BSN 266 HESI V2
1. M patient with chronic myelogenous leukemia (CML) with long-term cor- ticosteroid
therapy develops oral candidiasis and is experiencing pain whenchew or swallow. Which
action should the nurse implement first?: Administertopical analgesic as prescribed- relief of
the pain associated with oral candidiasis isthe highest priority for the client and the nurse
should administer topical analgesic as prescribed.
2. Patient is an obese adult, and the nurse is calculating BMI.Which additionalassessment
finding place the client at high risk for cardiac disease?: Large waist Circumference with
central fat.
3. What is the nurses actions in finding abdominal obesity and high waist-hipratio with a BMI
of 32? SATA: Discuss the importance of a regular exercise program
Measure the client's BP in both arms
Screen for a family history of diabetes mellitus.
4. A patient is hospitalized with IBD exacerbation and treated with coritcos- teroid. The
patient develops a rigid abdomen with rebound tenderness. Which action should the nurse
take?: Measure vital signs
5. Which instructions is most important for the nurse to emphasize in dis- charge teaching
in patients with COPD?: Report any changes in sputum color-
This is a sign of infection. It is a common problem in COPD patients and requestimmediate
antibiotic therapy to prevent an acute and prolonged exacerbation of COPD.
6. While caring for a client with full thickness burns covering 40% of the body, the nurse
observes purulent drainage from the wounds. Before reporting the finding, what is the best lab
value to evaluate?: Neutrophil count- The patient
is experiencing infection, so a nurse should review the neutrophil count beforecontacting the
HCP.
7. An older woman who experienced a cerebrovascular accident (CVA) hasdifficulty with
visual perception and she only eats half of the food on her meal tray. Her family expresses
concern about her nutritional status. Howshould the nurse respond to the family's concern?:
Demonstrate the use ofvisual scanning during meals to the client and family.
8. Best position for respiratory distress?: High Fowler's Position- High fowlershelps to
decrease venous return, which decreases fluid volume in the heart that results in decreased
cardiac workload.
9. A patient with peripheral artery disease has marked peripheral neuropath.An appropriate
nursing diagnosis for the patient is: High risk for injury
10. Type 2 diabetes patient discharge teaching patient and family: Check feetevery day for
cuts or injuries.
1. M patient with chronic myelogenous leukemia (CML) with long-term cor- ticosteroid
therapy develops oral candidiasis and is experiencing pain whenchew or swallow. Which
action should the nurse implement first?: Administertopical analgesic as prescribed- relief of
the pain associated with oral candidiasis isthe highest priority for the client and the nurse
should administer topical analgesic as prescribed.
2. Patient is an obese adult, and the nurse is calculating BMI.Which additionalassessment
finding place the client at high risk for cardiac disease?: Large waist Circumference with
central fat.
3. What is the nurses actions in finding abdominal obesity and high waist-hipratio with a BMI
of 32? SATA: Discuss the importance of a regular exercise program
Measure the client's BP in both arms
Screen for a family history of diabetes mellitus.
4. A patient is hospitalized with IBD exacerbation and treated with coritcos- teroid. The
patient develops a rigid abdomen with rebound tenderness. Which action should the nurse
take?: Measure vital signs
5. Which instructions is most important for the nurse to emphasize in dis- charge teaching
in patients with COPD?: Report any changes in sputum color-
This is a sign of infection. It is a common problem in COPD patients and requestimmediate
antibiotic therapy to prevent an acute and prolonged exacerbation of COPD.
6. While caring for a client with full thickness burns covering 40% of the body, the nurse
observes purulent drainage from the wounds. Before reporting the finding, what is the best lab
value to evaluate?: Neutrophil count- The patient
is experiencing infection, so a nurse should review the neutrophil count beforecontacting the
HCP.
7. An older woman who experienced a cerebrovascular accident (CVA) hasdifficulty with
visual perception and she only eats half of the food on her meal tray. Her family expresses
concern about her nutritional status. Howshould the nurse respond to the family's concern?:
Demonstrate the use ofvisual scanning during meals to the client and family.
8. Best position for respiratory distress?: High Fowler's Position- High fowlershelps to
decrease venous return, which decreases fluid volume in the heart that results in decreased
cardiac workload.
9. A patient with peripheral artery disease has marked peripheral neuropath.An appropriate
nursing diagnosis for the patient is: High risk for injury
10. Type 2 diabetes patient discharge teaching patient and family: Check feetevery day for
cuts or injuries.
