BSN 266 HESI V1 Questions with 100% Verified
Answers |Well Explained|
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?
A. Review the client's fluid intake prior to bedtime.
B. Obtain a fingerstick blood glucose level.
C. Palpate the bladder above the symphysis pubis.
D. Collect a urine specimen for culture analysis. - ANSWER -C. Palpate the
bladder above the symphysis pubis.
Explanation: The client's symptoms suggest possible urinary retention, which is
common in older males with benign prostatic hyperplasia (BPH). Palpating the
bladder above the symphysis pubis can help the nurse assess for bladder distention
and provide information to guide further evaluation and management.
The nurse has conducted a cancer prevention community education program. In
evaluating he participants' understanding of the carcinogens, which statement
indicates an accurate understanding?
A. Environmental factors such as sunlight and chemicals can cause cancer to
spread.
B. Carcinogens are substances that contain cancerous cells.
C. Substances that change a cell so that it becomes cancerous are potential sources
of cancer.
D. Carcinogens are in the environment and cannot be avoided. - ANSWER -C.
Substances that change a cell so that it becomes cancerous are potential sources of
cancer.
Explanation: Carcinogens are substances that can cause changes in a cell's DNA,
leading to the development of cancer. Understanding that carcinogens are potential
sources of cancer indicates accurate knowledge of this concept.
, A client with pheochromocytoma reports the onset of a severe headache. The
nurse observes that the client is very diaphoretic. Which assessment data should
the nurse obtain next?
A. Capillary glucose.
B. Oxygen saturation.
C. Body temperature.
D. Blood pressure. - ANSWER -D. Blood pressure.
Explanation: Clients with pheochromocytoma can experience paroxysmal episodes
of hypertension due to the release of catecholamines from the tumor. The onset of
a severe headache and diaphoresis in a client with pheochromocytoma may
indicate a hypertensive crisis, so the nurse should obtain the client's blood pressure
next.
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?
A. Nephrotic syndrome history.
B. Latent hepatitis C.
C. Crohn's disease with colectomy.
D. Type 2 diabetes mellitus - ANSWER -C. Crohn's disease with colectomy.
Explanation: Crohn's disease with a history of colectomy is a contraindication for
peritoneal dialysis due to the increased risk for peritonitis and complications
related to abdominal surgery. The other conditions listed do not directly
contraindicate peritoneal dialysis.
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet
and legs, and massive ascites. Which mechanism contributes to edema and ascites
in clients with cirrhosis?
A. Hypoalbuminemia that results in a decreased colloidal onoctic.
B. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
C. Decreased renin-angiotensin response related to an increase in renal blood flow.
D. Decreased portacaval pressure with greater collateral circulation. - ANSWER -
B. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
, Explanation: In cirrhosis, the liver's ability to produce albumin is compromised,
leading to hypoalbuminemia. This causes a decrease in colloidal oncotic pressure,
allowing fluid to leak into the interstitial spaces and leading to edema and ascites.
When providing care for an unconscious client who has seizures, which nursing
intervention is most essential?
A. Maintain the client in a semi-Fowler's position.
B. Keep the room at a comfortable temperature.
C. Ensure oral suction is available.
D. Provide frequent mouth care. - ANSWER -C. Ensure oral suction is available.
Explanation: Ensuring that oral suction is available is essential for an unconscious
client who has seizures. Suctioning can help to maintain a patent airway and
prevent aspiration of secretions during and after a seizure.
A client presents to the emergency department reporting chest pain that is
radiating to the left arm, shortness of breath, and diaphoresis. Which medication
should the nurse anticipate being prescribed by the healthcare provider?
A. Fentanyl.
B. Hydromorphone.
C. Oxycodone.
D. Morphine. - ANSWER -D. Morphine.
Explanation: Morphine is most commonly used to treat chest pain associated with
myocardial infarction (heart attack) as it provides pain relief, reduces anxiety, and
has a vasodilatory effect that can improve blood flow to the heart. The other
medications listed are not typically the first choice for managing chest pain related
to a heart attack.
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?
A. Maintain prescribed eye drop regimen.
B. Eat a diet high in carotene.
C. Wear prescription glasses.
D. Avoid frequent eye pressure measurement. - ANSWER -A. Maintain prescribed
eye drop regimen.
Answers |Well Explained|
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?
A. Review the client's fluid intake prior to bedtime.
B. Obtain a fingerstick blood glucose level.
C. Palpate the bladder above the symphysis pubis.
D. Collect a urine specimen for culture analysis. - ANSWER -C. Palpate the
bladder above the symphysis pubis.
Explanation: The client's symptoms suggest possible urinary retention, which is
common in older males with benign prostatic hyperplasia (BPH). Palpating the
bladder above the symphysis pubis can help the nurse assess for bladder distention
and provide information to guide further evaluation and management.
The nurse has conducted a cancer prevention community education program. In
evaluating he participants' understanding of the carcinogens, which statement
indicates an accurate understanding?
A. Environmental factors such as sunlight and chemicals can cause cancer to
spread.
B. Carcinogens are substances that contain cancerous cells.
C. Substances that change a cell so that it becomes cancerous are potential sources
of cancer.
D. Carcinogens are in the environment and cannot be avoided. - ANSWER -C.
Substances that change a cell so that it becomes cancerous are potential sources of
cancer.
Explanation: Carcinogens are substances that can cause changes in a cell's DNA,
leading to the development of cancer. Understanding that carcinogens are potential
sources of cancer indicates accurate knowledge of this concept.
, A client with pheochromocytoma reports the onset of a severe headache. The
nurse observes that the client is very diaphoretic. Which assessment data should
the nurse obtain next?
A. Capillary glucose.
B. Oxygen saturation.
C. Body temperature.
D. Blood pressure. - ANSWER -D. Blood pressure.
Explanation: Clients with pheochromocytoma can experience paroxysmal episodes
of hypertension due to the release of catecholamines from the tumor. The onset of
a severe headache and diaphoresis in a client with pheochromocytoma may
indicate a hypertensive crisis, so the nurse should obtain the client's blood pressure
next.
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?
A. Nephrotic syndrome history.
B. Latent hepatitis C.
C. Crohn's disease with colectomy.
D. Type 2 diabetes mellitus - ANSWER -C. Crohn's disease with colectomy.
Explanation: Crohn's disease with a history of colectomy is a contraindication for
peritoneal dialysis due to the increased risk for peritonitis and complications
related to abdominal surgery. The other conditions listed do not directly
contraindicate peritoneal dialysis.
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet
and legs, and massive ascites. Which mechanism contributes to edema and ascites
in clients with cirrhosis?
A. Hypoalbuminemia that results in a decreased colloidal onoctic.
B. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
C. Decreased renin-angiotensin response related to an increase in renal blood flow.
D. Decreased portacaval pressure with greater collateral circulation. - ANSWER -
B. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
, Explanation: In cirrhosis, the liver's ability to produce albumin is compromised,
leading to hypoalbuminemia. This causes a decrease in colloidal oncotic pressure,
allowing fluid to leak into the interstitial spaces and leading to edema and ascites.
When providing care for an unconscious client who has seizures, which nursing
intervention is most essential?
A. Maintain the client in a semi-Fowler's position.
B. Keep the room at a comfortable temperature.
C. Ensure oral suction is available.
D. Provide frequent mouth care. - ANSWER -C. Ensure oral suction is available.
Explanation: Ensuring that oral suction is available is essential for an unconscious
client who has seizures. Suctioning can help to maintain a patent airway and
prevent aspiration of secretions during and after a seizure.
A client presents to the emergency department reporting chest pain that is
radiating to the left arm, shortness of breath, and diaphoresis. Which medication
should the nurse anticipate being prescribed by the healthcare provider?
A. Fentanyl.
B. Hydromorphone.
C. Oxycodone.
D. Morphine. - ANSWER -D. Morphine.
Explanation: Morphine is most commonly used to treat chest pain associated with
myocardial infarction (heart attack) as it provides pain relief, reduces anxiety, and
has a vasodilatory effect that can improve blood flow to the heart. The other
medications listed are not typically the first choice for managing chest pain related
to a heart attack.
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?
A. Maintain prescribed eye drop regimen.
B. Eat a diet high in carotene.
C. Wear prescription glasses.
D. Avoid frequent eye pressure measurement. - ANSWER -A. Maintain prescribed
eye drop regimen.
