(Q&A) Hesi 90 question Med Surge
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Q.4 A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. While approaching the client, which intervention should the practical nurse (PN) implement first?
A. Explain daily schedule of unit activities.
B. Describe functions of the practical nurse (PN).
C. Offer the client a PRN medication.
D. Review client rights of hospitalization.
Answer: B. Describe functions of the practical nurse (PN). -
Q.12. The home health practical nurse (PN) visits a young male client with AIDS who has Kaposi's sarcoma and peripheral neuropathies. His parents, who provide care for the client, state that their son sleeps most of the time. The PN observes the client is semi-conscious with stable vital signs and cries out in pain when turned or moved. A fentanyl patch is in place and skin lesions are closed and dried. Which intervention should the PN implement?
A. Call for ambulance transportation to the hospital immediately.
B. Remove the fentanyl patch as directed by prescription.
C. Give a complete bed bath to further assess the client.
D. Discuss end-of-life decisions with the client's parents.
Answer: C. Give a complete bed bath to further assess the client. -
The practical nurse (PN) observes a client's eyes and identifies the presence of unilateral eyelid drooping that was not present during the previous assessment. Which follow-up evaluation by the PN is most important?
A. Test skin elasticity.
B. Determine level of consciousness.
C. Observe the color of the sclerae.
D. Measure visual acuity.
Answer: B. Determine level of consciousness. -
Twenty-four hours after receiving a telephone prescription for a client's medication, the practical nurse (PN) observes that the prescription has not been signed by the prescriber, which conflicts with agency policy. Which action should the PN take?
A. Hold the next dose of medication and assess the client.
B. Discontinue the medication immediately.
C. Continue to administer the medication as initially prescribed.
D. Contact the prescriber for a renewal of the prescription.
Answer: D. Contact the prescriber for a renewal of the prescription.