client to obtain prompt medical evaluation. 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 Submit - ✔✔c. Ask the client to explain his understanding of the term malignancy. 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 diagnosed with osteoarthritis. Which intervention should the practical nurse implement to help relieve joint pain and stiffness? a. Encourage the client to perform weight-bearing exercises. b. Teach the client how to perform range-of-motion exercises. c. Explain the use of ice and massage for pain relief. d. Instruct the client to take an analgesic before walking daily - ✔✔d. Instruct the client to take an analgesic before walking daily. Adequate pain management is important for the success of an exercise program. Keeping the joints active decreases pain, so taking an analgesic and walking daily is likely to help decrease joint pain and stiffness. A client diagnosed with prostate cancer is prescribed radioactive seed implantation (brachytherapy). What is the most important nursing action for the practical nurse (PN) to do? a. Follow radiation exposure precautions b. Encourage regular meals c. Collect all urine in sealed containers d. Avoid touching the client. - ✔✔a. Follow radiation exposure precautions. Clients being treated for prostate cancer with brachytherapy (radioactive seeds implant) should be placed on radiation exposure precautions. The PN needs to follow the institution's protocols put in place regarding the amount of time and distance needed to prevent excessive exposure that would pose a hazard to others. A client diagnosed with emphysema that is oxygen-dependent lives alone at home and manages self-care with no difficulty. Which finding should prompt the home health practical nurse to consult the registered nurse case manager? a. A pulse oximetry reading of 91% on oxygen at 2 L/m b. A weight loss of 5 pounds since the last monthly home visit c. The client reports feeling as tired as at the last visit by the nurse d. Upon entering the home, the PN noticed dirty dishes and clothing scattered around the home. - ✔✔b. A weight loss of 5 pounds since the last monthly home visit A weight loss of 5 pounds in 1 month is a concern. Clients with COPD need additional calorie intake because they are using up a lot from the energy they are using to breath. The practical nurse needs to consult with the registered nurse case manager for a nutrition consult The nurse has reinforced instructions to a client with diabetes mellitus on how to self-monitor for symptoms of diabetic ketoacidosis (DKA). The nurse realizes the instructions have been effective if the client can list which symptoms? (Select all that apply.) a. Fruity breath odor b. Rapid, weak pulse c. Cold, clammy skin d. Extreme thirst e. Urinary frequency f. Protruding eyeballs - ✔✔a. Fruity breath odor b. Rapid, weak pulse d. Extreme thirst e. Urinary frequency Diabetic ketoacidosis is caused by a profound deficiency of insulin. Some common characteristics include a sweet, fruity breath odor, a rapid weak pulse, extreme thirst, urinary frequency, and sunken-appearing eyeballs. A client mentions using garlic daily as an herb to lower cholesterol and triglyceride levels. Which nursing action is a priority? a. Monitor the client for signs of bleeding. b. Instruct the client that garlic tends to cause hypertension. c. This may relieve fever in the same way that acetaminophen does. d. Remind the patient to use tooth brushing and mouthwash to prevent garlic odor. - ✔✔a. Monitor the client for signs of bleeding. Garlic inhibits platelet aggregation in the same way that aspirin works, and the client should be monitored for bleeding. Garlic can lower the blood pressure, not raise it. It does not relieve fever. While the client will likely want to avoid garlic odor, it is not a priority. The practical nurse (PN) is reviewing the health histories of assigned clients. Which factors have a potential for development of throat cancer? (Select all that apply.) a. Tobacco use b. Excessive intake of alcohol c. Intake of hot and spicy foods d. Human papillomavirus (HPV) e. Lack of exercise f. Lack of dietary fiber - ✔✔a. Tobacco use b. Excessive intake of alcohol d. Human papillomavirus (HPV) Rationale: The most common risk factors for throat cancer are tobacco use, alcohol abuse, human papillomavirus (HPV), a diet lacking in fruits and vegetable, and gastroesophageal reflux disease (GERD). Foods seasoned with herbs and spices have shown to have some health benefits in decreasing the risk of developing cancer. A client has undergone craniotomy to remove a brain tumor. The client spent several days in the intensive care unit, and is now on the post-surgical unit. The nurse has urgently contact the surgeon to report signs of increasing intracranial pressure (ICP). Which was the most likely EARLY sign that the client was experiencing increased ICP? a. The client's blood pressure dropped from 128/70 to 124/68, preoperative BP 122/72 b. The client became more confused than he was upon transfer to the post-surgical unit. c. The client had a large amount of sanguineous drainage noted on the gauze dressings. d. The client's pulse rate had increased from 70 to 82 beats/min. - ✔✔b. The client became more confused than he was upon transfer to the post-surgical unit. Rationale: A change in the level of consciousness is most likely the earliest symptom of increased ICP. Vital sign changes can also occur, with a widening pulse pressure and bradycardia. Neither of these are indicated by data in the options. Sanguineous drainage does not indicate increased ICP. The home health practical nurse is visiting with a client who has a history of second-degree heart block and pacemaker placement 6 months ago. Which symptom compliant by the client would be indicative of pacemaker failure? a. Facial flushing b. Nausea c. Pounding headache d. Feelings of dizziness - ✔✔d. Feelings of dizziness Rationale: Feelings of dizziness may occur as the result of a decreased heart rate, leading to decreased cardiac output as a result of pacemaker failure. Which actions demonstrate to the practical nurse that the client understands the correct procedure administration of a metered dose inhaler (MDI)? (Select all that apply.) a. Sit or stand. b. Shake the inhaler. c. Attach the canister of medication to the mouthpiece. d. Breathe in through the mouth, filling the lungs. e. Use a spacer attachment and place the mouthpiece in the mouth. f. Close the lips around the mouthpiece. g. After inhaling the medication, hold the breath 10 seconds. - ✔✔b. Shake the inhaler. c. Attach the canister of medication to the mouthpiece. e. Use a spacer attachment and place the mouthpiece in the mouth. f. Close the lips around the mouthpiece. g. After inhaling the medication, hold the breath 10 seconds. Rationale: The correct sequence of MDI administration includes shaking the inhaler, attaching the canister to the mouthpiece, attaching the spacer, the client should then let their breath out through the mouth to empty the lungs and place the mouthpiece in the mouth, closing the lips and mouth around the mouthpiece, and inhaling medication and holding the breath for 10 seconds. The Centers for Disease Control and Prevention (CDC) has issued guidelines for health care workers in relation to protection from HIV. The practical nurse (PN) who suspects they may be pregnant is assigned a client who is HIV+. What 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. - ✔✔b. Wear gloves when coming in contact with the blood or body fluids of a client. Rationale: The CDC guidelines for standard precautions recommend that health care workers use gloves when coming in contact with blood or body fluids from any client because HIV is infectious before the client becomes aware of symptoms. Pregnancy of a nurse should not inhibit the nurse for taking care of a HIV+ client as long as standard precautions are observed. A practical nurse (PN) reinforced client teaching regarding the transmission of the HIV virus. Which statement by the client demonstrates an understanding of the reinforced teaching? a. "To be absolutely safe, I should wear two latex condoms during intercourse with an infected partner." b. "I may still contract HIV even though I am 62 years old." c. "Urinating immediately after having sexual relations will help reduce the risk of contracting HIV." d. "If I take AZT during my pregnancy, I will not give the virus to my unborn baby." - ✔✔b. "I may still contract HIV even though I am 62 years old." Rationale: More than 10% of all AIDS cases in the United States are among those older than 50 years of age. A client is diagnosed with fluid volume deficit. Which findings would the practical nurse document consistent with fluid volume deficit? (Select all that apply.) a. Tachycardia b. Diaphoresis c. Cool skin d. Heart failure e. Decreased urine output f. Increased thirst - ✔✔a. Tachycardia c. Cool skin e. Decreased urine output f. Increased thirst Rationale: Fluid volume deficit causes tachycardia because the body tries to compensate and pump blood efficiently. Cool skin is consistent with fluid volume deficit. Decreased urine output results from reduced fluid volume perfusing the kidneys. Thirst will be stimulated by the hypothalamus because of decreased fluid volume. During a clinic visit, a client reports to the practical nurse (PN) that they felt a solid mass in their breast during self-examination, but it was not painful. What instruction should the PN reinforce with the client? a. Continue to monitor the mass until the next scheduled annual medical examination. b. Notify the health care provider if the mass becomes soft or painful or starts to drain. c. Schedule an appointment with the health care provider for evaluation. d. Breast masses are usually insignificant if they feel soft or are easily movable. - ✔✔c. Schedule an appointment with the health care provider for evaluation. Rationale: A painless breast mass is an abnormal finding, and the PN should instruct the client to obtain prompt medical evaluation. A hospitalized client is receiving continuous nasogastric tube feedings at 90 mL/hour via a small-bore tube and an enteral infusion pump. Upon entering the client's room, which action should the practical nurse (PN) take first? a. Auscultate the client's breath sounds for a one minute. b. Ensure the client's head of bed is raised at least 30 degrees. c. Check placement of the nasogastric tube. d. Verify the prescribed feeding is hung. - ✔✔b. Ensure the client's head of bed is raised at least 30 degrees. Rationale: The 30 degrees is the minimum degree elevation of the head of the bed for a client receiving continuous tube feedings to prevent aspiration. The nurse is assisting with data collection for an older adult who is visiting the health care provider today. Which signs and symptoms should the nurse report to the health care provider as possible signs associated with colon cancer? (Select all that apply.) a. Rectal bleeding b. Weight gain c. Abdominal distention d. Sensation that bowels are not evacuating completely e. A diet high in vegetables such as cauliflower, cabbage, and kale - ✔✔a. Rectal bleeding c. Abdominal distention d. Sensation that bowels are not evacuating completely Rationale: Some signs and symptoms associated with colon cancer include rectal bleeding, abdominal distention, and a sensation the bowels are not evacuating completely. A diet high in cauliflower, cabbage, and kale is associated with a reduced, not increased, risk of colon cancer. A client who has colon cancer is more likely to have a weight loss rather than weight gain. A client with cirrhosis is being discharged home, with family members to provide the majority of the client's care. Which instructions are important to reinforce with the family regarding this client's care? (Select all that apply.) a. Maintain a low-fiber diet. b. Use a safety razor to shave the client. c. Avoid soap when bathing the client. d. Use a soft toothbrush and gentle oral care. e. Apply moisturizing lotion and turn the client frequently. - ✔✔c. Avoid soap when bathing the client. d. Use a soft toothbrush and gentle oral care. e. Apply moisturizing lotion and turn the client frequently. Rationale: A client with cirrhosis often has dry itchy skin. Soap can dry and irritate the skin further. To prevent skin breakdown, the skin should be kept moist and the client turned frequently. With cirrhosis, the liver is not able to produce some clotting factors, so bleeding prevention is a priority. The family should be instructed to use electric razors, not a safety razor, and to use a soft toothbrush when providing gentle oral care. 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." - ✔✔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. - ✔✔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. - ✔✔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. - ✔✔b. Set up a suction and Yankauer at client's bedside. [Show More]

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