BSN 225 HESI EXAM 2| 90 QUESTIONS WITH
CORRECT ANSWERS With Rationale
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 - ANSWER-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. -
ANSWER-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. - ANSWER-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." - ANSWER-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,
CORRECT ANSWERS With Rationale
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 - ANSWER-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. -
ANSWER-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. - ANSWER-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." - ANSWER-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,
