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HESI PN MEDICAL SURGICAL NGN {ALREADY
GRADED A+ } NEWEST VERSION
Nursing & Pharmacology Review Questions
- A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the
- "I will need to empty the bag every 4 to 6 hours."
- "I will use moisturizing soap to clean around the stoma before applying the bag."
- "I will use a skin sealant before I apply the bag."
- "I will cut the wafer opening one-fourth of an inch larger than the stoma."
- A nurse is reinforcing teaching with a client about breast self-examinations. Which
- "It is common for one breast to be larger than the other."
- "It is common for the skin on my breasts to dimple."
- "I will perform breast exams the day my period begins."
- "I will perform breast exams every other month."
- A nurse is preparing to obtain a postprandial blood glucose level from a client who
following statements by the client indicates an understanding of the teaching?
Correct Answer: C. "I will use a skin sealant before I apply the bag." Rationale: A skin sealant can protect the skin from irritation and help the bag stick better.Moisturizing soaps leave residue, and the wafer should fit snugly (not larger).
of the following statements by the client indicates an understanding of the teaching?
Correct Answer: A. "It is common for one breast to be larger than the other." Rationale: Asymmetry is normal. Dimpling is a sign of cancer. Exams should be done a week after the period starts, not the day it begins.
has diabetes mellitus. Which of the following actions should the nurse take?
a) Apply the first drop of blood to the test strip.
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b) Clean the client's finger with hexachlorophene.
c) Prick the central tip of the client's finger.
d) Hold the client's finger in a dependent position.
Correct Answer: D. Hold the client's finger in a dependent position.
Rationale: Gravity helps blood flow. The side of the finger should be pricked, not the tip. The first drop should be wiped away.
- A nurse is caring for a client who has a new prescription for nitroglycerin. The nurse
should monitor for which of the following adverse effects of the medication?• Nocturia • Increased saliva production • Flushing • Fever
Correct Answer: Flushing
Rationale: Nitroglycerin is a vasodilator; flushing is a common side effect caused by the dilation of blood vessels.
- A nurse is obtaining a medication history from a client who is to start taking
nitroglycerin for chest discomfort with activity. Which of the following medications should the nurse instruct the client to avoid taking within 24 hrs of using nitroglycerin?
a) Atorvastatin
b) Metformin
c) Sildenafil
d) Omeprazole
Correct Answer: C. Sildenafil
Rationale: Sildenafil (Viagra) and Nitroglycerin are both vasodilators. Taking them together can cause life-threatening hypotension.
- A nurse is providing directions to an assistive personnel about moving a client up in
- "Place a pillow under the client's head prior to repositioning."
bed.
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- "Keep your feet close together while moving the client"
- "Face in the direction of the client's movement"
- "Move the client's arms to his sides prior to repositioning."
Correct Answer: C. "Face in the direction of the client's movement"
Rationale: Facing the direction of movement maintains proper body mechanics and
ensures safe transfer.
- A nurse is contributing to the plan of care for a client who reports difficulty eating
due to chronic arthritis. Which of the following interventions should the nurse include in the plan?
a) Apply foam handles to the client's eating utensils.
b) Obtain a referral for physical therapy.
c) Have an assistive personnel feed the client.
d) Ask the provider for a prescription for a pureed diet.
Correct Answer: A. Apply foam handles to the client's eating utensils.
Rationale: Foam handles provide a larger, more comfortable grip, reducing strain on joints and promoting independence.
- A nurse enters a client's room and sees smoke coming from the bathroom. Which of
the following actions should the nurse take first?
a) Activate the fire alarm system.
b) Use a fire extinguisher at the source of the smoke.
c) Assist the client to a nearby common area.
d) Close the doors to the room and to the bathroom.
Correct Answer: C. Assist the client to a nearby common area.
Rationale: Follow RACE: Rescue (Assist client), Alarm, Contain, Extinguish. Rescue is first.
- A nurse is caring for a client who has cancer and has a WBC count of 4,000/mm3.
Which of the following actions should the nurse take?
a) Cleanse the client's toothbrush with hydrogen peroxide.
b) Instruct the client to use a disposable razor to shave.
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c) Decrease the client's protein intake.
d) Encourage the client to eat unpasteurized dairy products.
Correct Answer: A. Cleanse the client's toothbrush with hydrogen peroxide.
Rationale: The client has leukopenia (low WBC) and is at risk for infection. Toothbrushes can harbor bacteria. Disposable razors and unpasteurized dairy increase infection/bleeding risk.
- A nurse is caring for a client who is taking lithium and reports persistent nausea
and vomiting for 2 days. Which of the following laboratory values should the nurse report to the provider?
a) Potassium 4.0 mEq/L
b) Lithium 0.9 mEq/L
c) BUN 12 mg/dL
d) Sodium 132 mEq/L
Correct Answer: D. Sodium 132 mEq/L
Rationale: Hyponatremia (low sodium) can lead to lithium accumulation and toxicity.Normal sodium is 136-145 mEq/L.
- A nurse is assisting in the plan of care for a client who is dehydrated and is
receiving IV fluid replacement. Which of the following interventions should the nurse contribute to the plan of care?
a) Offer oral fluids every 4 hr.
b) Check for neck vein distention.
c) Limit oral fluids prior to bedtime.
d) Monitor pulse pressure every 6 hr.
Correct Answer: B. Check for neck vein distention.
Rationale: Neck vein distention is a sign of fluid overload/congestion, a risk during IV fluid replacement.
