BSN 266 HESI V2 || 100% NO ERROR.
Neutrophil count- The patient is experiencing infection, so a nurse should review the neutrophil
count before contacting the HCP. correct answers While caring for a client with full thickness
burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before
reporting the finding, what is the best lab value to evaluate?
Demonstrate the use of visual scanning during meals to the client and family. correct answers An
older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual
perception and she only eats half of the food on her meal tray. Her family expresses concern
about her nutritional status. How should the nurse respond to the family's concern?
High Fowler's Position- High fowlers helps to decrease venous return, which decreases fluid
volume in the heart that results in decreased cardiac workload. correct answers Best position for
respiratory distress?
High risk for injury correct answers A patient with peripheral artery disease has marked
peripheral neuropath. An appropriate nursing diagnosis for the patient is
Check feet every day for cuts or injuries. correct answers Type 2 diabetes patient discharge
teaching patient and family
Institute Contact precautions for staff and visitors
Send wound drainage for culture and sensitivity
Monitor the clients WBC count correct answers Plan of care for patient with skin lesions of
lower extremities with possible MRSA. SATA
Hematemesis- - Contact HCP if blood is visible in body fluids such as hematemesis. correct
answers A patient with acute anterior wall MI 1 week ago is given low-dose aspirin. The
medication is related to which problem and HCP should be notified?
Elevated blood urea nitrogen (BUN) correct answers For a patient with SLE exacerbation what is
the most important to report which assessment finding?
, Rate of pain on a scale from 0-10. correct answers Before selecting a medication to administer,
which action should the nurse implement in the post-op patient who reports incisional pain and
has 2 PRN analgesia available in MAR?
Keep patient NPO- Patient should be kept NPO until procedure is successfully completed. The
patient should not take anything by mouth. correct answers Patient had bariatric surgery 2
months ago who developed post-op strictures who is experiencing nausea and vomiting and
anorexia who is admitted for fluid resuscitation. Which intervention should the nurse implement?
Vital sign changes and ECGs- Priority parameters are vital sign changes related to hypovolemia
and ECG changes due to serum electrolyte loss, which can be life threatening. correct answers
Acute Kidney Injury due to aminoglycoside antibiotic moved from oliguric phase to the diuretic
phase. Which parameters are most important to monitor?
Nuts, chocolate, dark greens, and spinach. correct answers Patient has a calcium oxalate renal
stone. Which food are you going to teach the patient to avoid?
Pancreatitis- complications include pancreatitis that may manifest with upper left quadrant or
mid-epigastric pain which radiates to the back and accompanied by nausea, vomiting, and fever.
correct answers A patient had a cholecystectomy 2 days ago, the patient is febrile, abdominal
pain radiating to the back and has had 3 episodes of vomiting in the last 8 hours. The patient is
exhibiting symptoms for which condition?
Uncompensated Metabolic Alkalosis correct answers Patient has a bowel obstruction and ABGs
read ph- 7.50 PaCO2-42 and HCO3-33. How would you define this acid base balance?
Prescription strength Corticosteroids- decrease inflammation and help manage psoriasis plaques.
Psoriasis is a skin cell proliferation of the surface of the skin causing thick silvery scales or itchy
red patches. correct answers Psoriasis with silvery, scaly areas on elbows and palms that burn
and bleed. Which prescription should the nurse teach the client to use for skin condition?
Neutrophil count- The patient is experiencing infection, so a nurse should review the neutrophil
count before contacting the HCP. correct answers While caring for a client with full thickness
burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before
reporting the finding, what is the best lab value to evaluate?
Demonstrate the use of visual scanning during meals to the client and family. correct answers An
older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual
perception and she only eats half of the food on her meal tray. Her family expresses concern
about her nutritional status. How should the nurse respond to the family's concern?
High Fowler's Position- High fowlers helps to decrease venous return, which decreases fluid
volume in the heart that results in decreased cardiac workload. correct answers Best position for
respiratory distress?
High risk for injury correct answers A patient with peripheral artery disease has marked
peripheral neuropath. An appropriate nursing diagnosis for the patient is
Check feet every day for cuts or injuries. correct answers Type 2 diabetes patient discharge
teaching patient and family
Institute Contact precautions for staff and visitors
Send wound drainage for culture and sensitivity
Monitor the clients WBC count correct answers Plan of care for patient with skin lesions of
lower extremities with possible MRSA. SATA
Hematemesis- - Contact HCP if blood is visible in body fluids such as hematemesis. correct
answers A patient with acute anterior wall MI 1 week ago is given low-dose aspirin. The
medication is related to which problem and HCP should be notified?
Elevated blood urea nitrogen (BUN) correct answers For a patient with SLE exacerbation what is
the most important to report which assessment finding?
, Rate of pain on a scale from 0-10. correct answers Before selecting a medication to administer,
which action should the nurse implement in the post-op patient who reports incisional pain and
has 2 PRN analgesia available in MAR?
Keep patient NPO- Patient should be kept NPO until procedure is successfully completed. The
patient should not take anything by mouth. correct answers Patient had bariatric surgery 2
months ago who developed post-op strictures who is experiencing nausea and vomiting and
anorexia who is admitted for fluid resuscitation. Which intervention should the nurse implement?
Vital sign changes and ECGs- Priority parameters are vital sign changes related to hypovolemia
and ECG changes due to serum electrolyte loss, which can be life threatening. correct answers
Acute Kidney Injury due to aminoglycoside antibiotic moved from oliguric phase to the diuretic
phase. Which parameters are most important to monitor?
Nuts, chocolate, dark greens, and spinach. correct answers Patient has a calcium oxalate renal
stone. Which food are you going to teach the patient to avoid?
Pancreatitis- complications include pancreatitis that may manifest with upper left quadrant or
mid-epigastric pain which radiates to the back and accompanied by nausea, vomiting, and fever.
correct answers A patient had a cholecystectomy 2 days ago, the patient is febrile, abdominal
pain radiating to the back and has had 3 episodes of vomiting in the last 8 hours. The patient is
exhibiting symptoms for which condition?
Uncompensated Metabolic Alkalosis correct answers Patient has a bowel obstruction and ABGs
read ph- 7.50 PaCO2-42 and HCO3-33. How would you define this acid base balance?
Prescription strength Corticosteroids- decrease inflammation and help manage psoriasis plaques.
Psoriasis is a skin cell proliferation of the surface of the skin causing thick silvery scales or itchy
red patches. correct answers Psoriasis with silvery, scaly areas on elbows and palms that burn
and bleed. Which prescription should the nurse teach the client to use for skin condition?
