Hesi Review #1 Bsn 266 Questions And Answers With
Rationale
A client with acute osteomyelitis has undergone surgical debridement of the diseased bone
and asks the nurse how long will antibiotics have to be administered. Which information
should the nurse communicate?
A. Oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis.
B. Parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year.
C. Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8
weeks. Parenteral antibiotics for 2 to 3 weeks, then oral antibiotics for 4 weeks
C
Treatment of acute osteomyelitis requires the administration of high doses of parenteral
antibiotics for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks
In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which
positioning should the nurse should use to maintain optimal functioning?
A. Mid-Fowlers with knees supported.
B. Supine with trochanter rolls to the hips.
C. Sim's position alternated with right lateral position q2
hours. Left lateral, supine, brief periods on the right side, and
prone
D
Rationale
After an acute stroke, a positioning and turning schedule that minimizes lying on the
affected side, which can impair circulation and cause pain, and includes the prone position
to help prevent flexion contractures of the hips, prepares the client for optimal functioning
and ambulation.
Which preexisting diagnosis places a client at the greatest risk of developing superior vena
cava syndrome?
A. Carotid stenosis.
B. Steatosis hepatitis.
C. Metastatic cancer.
D. Clavicular fracture.
C
Rationale
Superior vena cava syndrome occurs when the superior vena cava (SVC) is compressed by
outside structures, such as a growing tumor that impedes the return blood flow to the
heart. Superior vena cava syndrome is likely to occur with metastatic cancer from a
primary tumor in the upper lobe of the right lung that compresses the superior vena cava.
,The nurse is giving discharge instructions to a client with chronic prostatitis. What
instruction should the nurse provide the client to reduce the risk of spreading the infection
to other areas of the client's urinary tract?
A. Wear a condom when having sexual intercourse.
B. Avoid consuming alcohol and caffeinated beverages.
C. Empty the bladder completely with each voiding.
D. Have intercourse or masturbate at least twice a
week. D
Rationale
The prostate is not easily penetrated by antibiotics and can serve as a reservoir for
microorganisms, which can infect other areas of the genitourinary tract. Draining the
prostate regularly through intercourse or masturbation decreases the number of
microorganisms present and reduces the risk for further infection from stored
contaminated seminal fluids
During the initial outbreak of genital herpes simplex for a female client, what should be the
nurse's primary focus in planning care?
A. Promotion of comfort.
B. Prevention of pregnancy.
C. Instruction in condom use.
Information about transmission
A
Rationale
The initial outbreak of genital herpes simplex in a woman causes severe discomfort.
Promotion of comfort is the first priority
A client who has a chronic cough with blood-tinged sputum returns to the unit after a
bronchoscopy. What nursing interventions should be implemented in the immediate post-
procedural period?
A. Keep the client on bed rest for eight hours.
B. Check vital signs every 15 minutes for two hours.
C. Allow the client nothing by mouth until the gag reflex returns.
D. Encourage fluid intake to promote elimination of the contrast
media. C
Rationale
The nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior to
bronchoscopy, and the bronchoscope is coated with lidocaine (Xylocaine) gel to inhibit the
gag reflex and prevent laryngeal spasm during insertion. The client should be NPO until
the client's gag reflex returns to prevent aspiration from any oral intake or secretions.
The nurse is assessing a client admitted from the emergency room with gastrointestinal
bleeding related to peptic ulcer disease (PUD). Which physiological factors can
produce ulceration? (Select all that apply.)
,Select all that apply
A. Vagal stimulation.
B. An increased level of stress.
C. Decreased duodenal inhibition.
D. Hypersecretion of hydrochloric
acid. An increased number of parietal
cells D,E
Rationale
Hypersecretion of gastric juices and an increased number of parietal cells that stimulate
secretion are most often the causes of ulceration. Vagal stimulation and decreased
duodenal inhibition also increase the secretion of caustic fluids.
The nurse is caring for a client with non-Hodgkin’s lymphoma who is receiving
chemotherapy. Laboratory results reveal a platelet count of 10,000/ml. What action should
the nurse implement?
A. Encourage fluids to 3000 ml/day.
B. Check stools for occult blood.
C. Provide oral hygiene every 2
hours. Check for fever every 4 hours
B
Rationale
Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common
side effect of chemotherapy. A client with thrombocytopenia should be assessed
frequently for occult bleeding in the emesis, sputum, feces, urine, nasogastric secretions,
or wounds.
Which action should the nurse implement on the scheduled day of surgery for a client with
type 1 diabetes mellitus (DM)?
A. Obtain a prescription for an adjusted dose of insulin.
B. Administer an oral anti-diabetic agent.
C. Give an insulin dose using parameters of a sliding
scale. Withhold insulin while the client is NPO
A
Rationale
Stressors, such as surgery, increase serum glucose levels. A client with type 1 DM who is
NPO for scheduled surgery should receive a prescribed adjusted dose of insulin.
The nurse should explain to a client with lung cancer that pleurodesis is performed to
achieve which expected outcome?
A. Prevent the formation of effusion fluid.
B. Remove fluid from the intrapleural space.
C. Debulk tumor to maintain patency of air
passages. Relieve empyema after pneumonectomy
A
, Rationale
Instillation of a sclerosing agent to create pleurodesis is aimed at preventing the formation
of a pleural effusion by causing the pleural spaces sealed together, thereby preventing the
accumulation of pleural fluid.
The nurse obtains a client's history that includes right mastectomy and radiation therapy
for cancer of the breast 10 years ago. Which current health problem should the nurse
consider is a consequence of the radiation therapy?
A. Asthma.
B. Myocardial infarction.
C. Chronic esophagitis with gastroesophageal
reflux. Pathologic fracture of two ribs on the right
chest
D
Rationale
The ribs lie in the radiation pathway and lose density over time, becoming thin and brittle,
so the occurence of two right-sided ribs with pathological fractures resulting without
evidence of trauma is related to radiation damage
Three weeks after discharge for an acute myocardial infarction (MI), a client returns to the
cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells the
nurse that he sleeps fine but that his wife moved into the spare bedroom to sleep when he
returned home. He states, "I guess we will never have sex again after this." Which
response is best for the nurse to provide?
A. Sexual intercourse can be strenuous on your heart, but closeness and intimacy, such
as holding and cuddling, can be maintained with your wife.
B. Sexual activity can be resumed whenever you and your wife feel like it because the
sexual response is more emotional rather than physical.
C. You should discuss your questions about your sexual activity with your healthcare
provider because sexual activity may be limited by your heart damage.
D. Sexual activity is similar in cardiac workload and energy expenditure as climbing two
flights of stairs and may be resumed like other activities
D
Rationale
Sexual intercourse after an MI, or acute coronary syndrome, has been found to require no
more energy expenditure or cardiac stress than walking briskly up two flights of stairs, so
if you do not experience shortness of breath or chest discomfort doing the stairs then you
should be okay to resume sexual activity
The nurse is caring for a client scheduled to undergo insertion of a percutaneous
endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube
differs from a gastrostomy tube (GT). Which explanation best describes how they are
different?
Rationale
A client with acute osteomyelitis has undergone surgical debridement of the diseased bone
and asks the nurse how long will antibiotics have to be administered. Which information
should the nurse communicate?
A. Oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis.
B. Parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year.
C. Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8
weeks. Parenteral antibiotics for 2 to 3 weeks, then oral antibiotics for 4 weeks
C
Treatment of acute osteomyelitis requires the administration of high doses of parenteral
antibiotics for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks
In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which
positioning should the nurse should use to maintain optimal functioning?
A. Mid-Fowlers with knees supported.
B. Supine with trochanter rolls to the hips.
C. Sim's position alternated with right lateral position q2
hours. Left lateral, supine, brief periods on the right side, and
prone
D
Rationale
After an acute stroke, a positioning and turning schedule that minimizes lying on the
affected side, which can impair circulation and cause pain, and includes the prone position
to help prevent flexion contractures of the hips, prepares the client for optimal functioning
and ambulation.
Which preexisting diagnosis places a client at the greatest risk of developing superior vena
cava syndrome?
A. Carotid stenosis.
B. Steatosis hepatitis.
C. Metastatic cancer.
D. Clavicular fracture.
C
Rationale
Superior vena cava syndrome occurs when the superior vena cava (SVC) is compressed by
outside structures, such as a growing tumor that impedes the return blood flow to the
heart. Superior vena cava syndrome is likely to occur with metastatic cancer from a
primary tumor in the upper lobe of the right lung that compresses the superior vena cava.
,The nurse is giving discharge instructions to a client with chronic prostatitis. What
instruction should the nurse provide the client to reduce the risk of spreading the infection
to other areas of the client's urinary tract?
A. Wear a condom when having sexual intercourse.
B. Avoid consuming alcohol and caffeinated beverages.
C. Empty the bladder completely with each voiding.
D. Have intercourse or masturbate at least twice a
week. D
Rationale
The prostate is not easily penetrated by antibiotics and can serve as a reservoir for
microorganisms, which can infect other areas of the genitourinary tract. Draining the
prostate regularly through intercourse or masturbation decreases the number of
microorganisms present and reduces the risk for further infection from stored
contaminated seminal fluids
During the initial outbreak of genital herpes simplex for a female client, what should be the
nurse's primary focus in planning care?
A. Promotion of comfort.
B. Prevention of pregnancy.
C. Instruction in condom use.
Information about transmission
A
Rationale
The initial outbreak of genital herpes simplex in a woman causes severe discomfort.
Promotion of comfort is the first priority
A client who has a chronic cough with blood-tinged sputum returns to the unit after a
bronchoscopy. What nursing interventions should be implemented in the immediate post-
procedural period?
A. Keep the client on bed rest for eight hours.
B. Check vital signs every 15 minutes for two hours.
C. Allow the client nothing by mouth until the gag reflex returns.
D. Encourage fluid intake to promote elimination of the contrast
media. C
Rationale
The nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior to
bronchoscopy, and the bronchoscope is coated with lidocaine (Xylocaine) gel to inhibit the
gag reflex and prevent laryngeal spasm during insertion. The client should be NPO until
the client's gag reflex returns to prevent aspiration from any oral intake or secretions.
The nurse is assessing a client admitted from the emergency room with gastrointestinal
bleeding related to peptic ulcer disease (PUD). Which physiological factors can
produce ulceration? (Select all that apply.)
,Select all that apply
A. Vagal stimulation.
B. An increased level of stress.
C. Decreased duodenal inhibition.
D. Hypersecretion of hydrochloric
acid. An increased number of parietal
cells D,E
Rationale
Hypersecretion of gastric juices and an increased number of parietal cells that stimulate
secretion are most often the causes of ulceration. Vagal stimulation and decreased
duodenal inhibition also increase the secretion of caustic fluids.
The nurse is caring for a client with non-Hodgkin’s lymphoma who is receiving
chemotherapy. Laboratory results reveal a platelet count of 10,000/ml. What action should
the nurse implement?
A. Encourage fluids to 3000 ml/day.
B. Check stools for occult blood.
C. Provide oral hygiene every 2
hours. Check for fever every 4 hours
B
Rationale
Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common
side effect of chemotherapy. A client with thrombocytopenia should be assessed
frequently for occult bleeding in the emesis, sputum, feces, urine, nasogastric secretions,
or wounds.
Which action should the nurse implement on the scheduled day of surgery for a client with
type 1 diabetes mellitus (DM)?
A. Obtain a prescription for an adjusted dose of insulin.
B. Administer an oral anti-diabetic agent.
C. Give an insulin dose using parameters of a sliding
scale. Withhold insulin while the client is NPO
A
Rationale
Stressors, such as surgery, increase serum glucose levels. A client with type 1 DM who is
NPO for scheduled surgery should receive a prescribed adjusted dose of insulin.
The nurse should explain to a client with lung cancer that pleurodesis is performed to
achieve which expected outcome?
A. Prevent the formation of effusion fluid.
B. Remove fluid from the intrapleural space.
C. Debulk tumor to maintain patency of air
passages. Relieve empyema after pneumonectomy
A
, Rationale
Instillation of a sclerosing agent to create pleurodesis is aimed at preventing the formation
of a pleural effusion by causing the pleural spaces sealed together, thereby preventing the
accumulation of pleural fluid.
The nurse obtains a client's history that includes right mastectomy and radiation therapy
for cancer of the breast 10 years ago. Which current health problem should the nurse
consider is a consequence of the radiation therapy?
A. Asthma.
B. Myocardial infarction.
C. Chronic esophagitis with gastroesophageal
reflux. Pathologic fracture of two ribs on the right
chest
D
Rationale
The ribs lie in the radiation pathway and lose density over time, becoming thin and brittle,
so the occurence of two right-sided ribs with pathological fractures resulting without
evidence of trauma is related to radiation damage
Three weeks after discharge for an acute myocardial infarction (MI), a client returns to the
cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells the
nurse that he sleeps fine but that his wife moved into the spare bedroom to sleep when he
returned home. He states, "I guess we will never have sex again after this." Which
response is best for the nurse to provide?
A. Sexual intercourse can be strenuous on your heart, but closeness and intimacy, such
as holding and cuddling, can be maintained with your wife.
B. Sexual activity can be resumed whenever you and your wife feel like it because the
sexual response is more emotional rather than physical.
C. You should discuss your questions about your sexual activity with your healthcare
provider because sexual activity may be limited by your heart damage.
D. Sexual activity is similar in cardiac workload and energy expenditure as climbing two
flights of stairs and may be resumed like other activities
D
Rationale
Sexual intercourse after an MI, or acute coronary syndrome, has been found to require no
more energy expenditure or cardiac stress than walking briskly up two flights of stairs, so
if you do not experience shortness of breath or chest discomfort doing the stairs then you
should be okay to resume sexual activity
The nurse is caring for a client scheduled to undergo insertion of a percutaneous
endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube
differs from a gastrostomy tube (GT). Which explanation best describes how they are
different?
