BSN 266||BSN 266 FALL 2024 - HESI
FUNDAMENTALS EXAM QUESTION
WITH VERIFIED ANSWERS LATEST
UPDATE A+ GRADED
The nurse is caring for a client on hospice who was started on a 25
mcg/hr Fentanyl patch yesterday at 0800. The nurse completes an
assessment today at 2000 and reviews the following assessment data:
Yesterday 0800
BP 98/60
HR 110
RR 24
O2SAT 94%
PAIN 6/10
INTERVENTIONS
Fentanyl patch 25mcg/hr applied
Yesterday 2000
100/55
100
20
95%
,2/10
Reposition, visiting with family
Today 0800
92/40
104
24
92%
4/10
Ice pack applied
Today 2000
100/65
110
24
94%
7/10
Which intervention is best for the nurse to provide?
a. explain that the fentanyl patch takes time to become effective, and
they should experience relief soon.
b. offer to administer 5mg of morphine orally as prescribed for
breakthrough pain
,c. reposition the client and offer to give a back rub.
d. call the provider to provide an update on the client's condition
(CORRECT ANSWER) b. offer to administer 5mg of morphine orally as
prescribed for breakthrough pain
Rationale:
A fentanyl patch is effective for 72 hours before it needs to be replaced.
This breakthrough pain is evidenced by a decline in pain rating followed
by an elevated pain rating during the time that the fentanyl patch should
still be effective.
When changing a client's post-op wound dressing, the nurse notes
yellow purulent drainage. What action should the nurse take?
a. Notify the healthcare provider.
b. Cover the wound with clean gauze and secure.
c. Irrigate the wound with sterile water and leave open to air.
d. Irrigate the wound with normal saline and pack with gauze.
(CORRECT ANSWER) a. Notify the healthcare provider.
Rationale:
Yellow purulent drainage is an indication of an infection. This finding
should be reported to the healthcare provider for assessment and
intervention.
, Choices B, C, and D are all incorrect because the priority action is to
notify the healthcare provider of the status of the wound. Further wound
management (cultures, irrigation, or no irrigation, packing or no
packing, antibiotics, etc.) should be determined after assessment of the
site by the surgical team. Irrigating the wound before assessment has
been completed may interfere with medical decision-making and hsould
be avoided.
The healthcare provider prescribes enteral feeds of Jevity 1.2 cal at
66mL/hour over 20 hours, and free water flushes of 225 mL q 4 hours x
24 hr via nasogastric tube. How many mL of total fluid will the client
receive in 24 hours? (Enter numerical value only. If rounding is required,
round to one decimal place.) (CORRECT ANSWER) 2670 mL
Rationale:
66mL/hour x 20 hours = 1320 mL
Then it is necessary to calculate the amount of fluid from the free water
flushes.
Free water flushes every 4 hours for 24 hours = 6 flushes
225 mL x 65 flushes = 1350 mL
Finally, add the two sums together:
1320 mL + 1350 mL = 2670 mL in 24 hours
FUNDAMENTALS EXAM QUESTION
WITH VERIFIED ANSWERS LATEST
UPDATE A+ GRADED
The nurse is caring for a client on hospice who was started on a 25
mcg/hr Fentanyl patch yesterday at 0800. The nurse completes an
assessment today at 2000 and reviews the following assessment data:
Yesterday 0800
BP 98/60
HR 110
RR 24
O2SAT 94%
PAIN 6/10
INTERVENTIONS
Fentanyl patch 25mcg/hr applied
Yesterday 2000
100/55
100
20
95%
,2/10
Reposition, visiting with family
Today 0800
92/40
104
24
92%
4/10
Ice pack applied
Today 2000
100/65
110
24
94%
7/10
Which intervention is best for the nurse to provide?
a. explain that the fentanyl patch takes time to become effective, and
they should experience relief soon.
b. offer to administer 5mg of morphine orally as prescribed for
breakthrough pain
,c. reposition the client and offer to give a back rub.
d. call the provider to provide an update on the client's condition
(CORRECT ANSWER) b. offer to administer 5mg of morphine orally as
prescribed for breakthrough pain
Rationale:
A fentanyl patch is effective for 72 hours before it needs to be replaced.
This breakthrough pain is evidenced by a decline in pain rating followed
by an elevated pain rating during the time that the fentanyl patch should
still be effective.
When changing a client's post-op wound dressing, the nurse notes
yellow purulent drainage. What action should the nurse take?
a. Notify the healthcare provider.
b. Cover the wound with clean gauze and secure.
c. Irrigate the wound with sterile water and leave open to air.
d. Irrigate the wound with normal saline and pack with gauze.
(CORRECT ANSWER) a. Notify the healthcare provider.
Rationale:
Yellow purulent drainage is an indication of an infection. This finding
should be reported to the healthcare provider for assessment and
intervention.
, Choices B, C, and D are all incorrect because the priority action is to
notify the healthcare provider of the status of the wound. Further wound
management (cultures, irrigation, or no irrigation, packing or no
packing, antibiotics, etc.) should be determined after assessment of the
site by the surgical team. Irrigating the wound before assessment has
been completed may interfere with medical decision-making and hsould
be avoided.
The healthcare provider prescribes enteral feeds of Jevity 1.2 cal at
66mL/hour over 20 hours, and free water flushes of 225 mL q 4 hours x
24 hr via nasogastric tube. How many mL of total fluid will the client
receive in 24 hours? (Enter numerical value only. If rounding is required,
round to one decimal place.) (CORRECT ANSWER) 2670 mL
Rationale:
66mL/hour x 20 hours = 1320 mL
Then it is necessary to calculate the amount of fluid from the free water
flushes.
Free water flushes every 4 hours for 24 hours = 6 flushes
225 mL x 65 flushes = 1350 mL
Finally, add the two sums together:
1320 mL + 1350 mL = 2670 mL in 24 hours
