HESI BSN 225 || WITH CERTIFIED ANSWERS.
A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical
procedure. Which laboratory test indicates the client's protein status for the longest length of
time?
a. Transferrin
b. Prealbumin
c. Serum albumin
d. Urine urea nitrogen correct answers c. Serum albumin
Rationale: Serum albumin has a long half-life and is the best long-term indicator of the body's
entry into a catabolic state following protein depletion from malnutrition or stress of chronic
illness (C).
The nurse is digitally removing a fecal impaction for a client. The nurse should stop the
procedure and take corrective action if which client reaction is noted?
a. Temperature increases from 98.8 to 99.0 F.
b. Pulse rate decreases from 78 to 52 beats/min.
c. Respiratory rate increases from 16 to 24 breaths/min.
d. Blood pressure increases from 110/84 to 118/88 mm/Hg. correct answers b. Pulse rate
decreases from 78 to 52 beats/min.
Rationale: Parasympathetic reaction can occur as a result of digital stimulation of the anal
sphincter, which should be stopped if the client experiences a vagal response, such as
bradycardia (B).
Which statement is an example of a correctly written nursing diagnosis statement?
a. Altered tissue perfusion related to congestive heart failure.
b. Altered urinary elimination related to urinary tract infection.
c. Risk for impaired tissue integrity related to client's refusal to turn.
d. Ineffective coping related to response to positive biopsy test results. correct answers d.
Ineffective coping related to response to positive biopsy test results.
, Rationale: The first part of the nursing diagnosis statement is the "diagnostic label" and is
followed by "related to" the cause, which should direct the nurse to the appropriate interventions.
The daughter of an older woman who became depressed following the death of her husband asks,
"My mother was always well-adjusted until my father died. Will she tend to be sick from now
on?" Which response is best for the nurse to provide?
a. "She is almost sure to be less able to adapt than before."
b. "It's highly likely that she will recover and return to her pre-illness state."
c. "If you can interest her in something besides religion, it will help her stay well."
d. "Cultural strains contribute to each woman's tendencies for recurrences of depression." correct
answers b. "It's highly likely that she will recover and return to her pre-illness state."
Rationale:
Analysis of behavior patterns using Erikson's framework can identify age-appropriate or arrested
development of normal interpersonal skills. Erikson describes the successful resolution of a
developmental crisis in the later years (older than 65-years) to include the achievement of a sense
of integrity and fulfillment, wisdom, and a willingness to face one's own mortality and accept the
death of others (B).
A client is demonstrating a positive Chvostek's sign. What action should the nurse take?
a. Observe the client's pupil size and response to light.
b. Ask the client about numbness or tingling in the hands.
c. Assess the client's serum potassium level.
d. Restrict dietary intake of calcium-rich foods. correct answers b. Ask the client about numbness
or tingling in the hands.
Rationale: A positive Chvostek's sign is an indication of hypocalcemia, so the client should be
assessed for the subjective symptoms of hypocalcemia, such as numbness or tingling of the
hands (B) or feet.
A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal
meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What
action should the nurse implement?
A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical
procedure. Which laboratory test indicates the client's protein status for the longest length of
time?
a. Transferrin
b. Prealbumin
c. Serum albumin
d. Urine urea nitrogen correct answers c. Serum albumin
Rationale: Serum albumin has a long half-life and is the best long-term indicator of the body's
entry into a catabolic state following protein depletion from malnutrition or stress of chronic
illness (C).
The nurse is digitally removing a fecal impaction for a client. The nurse should stop the
procedure and take corrective action if which client reaction is noted?
a. Temperature increases from 98.8 to 99.0 F.
b. Pulse rate decreases from 78 to 52 beats/min.
c. Respiratory rate increases from 16 to 24 breaths/min.
d. Blood pressure increases from 110/84 to 118/88 mm/Hg. correct answers b. Pulse rate
decreases from 78 to 52 beats/min.
Rationale: Parasympathetic reaction can occur as a result of digital stimulation of the anal
sphincter, which should be stopped if the client experiences a vagal response, such as
bradycardia (B).
Which statement is an example of a correctly written nursing diagnosis statement?
a. Altered tissue perfusion related to congestive heart failure.
b. Altered urinary elimination related to urinary tract infection.
c. Risk for impaired tissue integrity related to client's refusal to turn.
d. Ineffective coping related to response to positive biopsy test results. correct answers d.
Ineffective coping related to response to positive biopsy test results.
, Rationale: The first part of the nursing diagnosis statement is the "diagnostic label" and is
followed by "related to" the cause, which should direct the nurse to the appropriate interventions.
The daughter of an older woman who became depressed following the death of her husband asks,
"My mother was always well-adjusted until my father died. Will she tend to be sick from now
on?" Which response is best for the nurse to provide?
a. "She is almost sure to be less able to adapt than before."
b. "It's highly likely that she will recover and return to her pre-illness state."
c. "If you can interest her in something besides religion, it will help her stay well."
d. "Cultural strains contribute to each woman's tendencies for recurrences of depression." correct
answers b. "It's highly likely that she will recover and return to her pre-illness state."
Rationale:
Analysis of behavior patterns using Erikson's framework can identify age-appropriate or arrested
development of normal interpersonal skills. Erikson describes the successful resolution of a
developmental crisis in the later years (older than 65-years) to include the achievement of a sense
of integrity and fulfillment, wisdom, and a willingness to face one's own mortality and accept the
death of others (B).
A client is demonstrating a positive Chvostek's sign. What action should the nurse take?
a. Observe the client's pupil size and response to light.
b. Ask the client about numbness or tingling in the hands.
c. Assess the client's serum potassium level.
d. Restrict dietary intake of calcium-rich foods. correct answers b. Ask the client about numbness
or tingling in the hands.
Rationale: A positive Chvostek's sign is an indication of hypocalcemia, so the client should be
assessed for the subjective symptoms of hypocalcemia, such as numbness or tingling of the
hands (B) or feet.
A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal
meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What
action should the nurse implement?
