BSN 266 HESI REVIEW EXAM 125
QUESTIONS WITH ANSWERS
Question 1 of 55
The nurse is evaluating a client's understanding about the DASH
(Dietary Approaches to Stop Hypertension) eating plan. Which
behavior indicates that the client is adhering to the eating plan?
- A Uses only lactose-free dairy products.
- B Carefully cleans and peels all fresh fruit and vegetables.
- C No longer incudes grains in daily diet.
- D Enjoys fat-free yogurt as an occasional snack food. - Correct
answer - D Enjoys fat-free yogurt as an occasional snack food.
Question 2 of 55
A client who has a history of hypothyroidism was initially admitted
with lethargy and confusion. Which additional finding warrants the
most immediate action by the nurse? [Hematocrit (Reference
Range: Male: 42% to 52% (0.42 to 0.52 volume fraction)]
- A Further decline in level of consciousness.
- B Hematocrit of 30% (0.30 volume fraction)
- C Cold and dry skin.
- D Facial puffiness and periorbital edema - Correct answer - A
Further decline in level of consciousness.
Question 3 of 55
The nurse is caring for a client with a burn that is severely
edematous with a wound bed that is brown and yellow in
appearance. The client expresses feeling no pain. Which
classification of burn depth should the nurse document?
- A Deep full-thickness.
- B Full thickness.
,- C Deep partial-thickness.
- D Superficial partial-thickness. - Correct answer - B Full
thickness.
Question 4 of 55
An older client who is agitated, dyspneic, orthopneic, and using
accessory muscles to breathe is admitted for further treatment.
Initial assessment includes a heart rate 128 beats/minute and
irregular, respirations 38 breaths/minute, blood pressure 168/100
mm Hg, wheezes and crackles in all lung fields. An hour after the
administration of furosemide 60 mg intravenous (IV), which
assessment(s) should the nurse obtain to determine the client's
response to treatment? (Select all that apply.)
- A Urinary output.
- B Oxygen saturation.
- C Pain scale.
- D Lung sounds.
- E Skin elasticity. - Correct answer - A Urinary output.
- B Oxygen saturation.
- D Lung sounds.
Orthopneic position, sometimes called tripod position, is a sitting
position where an individual leans slightly forward with their arms
propped up on an overbed table or their knees.
Orthopnea is the sensation of breathlessness in the recumbent
(lying down) position, relieved by sitting or standing.
Question 5 of 55
A client is diagnosed with chronic kidney disease and needs to
begin dialysis. Which condition entered on the client's medical
record should the nurse recognize as a contraindication for
peritoneal dialysis?
,- A Nephrotic syndrome history.
- B Crohn's disease with colectomy.
- C Type 2 diabetes mellitus.
- D Latent hepatitis C. - Correct answer - B Crohn's disease with
colectomy.
Question # 5
Rationale - B Crohn's disease with colectomy.
The nurse should recognize that clients with extensive intra-
abdominal surgical history are not candidates for peritoneal
dialysis, as these clients may have decreased peritoneal
membrane surface areas and scar tissue formation, which would
make it insufficient for adequate dialysis exchange.
Question 6 of 55
The nurse assesses a client with cirrhosis and finds 4+ pitting
edema of the feet and legs, and massive ascites. Which
mechanism contributes to edema and ascites in clients with
cirrhosis?
- A Decreased portacaval pressure with greater collateral
circulation.
- B Hyperaldosteronism causing an increased sodium
reabsorption in renal tubules.
- C Decreased renin-angiotensin response related to an increase
in renal blood flow.
- D Hypoalbuminemia that results in a decreased colloidal oncotic
pressure. - Correct answer - D Hypoalbuminemia that results in a
decreased colloidal oncotic pressure.
The three main things that the liver produces are albumin, bile
(digestive enzymes), and prothrombin (clotting factors).
Albumin plays many important roles including maintenance of
appropriate osmotic pressure, binding and transport of various
substances like hormones, drugs etc. In blood, and neutralisation
of free radicals. It prevents fluid from leaking out of blood vessels
, into your tissues. Albumin is also responsible for transporting
vitamins, enzymes and hormones throughout your body. Albumin
makes up 50% of the proteins found in your plasma.
Question 7 of 55
While assessing a client with degenerative joint disease, the
nurse observes Heberden's nodes, large prominences on the
client's fingers that are reddened. The client reports that the
nodes are painful. Which action should the nurse take?
- A Review the client's dietary intake of high-protein foods.
- B Discuss approaches to chronic pain control with the client.
- C Notify the healthcare provider of the finding immediately.
- D Assess the client's radial pulses and capillary refill time. -
Correct answer - B Discuss approaches to chronic pain control
with the client.
Question 8 of 55
Which information should the nurse include in the teaching plan of
a client diagnosed with gastroesophageal reflux disease (GERD)?
- A Adjust food intake to three full meals per day and no snacks.
- B Minimize symptoms by wearing loose, comfortable clothing.
- C Avoid participation in any aerobic exercise programs.
- D Sleep without pillows at night to maintain neck alignment. -
Correct answer - B Minimize symptoms by wearing loose,
comfortable clothing.
Question 9 of 55
The nurse assesses a client with petechiae and ecchymosis
scattered across the arms and legs. Which laboratory result
should the nurse review?
- A Red blood cell count.
- B Hemoglobin levels.
QUESTIONS WITH ANSWERS
Question 1 of 55
The nurse is evaluating a client's understanding about the DASH
(Dietary Approaches to Stop Hypertension) eating plan. Which
behavior indicates that the client is adhering to the eating plan?
- A Uses only lactose-free dairy products.
- B Carefully cleans and peels all fresh fruit and vegetables.
- C No longer incudes grains in daily diet.
- D Enjoys fat-free yogurt as an occasional snack food. - Correct
answer - D Enjoys fat-free yogurt as an occasional snack food.
Question 2 of 55
A client who has a history of hypothyroidism was initially admitted
with lethargy and confusion. Which additional finding warrants the
most immediate action by the nurse? [Hematocrit (Reference
Range: Male: 42% to 52% (0.42 to 0.52 volume fraction)]
- A Further decline in level of consciousness.
- B Hematocrit of 30% (0.30 volume fraction)
- C Cold and dry skin.
- D Facial puffiness and periorbital edema - Correct answer - A
Further decline in level of consciousness.
Question 3 of 55
The nurse is caring for a client with a burn that is severely
edematous with a wound bed that is brown and yellow in
appearance. The client expresses feeling no pain. Which
classification of burn depth should the nurse document?
- A Deep full-thickness.
- B Full thickness.
,- C Deep partial-thickness.
- D Superficial partial-thickness. - Correct answer - B Full
thickness.
Question 4 of 55
An older client who is agitated, dyspneic, orthopneic, and using
accessory muscles to breathe is admitted for further treatment.
Initial assessment includes a heart rate 128 beats/minute and
irregular, respirations 38 breaths/minute, blood pressure 168/100
mm Hg, wheezes and crackles in all lung fields. An hour after the
administration of furosemide 60 mg intravenous (IV), which
assessment(s) should the nurse obtain to determine the client's
response to treatment? (Select all that apply.)
- A Urinary output.
- B Oxygen saturation.
- C Pain scale.
- D Lung sounds.
- E Skin elasticity. - Correct answer - A Urinary output.
- B Oxygen saturation.
- D Lung sounds.
Orthopneic position, sometimes called tripod position, is a sitting
position where an individual leans slightly forward with their arms
propped up on an overbed table or their knees.
Orthopnea is the sensation of breathlessness in the recumbent
(lying down) position, relieved by sitting or standing.
Question 5 of 55
A client is diagnosed with chronic kidney disease and needs to
begin dialysis. Which condition entered on the client's medical
record should the nurse recognize as a contraindication for
peritoneal dialysis?
,- A Nephrotic syndrome history.
- B Crohn's disease with colectomy.
- C Type 2 diabetes mellitus.
- D Latent hepatitis C. - Correct answer - B Crohn's disease with
colectomy.
Question # 5
Rationale - B Crohn's disease with colectomy.
The nurse should recognize that clients with extensive intra-
abdominal surgical history are not candidates for peritoneal
dialysis, as these clients may have decreased peritoneal
membrane surface areas and scar tissue formation, which would
make it insufficient for adequate dialysis exchange.
Question 6 of 55
The nurse assesses a client with cirrhosis and finds 4+ pitting
edema of the feet and legs, and massive ascites. Which
mechanism contributes to edema and ascites in clients with
cirrhosis?
- A Decreased portacaval pressure with greater collateral
circulation.
- B Hyperaldosteronism causing an increased sodium
reabsorption in renal tubules.
- C Decreased renin-angiotensin response related to an increase
in renal blood flow.
- D Hypoalbuminemia that results in a decreased colloidal oncotic
pressure. - Correct answer - D Hypoalbuminemia that results in a
decreased colloidal oncotic pressure.
The three main things that the liver produces are albumin, bile
(digestive enzymes), and prothrombin (clotting factors).
Albumin plays many important roles including maintenance of
appropriate osmotic pressure, binding and transport of various
substances like hormones, drugs etc. In blood, and neutralisation
of free radicals. It prevents fluid from leaking out of blood vessels
, into your tissues. Albumin is also responsible for transporting
vitamins, enzymes and hormones throughout your body. Albumin
makes up 50% of the proteins found in your plasma.
Question 7 of 55
While assessing a client with degenerative joint disease, the
nurse observes Heberden's nodes, large prominences on the
client's fingers that are reddened. The client reports that the
nodes are painful. Which action should the nurse take?
- A Review the client's dietary intake of high-protein foods.
- B Discuss approaches to chronic pain control with the client.
- C Notify the healthcare provider of the finding immediately.
- D Assess the client's radial pulses and capillary refill time. -
Correct answer - B Discuss approaches to chronic pain control
with the client.
Question 8 of 55
Which information should the nurse include in the teaching plan of
a client diagnosed with gastroesophageal reflux disease (GERD)?
- A Adjust food intake to three full meals per day and no snacks.
- B Minimize symptoms by wearing loose, comfortable clothing.
- C Avoid participation in any aerobic exercise programs.
- D Sleep without pillows at night to maintain neck alignment. -
Correct answer - B Minimize symptoms by wearing loose,
comfortable clothing.
Question 9 of 55
The nurse assesses a client with petechiae and ecchymosis
scattered across the arms and legs. Which laboratory result
should the nurse review?
- A Red blood cell count.
- B Hemoglobin levels.
