1 | P a g e HES I PN MEDICAL SURGICAL NGN NEWEST 2024 VERSION 1 COMPLETE 55 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS ) |ALREADY GRADED A+ A client residing in a memory care nursing facility with a diagnosis of diabetes approaches the nurse crying, saying "I just do not feel good." What action should the practical nurse take first? A) Clarify the meaning of what is feeling good. B) Reassure the client that they are safe and okay. C) Give the client a glass of orange juice. D) Obtain a fingerstick blood glucose test. - ANSWER - D) Obtain a fingerstick blood glucose test. Rationale: An early sign of hypoglycemia increases confusion and/or irritability, sometimes described as "feeling bad." Based on the history of diabetes, the PN should first obtain objective data of a 2 | P a g e fingerstick blood glucose level to provide information to guide further nursing actions. 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. - ANSWER - 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. 3 | P a g e 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. In order to provide culturally competent care to a group of clients, what action must the practical nurse do first? A) Treat each client the same, regardless of race or religion. B) Ensure that all Native American clients have access to a shaman. C) Understand one's own world views in addition to the client's. D) Include the family in the plan of care for older adult clients. - ANSWER - C) Understand one's own world views in addition to the client's. Rationale: 4 | P a g e *The nurse should understand their own values and views to prevent those beliefs being imparted to others, in addition to understanding the client's cultural views when providing cultural competent care. *Treating every client the same or assuming that all clients share the same values does not exhibit cultural competence or sensitivity. 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:
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