BSN HESI 266 EXAM 2|| ACTUAL EXAM ALL QUESTIONS AND CORRECT ANSWERS ALREADY GRADED A+|| LATEST AND COMPLETE VERSION 2025 WITH VERIFIED SOLUTIONS|| ASSURED PASS!!!

BSN HESI 266 EXAM 2|| ACTUAL EXAM ALL QUESTIONS AND CORRECT ANSWERS ALREADY GRADED A+|| LATEST AND COMPLETE VERSION 2025 WITH VERIFIED SOLUTIONS|| ASSURED PASS!!! Client is recovering from a transurethral prostatectomy. Which activity should be limited until after the first postoperative visit with the healthcare provider? - ANSWER: Drink 3L A client with stage IV bone cancer is admitted to the hospital for a 1-10 scale. Which intervention should the nurse implement? - ANSWER: Administer opioid and non-opioid medications simultaneously A client experiences an AOB incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider? - ANSWER: a. low back pain and hypotension When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include? - ANSWER: c. Eat a high fibre diet and increase fluid intake. The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best initial nursing action? - ANSWER: c. Increase the f low of the bladder irrigation A client wit lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and difficult to arouse. When performing a head -to-toe assessment, the nurse discovers four analgesic patches on - ANSWER: Remove all morphine patches Coming down the basement steps, a client is brought to the emergency room X-ray cast, which assessment finding warrants immediate Intervention by the nurse? - ANSWER: Right foot pale with sluggish capillary refill An overweight, young adult who was recently Check finger stick glucose diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.) - ANSWER: a. Check finger stick glucose b. Assess skin temperature and moisture c. Measure pulse and blood pressure A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next? - ANSWER: d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring While completing a health assessment for a client with migraine headaches, the nurse assesses bilateral weakness in the client’s hand grips. The client reports joint pain and trouble twisting a door knob due to weaknesses. Which action should the nurses take in response to these figures? - ANSWER: c. Gather additional assessment data about the pain and weakness. The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment? - ANSWER: b. Tenderness upon palpation and generalized erythema An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis leakage. The client's abdomen is tender to touch, and the vital signs are temperature 101* F (38 3* C). heart rate 130 beats/minute, Respiratory rate 26 breaths/minute, and blood pressure 100/50 mmHg. Which intervention is most important for the nurse to include in the client's plan of care? - ANSWER: c. Strict IV fluid replacement A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instructions should the nurse provide? - ANSWER: d. Wearing gloves when handling cold items guards against painful spasms. A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond? - ANSWER: d. Describe the use of an elimination diet to find trigger foods The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi.? - ANSWER: b. Eats a vegetarian diet with cheese 2 to 3 times a day. An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary system, and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement? - ANSWER: c. Palpate the bladder above the symphysis pubis. A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis? - ANSWER: c. Crohn's disease with colectomy. When providing care for an unconscious client who has seizures. Which nursing intervention is most essential? - ANSWER: c. Ensure oral suction is available. A client presents to the emergency department reporting chest pain that is radiation to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider? - ANSWER: d. Morphine An adult who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurses to provide this client? - ANSWER: a. Maintain prescribed eye drop regimen Which information should the nurse include on the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? - ANSWER: c. Minimize symptoms by wearing loose, comfortable clothing. A client arrives to the emergency department reporting an intermittent fever and night sweats for the past 3 weeks and has developed a productive cough containing small amounts of blood. Which intervention should the nurse prioritize? - ANSWER: a. Move into airborne isolation A client receives a prescription for 1 liter of Ringer's intravenously to be infused over 6 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only. If rounding is required, round to the nearest whole number.) - ANSWER: 167 mL 1000mL/6(hours) =166.6=167mL The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? - ANSWER: b. Eating patterns of dietary intake. An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? - ANSWER: c. Assist client to an upright position. Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy? - ANSWER: a. Monitor the client's intravenous site hourly during the treatment The home health nurse provides teaching about self injection to a client who was recently diagnosed with diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen as seen in the video, which instruction should the nurse provide? (Please view the video to select the option that applies. To repeat the video, click the play button again.) - ANSWER: a. Continue with the insulin injection. An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate 128 beats/minute and irregular, respirations 38 breathe/minute. Blood pressure 168/100 mmHg, wheezes, and crackles in all lung fields. An hour after the administration of furosemide 60 mg IV. Which assessments should the nurse obtain to determine the client's response to treatment? Select at that apply. - ANSWER: a. Oxygen saturation c. Lung sounds d. Urinary output While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? - ANSWER: a. White blood cell (WBC) count The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review? - ANSWER: b. Platelet count. A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for the continuous bladder irrigation with normal saline is infused and the nurse observes dark-pink tinged outflow with blood clots in the tubing collection bag. Which action should the nurse take? - ANSWER: a. Monitoring catheter drainage (pic one says this) The nurse is preparing a client for surgery who was admitted to the emergency centre following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units subcutaneously daily. What is the priority nursing action? - ANSWER: a. Notify the healthcare provider of the client's medication history. An obese client with emphysema who smokes at least a pack of cigarettes daily is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy is initiated and it’s determined that the client will be discharged with oxygen. Which information is most important for the nurse to emphasize in the discharge teaching plan? - ANSWER: b. Guidelines for oxygen use. The healthcare provider prescribes penicillin 200,000 units intramuscularly for a client with pneumonia. The available vial is labelled, "Penicillin 500,000 units/mL". How many mL should the nurse administer to this client? (Enter numerical value only. If rounding is required, round the nearest tenth.) - ANSWER: 0.4 The nurse is caring for a client in the post anaesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs; heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement? - ANSWER: Medicate for pain and monitor vital signs according to protocol. While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take? - ANSWER: b. Discuss approaches to chronic pain control with the client. A client with draining skin lesions of the lover extremity is admitted with possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply.) - ANSWER: b. Monitor the client's white blood cell count. c. Send wound drainage for culture and sensitivity e. Institute contact precautions for staff and visitors