BSN 266 HESI Final
1. The nurse administering the second unit of whole blood to an older adultclient who was
admitted yesterday with gastrointestinal (GI bleeding) which parameters should the nurse
monitor that indicate fluid overload?
A. Bounding pulse, hypertension, and distended neck veins
B. Thready pulse, hypotension and chest or back pain
C. Urticaria, itching and wheezing
D. Chills, fever, and tachycardia: A. Bounding pulse, hypertension and distendedneck veins
Bounding pulse, hypertension and distended neck veins are signs of fluid overloadwhich can
occur during blood transfusions especially in older adults.
Thready pulse, hypotension, and chest or back pain are more indicative of shock orsevere
anemia rather than fluid overload
Urticaria itching, and wheezing suggest an allergic reaction
Chills, fever, and tachycardia can indicate a febrile or transfusion reaction but arenot specific
to fluid overload
2. The nurse is teaching a client with cancer about skincare for the portalsite receiving
external beam radiation, Which client action about skincare indicates a need for further
teaching?
A. Washes the radiation site with antibacterial soap and water
B. Applies prescribed lotions to the radiation site
C. Wears clothing to cover the radiation site.
D. Dries the area with patting motions after taking a shower.: A. Washes theradiation with
antibacterial soap and water.
Washing the radiation site with antibacterial soap and water is not recommended. Clients
undergoing radiation therapy are typically advised to use gently, mild soapsand to avoid
,scrubbing or using harsh cleansers on the treated area, Antibacterial soap may be to harsh and
could lead to skin irritation.
Applying prescribed lotions to the radiation site is generally a recommended part of skin care
during radiation therapy, as it helps keep the skin moisturized and reducesirritation
Wearing clothing to cover the radiation site is a good practice to protect the areafrom sun
exposure and potential irritations
Drying the area with patting motions after taking a shower is the correct way to dry the
radiation site, as it minimizes friction and reduces the risk of skin damage.
3. The nurse observes that a client with Parkinson's disease (PD) has a masklike face. Which
follow up assessment is MOST important for the nurse to implement?
A. Determine ability to chew and swallow
B. Note the frequency of drooling
C. Assess patterns of speech
D. Observe the appearance of oral mucosa: A. Determine the ability to chew andswallow.
The ability to chew and swallow is crucial for preventing aspiration and maintainingnutrition
While noting the frequency of drooling is important it is not the most critical Observing the
appearance of oral mucosa is less critical than ability to swallow
Assessing speech patterns is important but secondary to swallowing ability in termsof
immediate safety
4. NGN scenario 2: Amputation
The client is a 48 year old male with gangrene of the right lower leg which has not been
responsive to treatment. A below the knee amputation (BKA) ofthe right lower leg has been
performed. The client has a history of peripheralvascular disease and hypertension and has a
peacemaker for 2nd degree TypeII heart block. Highlight the assessment findings that require
follow up by thenurse?: Right leg hanging
Right leg cool to touch Left leg whole paragraph
5. NGN Scenario 2: Amputation:
, Select the 3 assessment findings that indicate ineffective peripheral tissueperfusion for this
client:: Capillary refill
Edema Pale skin
6. NGN Scenario 2: Amputation:
Drag the word choices to complete the sentence. The client is at risk for
, and .: InfectionContractures
Neuroma
7. NGN Scenario 2: Amputation:
For each action click to indicate whether the actions are indicated or con-
traindicated for postoperative amputation.: B. Assessment for grieving
C. Instructions on equipment
D. Strengthening exercises
F. Collaborative care
8. NGN Scenario 2 Amputation:
which items should the nurse teach the client? SATA: A. Alternating position
B. Use of equipment
C. Therapeutic coping
D. Prevention of skin breakdown
9. NGN Scenario 2: Amputation:
For each client activity, click to indicate whether the activity shows positiveor negative health
promotion post amputation due to extensive peripheral vascular disease.: A. Insures about
blood pressure: Positive
B. Ask questions about self care-Positive
C. Avoids looking at residual limb-negative
D. Requests nurse to perform wound care-negative
E. Turns side to side-Positive
F. Executes pull ups on trapeze bar-positive
10. Which client has the highest risk for developing skin cancer?
A. A 65 year old fair skinned client who is a construction worker.
1. The nurse administering the second unit of whole blood to an older adultclient who was
admitted yesterday with gastrointestinal (GI bleeding) which parameters should the nurse
monitor that indicate fluid overload?
A. Bounding pulse, hypertension, and distended neck veins
B. Thready pulse, hypotension and chest or back pain
C. Urticaria, itching and wheezing
D. Chills, fever, and tachycardia: A. Bounding pulse, hypertension and distendedneck veins
Bounding pulse, hypertension and distended neck veins are signs of fluid overloadwhich can
occur during blood transfusions especially in older adults.
Thready pulse, hypotension, and chest or back pain are more indicative of shock orsevere
anemia rather than fluid overload
Urticaria itching, and wheezing suggest an allergic reaction
Chills, fever, and tachycardia can indicate a febrile or transfusion reaction but arenot specific
to fluid overload
2. The nurse is teaching a client with cancer about skincare for the portalsite receiving
external beam radiation, Which client action about skincare indicates a need for further
teaching?
A. Washes the radiation site with antibacterial soap and water
B. Applies prescribed lotions to the radiation site
C. Wears clothing to cover the radiation site.
D. Dries the area with patting motions after taking a shower.: A. Washes theradiation with
antibacterial soap and water.
Washing the radiation site with antibacterial soap and water is not recommended. Clients
undergoing radiation therapy are typically advised to use gently, mild soapsand to avoid
,scrubbing or using harsh cleansers on the treated area, Antibacterial soap may be to harsh and
could lead to skin irritation.
Applying prescribed lotions to the radiation site is generally a recommended part of skin care
during radiation therapy, as it helps keep the skin moisturized and reducesirritation
Wearing clothing to cover the radiation site is a good practice to protect the areafrom sun
exposure and potential irritations
Drying the area with patting motions after taking a shower is the correct way to dry the
radiation site, as it minimizes friction and reduces the risk of skin damage.
3. The nurse observes that a client with Parkinson's disease (PD) has a masklike face. Which
follow up assessment is MOST important for the nurse to implement?
A. Determine ability to chew and swallow
B. Note the frequency of drooling
C. Assess patterns of speech
D. Observe the appearance of oral mucosa: A. Determine the ability to chew andswallow.
The ability to chew and swallow is crucial for preventing aspiration and maintainingnutrition
While noting the frequency of drooling is important it is not the most critical Observing the
appearance of oral mucosa is less critical than ability to swallow
Assessing speech patterns is important but secondary to swallowing ability in termsof
immediate safety
4. NGN scenario 2: Amputation
The client is a 48 year old male with gangrene of the right lower leg which has not been
responsive to treatment. A below the knee amputation (BKA) ofthe right lower leg has been
performed. The client has a history of peripheralvascular disease and hypertension and has a
peacemaker for 2nd degree TypeII heart block. Highlight the assessment findings that require
follow up by thenurse?: Right leg hanging
Right leg cool to touch Left leg whole paragraph
5. NGN Scenario 2: Amputation:
, Select the 3 assessment findings that indicate ineffective peripheral tissueperfusion for this
client:: Capillary refill
Edema Pale skin
6. NGN Scenario 2: Amputation:
Drag the word choices to complete the sentence. The client is at risk for
, and .: InfectionContractures
Neuroma
7. NGN Scenario 2: Amputation:
For each action click to indicate whether the actions are indicated or con-
traindicated for postoperative amputation.: B. Assessment for grieving
C. Instructions on equipment
D. Strengthening exercises
F. Collaborative care
8. NGN Scenario 2 Amputation:
which items should the nurse teach the client? SATA: A. Alternating position
B. Use of equipment
C. Therapeutic coping
D. Prevention of skin breakdown
9. NGN Scenario 2: Amputation:
For each client activity, click to indicate whether the activity shows positiveor negative health
promotion post amputation due to extensive peripheral vascular disease.: A. Insures about
blood pressure: Positive
B. Ask questions about self care-Positive
C. Avoids looking at residual limb-negative
D. Requests nurse to perform wound care-negative
E. Turns side to side-Positive
F. Executes pull ups on trapeze bar-positive
10. Which client has the highest risk for developing skin cancer?
A. A 65 year old fair skinned client who is a construction worker.
