HESI BSN 225 Questions and Answers New (2024/2025) Solved 100% Correct

A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? a. Hydrogel. b. Exudate absorber. c. Wet to moist dressing. d. Transparent adhesive film. - c. Wet to moist dressing. Rationale: To provide moisture and loosen the necrotic tissue, the eschar should be covered first with wet to moist dressings (C), which are discontinued and then a hydrogel alginate can be placed in the prepared wound bed to prevent further damage of granulating any surrounding tissue. A client is demonstrating a positive Chvostek's sign. What action should the nurse take? a. Observe the client's pupil size and response to light. b. Ask the client about numbness or tingling in the hands. c. Assess the client's serum potassium level. d. Restrict dietary intake of calcium-rich foods. - b. Ask the client about numbness or tingling in the hands. Rationale: A positive Chvostek's sign is an indication of hypocalcemia, so the client should be assessed for the subjective symptoms of hypocalcemia, such as numbness or tingling of the hands (B) or feet. A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time? a. Transferrin b. Prealbumin c. Serum albumin d. Urine urea nitrogen - c. Serum albumin Rationale: Serum albumin has a long half-life and is the best long-term indicator of the body's entry into a catabolic state following protein depletion from malnutrition or stress of chronic illness (C).A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement? a. Document the client's request in the medical record. b. Ask the client if this decision has been discussed with his healthcare provider. c. Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. d. Advise the client to designate a person to make healthcare decisions when the client is unable to do so. - b. Ask the client if this decision has been discussed with his healthcare provider. Rationale: Advance directives are written statements of a person's wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider (B). A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration? a. Suggest that other cultural practices be substituted by the family members. b. Examine one's own culturally based values, beliefs, attitudes, and practices. c. Explain to the family that multiple visitors are exhausting to the client. d. Allow the situation to continue until a family member's action may harm the client. - b. Examine one's own culturally based values, beliefs, attitudes, and practices. Rationale: Acknowledging a client's beliefs and customs related to sickness and health care are valuable components in the plan of care that prevents conflict between the goals of nursing and the client's cultural practices. Cultural sensitivity begins with examining one's own cultural values to compare, recognize, and acknowledge cultural bias. An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first? a. Apply flannel pajamas to provide warmth. b. Administer a PRN dose of ibuprofen. c. Perform range of motion exercises in a warm tub.d. Drape the sheets over the footboard of the bed. - d. Drape the sheets over the footboard of the bed. Rationale: The nurse should first provide an immediate comfort measure to address the client's complaint about the linens and drape the linens over the footboard of the bed (D) instead of tucking them under the mattress, which can add pressure perceived by the client as the source of her pain. As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the treatment room, he cries continuously. What intervention should the nurse implement? a. Take the child back to his room. b. Recruit others to restrain the child. c. Ask the mother to be present to soothe the child. d. Show the child how to manipulate the equipment. - c. Ask the mother to be present to soothe the child.