BSN 266 HESI V2
Neutrophil count- The patient is experiencing infection, so a nurse should review
the neutrophil count before contacting the HCP. - CORRECT ANSWER-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 ANSWER-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 ANSWER-Best position for respiratory distress?
High risk for injury - CORRECT ANSWER-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 ANSWER-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 ANSWER-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 ANSWER-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 ANSWER-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 ANSWER-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
ANSWER-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 ANSWER-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 ANSWER-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 ANSWER-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 ANSWER-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
Neutrophil count- The patient is experiencing infection, so a nurse should review
the neutrophil count before contacting the HCP. - CORRECT ANSWER-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 ANSWER-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 ANSWER-Best position for respiratory distress?
High risk for injury - CORRECT ANSWER-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 ANSWER-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 ANSWER-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 ANSWER-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 ANSWER-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 ANSWER-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
ANSWER-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 ANSWER-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 ANSWER-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 ANSWER-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 ANSWER-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
