HESI Med Surg BSN

HESI Med Surg BSN 266 2023 2024
Client64is64recovering64from64a64transurethral64prostatectomy.64Which64activity64should64
be64limited64until64after64the64first64postoperative64visit64with64the64healthcare64provider?
64-64Drink643L


A64client64with64stage64IV64bone64cancer64is64admitted64to64the64hospital64for64a641-
1064scale.64Which64intervention64should64the64nurse64implement?64-
64Administer64opioid64and64non-opioid64medications64simultaneously


A64client64experiences64an64AOB64incompatibility64reaction64after64multiple64blood64transf
usions.64Which64finding64should64the64nurse64report64immediately64to64the64health64care
64provider?


a. low64back64pain64and64hypotension

b. rhinitis64and64nasal64stuffiness

c. delayed64painful64rash64with64urticarial

d. arthritic64joint64changes64and64chronic64pain64-
64a.64low64back64pain64and64hypotension


ANSWER:64(A)64LOW64BACK64PAIN64AND64HYPOTENSTION

When64conducting64discharge64teaching64for64a64client
diagnosed64with64diverticulosis,64which64diet64instruction64should64the64nurse64include?

a. Have64small64frequent64meals64and64sit64up64for64at64least64two64hours64after64meals.

b. Eat64a64bland64diet64and64avoid64spicy64foods.

c. Eat64a64high64fiber64diet64and64increase64fluid64intake.

d. Eat64a64soft64diet64with64increased64intake64of64milk64and64milk64products64-
64c.64Eat64a64high64fiber64diet64and64increase64fluid64intake.


ANSWER64(C)64EAT64A64HIGH-FIBER64DIET64AND64INCREASE64FLUID64INTAKE

The64nurse64observes64an64increased64number64of64blood64clots64in64the64drainage64
tubing64of64a64client64with64continuous64bladder64irrigation64following64a64transurethr
al64resection64of64the64prostate64(TURP).64What64is64the64best64initial64nursing64actio
n?

a. Provide64additional64oral64fluid64intake

b. Measure64the64client's64intake64and64output.

c. Increase64the64flow64of64the64bladder

,irrigation

d. Administer64a64PRN64dose64of64an64antispasmodic64agent64-
64c.64Increase64the64flow64of64the64bladder
irrigation


ANSWER64(C)64Increase64the64flow64of64the64bladder64irrigation

A64client64wit64lung64cancer64who64wears64a64subcutaneous64morphine64sulfate64patch64f
or64pain64is64short64of64breath64and64difficult64to64arouse.64When64performing64a64head
-to-toe64assessment,64the64nurse64discovers64four64analgesic64patches64on64-
64Remove64all64morphine64patches


Coming64down64the64basement64steps,64a64client64is64brought64to64the64emergency64roo
m64X-ray64...64cast,64which64assessment64finding64warrants64immediate
Intervention64by64the64nurse?64-64Right64foot64pale64with64sluggish64capillary64refill

An64overweight,64young64adult64who64was
recently64Check64finger64stick64glucose64diagnosed64with64type64264diabetes64mellitus64is
64admitted64for64a64hernia64repair.64He64tells64the64nurse64that64he64is64feeling64very64we
ak64and64jittery.

Which64actions64should64the64nurse64implem
ent?64(Select64all64that64apply.)

a. Check64finger64sti
ck64glucose

b. Assess64skin64temperatu
re64and64moisture

c. Measure64pulse64and64blood
64pressure64-
64a.64Check64finger64stick64gluc
ose

b.64Assess64skin64temperature
64and64moisture


c.64Measure64pulse64and64bloo
d64pressure

ANSWER:64(CAM)

A64client64who64underwent64cardiac64stent64placement64four64days64ago64arrive
s64to64the64emergency64department64reporting64a64sudden64onset64of64chest64
pressure64and64shortness64of64breath.64Which64action64should64the64nurse64ta
ke64next?

, a. Listen64for64extra64heart64sounds,64murmurs,6
4and64r64hythm64with64the64bell64of
the64stethoscope.

b. Evaluate64upper64and64lower64extremities64for64perfusion,64pulse64
volume,64and64pitting64edema.

c. Verify64troponin64level64assessments64are64scheduled64every643-
664hours64for64a64series64of64three.

d. Obtain64a6412-lead64electrocardiogram64and64begin64continuous64cardiac64monitoring
.64-64d.64Obtain64a6412-
lead64electrocardiogram64and64begin64continuous64cardiac64monitoring

While64completing64a64health64assessment64for64a64client64with64migraine64headaches,64
the64nurse64assesses64bilateral64weakness64in64the64clients64hand64grips.64The64client64r
eports64joint64pain64and64trouble64twisting64a64door64knob64due64to64weaknesses.64Whic
h64action64should64the64nurses64take64in64response64to64these64figures?

a. Implement64fall64precautions64to64reduce64the64clients64risk64of64injury.

b. Explain64that64relief64of64the64migraine64pain64will64reduce64related64symptoms.

c. Gather64additional64assessment64data64about64the64pain64and64weakness.

d. Consult64with64the64occupational64therapist64for64a64functional64assessment64-
64c.64Gather64additional64assessment64data64about64the64pain64and64weakness.


The64nurse64is64caring64for64a64client64diagnosed64with64psoriasis64vulgaris64who64is64rec
eiving64psoralen64and64ultraviolet64A64light64(PUVA)64treatment.
Which64assessment64finding64indicates64that64the64client64has64been64overexposed64to64t
he64treatment?

a. Thick64skin64plaques64topped64by64silvery64white64scales

b. Tenderness64upon64palpation64and64generalized64erythema

c. Brown,64rough,64greasy,64wart-like64papules64on64the64face

d. Requires64sunglasses64because64sunlight64hurts64eyes64-
64b.64Tenderness64upon64palpation64and64generalized64erythema


An64adult64client64who64had64a64gastric64bypass64surgery64264weeks64ago,64is64admitted6
4with64possible64anastomosis64leakage.64The64client's64abdomen64is64tender64to64touch,6
4and64the64vital64signs64are64temperature64101*64F64(38643*64C).64heart64rate6413064beat
s/minute,64Respiratory64rate642664breaths/minute,64and64blood64pressure64100/5064mm
Hg.