BSN 266 Practice HESI
Terms in this set (115)
A client with a completed ischemic D. Give an antihypertensive medication.
stroke has a blood pressure of 180/90 Rationale
mm Hg. Which action should the nurse Most ischemic strokes occur during sleep when baseline blood pressure declines or
implement? blood viscosity increases due to minimal fluid intake. Completed strokes usually
A. Position the head of the bed (HOB) flat. produce neurologic deficits within an hour, and the client's current elevated
B. Withhold intravenous fluids. blood pressure requires antihypertensive medication.
C.Administer a bolus of IV fluids.
D.Give an antihypertensive medication.
A client who is receiving A. "Chemotherapy affects the cells of the body that grow rapidly, both normal and
chemotherapy asks the nurse, "Why is so malignant."
much of my hair falling out each day?" Rationale
Which response by the nurse best The common adverse effects of chemotherapy (nausea, vomiting, alopecia,
explains the reason for alopecia? bone marrow depression) are due to chemotherapy's effect on the rapidly
A. "Chemotherapy affects the cells of reproducing cells, both normal and malignant.
the body that grow rapidly, both
normal and malignant."
B."Alopecia is a common side effect
you will experience during long-term
steroid therapy."
C. "Your hair will grow back completely
after your course of chemotherapy
is completed."
D."The chemotherapy causes
permanent alterations in your hair
follicles that lead to hair loss."
,After checking the urinary drainage A. Report the findings to the surgeon.
system for kinks in the tubing, the nurse Rationale
determines that a client who has An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly
returned from the post-anesthesia care (1 ml/kg/hour). Dark, concentrated, and low volume of urine output should be
has a dark, concentrated urinary reported to the surgeon.
output of 54 ml for the last 2 hours.
What priority nursing action should be
implemented?
A. Report the findings to the surgeon.
B.Irrigate the indwelling urinary catheter.
C.Apply manual pressure to the bladder.
D.Increase the IV flow rate for 15 minutes.
A male client who smokes two packs of B, C and
cigarettes a day states he understands that D
smoking cigarettes is contributing to the Rationale
difficulty that he and his wife are having Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is
in getting pregnant and wants to know if also negatively affected by low testerone levels and obesity.
other factors could be contributing to
their difficulty. What information is best
for the nurse to provide? (Select all that
apply.) Select all that apply
A. Marijuana cigarettes do not affect
sperm count.
B.Alcohol consumption can cause
erectile dysfunction.
C. Low testosterone levels affect sperm
production.
D.Cessation of smoking improves
general health and fertility.
E.Obesity has no effect on sperm
production.
A client with gastroesophageal reflux D. Raising the head of the bed on blocks.
disease (GERD) has been experiencing Rationale
severe reflux during sleep. Which Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce
recommendation by the nurse is most reflux and subsequent aspiration is the most non-pharmacological effective
effective to assist the client? recommendation for a client experiencing severe gastroesophageal reflux during
A. Losing weight. sleep.
B.Decreasing caffeine intake.
C. Avoiding large meals.
D.Raising the head of the bed on blocks.
A 51-year-old truck driver who smokes A. Information about smoking cessation.
two packs of cigarettes a day and is 30 Rationale
pounds overweight is diagnosed with Smoking has been associated with ulcer formation, and stopping or decreasing the
having a gastric ulcer. What content is number of cigarettes smoked per day is an important aspect of ulcer management.
most important for the nurse to include
in the discharge teaching for this
client?
A. Information about smoking cessation.
B.Diet instructions for a low-residue diet.
C. Instructions on a weight-loss program.
D. The importance of increasing
milk in the diet.
, What types of medications should the D. Bronchodilators and steroids.
nurse expect to administer to a client Rationale
during an acute respiratory distress Besides supplemental oxygen, this client with ARDS needs medications to widen
episode? air passages, increase air space, and reduce alveolar membrane inflammation, such
A. Vasodilators and hormones. as bronchodilators and steroids.
B. Analgesics and sedatives.
C.Anticoagulants and expectorants.
D.Bronchodilators and steroids.
A female client is brought to the clinic D. Collect further data to determine whether self-neglect is occurring.
by her daughter for a flu shot. She has Rationale
lost significant weight since the last visit. She Changes in weight and hygiene may be indicators of self-neglect or neglect
has poor personal hygiene and by family members. Further assessment is needed before notifying social
inadequate clothing for the weather. services or discussing a need for counseling.
The client states that she lives alone and
denies problems or concerns. What
action should the nurse implement?
A. Notify social services immediately
of suspected elderly abuse.
B.Discuss the need for mental
health counseling with the
daughter.
C. Explain to the client that she needs
to take better care of herself.
D.Collect further data to determine
whether self-neglect is occurring.
The nurse is assisting a client out of bed for D. Allow the client to sit with the bed in a high Fowler's position.
the first time after surgery. What action Rationale
should the nurse do first? The first step is to raise the head of the bed to a high Fowler's position, which allow
A. Place a chair at a right angle to venous return to compensate from lying flat and the vasodilation effects of
the bedside. perioperative drugs. This helps prevent the client from becoming light-headed and
B.Encourage deep breathing prior to decreases the chance of a client fall.
standing.
C. Help the client to sit and dangle legs on
the side of the bed.
D. Allow the client to sit with the bed
in a
high Fowler's position.
A 32-year-old female client complains B. Inability to get pregnant.
of severe abdominal pain each month Rationale
before her menstrual period, painful Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common
intercourse, and painful defecation. symptoms of endometriosis, which is the abnormal displacement of endometrial
Which additional history should the tissue in the dependent areas of the pelvic peritoneum. A history of infertility is
nurse obtain that is consistent with the another common finding associated with endometriosis.
client's complaints?
A. Frequent urinary tract infections.
B.Inability to get pregnant.
C. Premenstrual syndrome.
D.Chronic use of laxatives.
Terms in this set (115)
A client with a completed ischemic D. Give an antihypertensive medication.
stroke has a blood pressure of 180/90 Rationale
mm Hg. Which action should the nurse Most ischemic strokes occur during sleep when baseline blood pressure declines or
implement? blood viscosity increases due to minimal fluid intake. Completed strokes usually
A. Position the head of the bed (HOB) flat. produce neurologic deficits within an hour, and the client's current elevated
B. Withhold intravenous fluids. blood pressure requires antihypertensive medication.
C.Administer a bolus of IV fluids.
D.Give an antihypertensive medication.
A client who is receiving A. "Chemotherapy affects the cells of the body that grow rapidly, both normal and
chemotherapy asks the nurse, "Why is so malignant."
much of my hair falling out each day?" Rationale
Which response by the nurse best The common adverse effects of chemotherapy (nausea, vomiting, alopecia,
explains the reason for alopecia? bone marrow depression) are due to chemotherapy's effect on the rapidly
A. "Chemotherapy affects the cells of reproducing cells, both normal and malignant.
the body that grow rapidly, both
normal and malignant."
B."Alopecia is a common side effect
you will experience during long-term
steroid therapy."
C. "Your hair will grow back completely
after your course of chemotherapy
is completed."
D."The chemotherapy causes
permanent alterations in your hair
follicles that lead to hair loss."
,After checking the urinary drainage A. Report the findings to the surgeon.
system for kinks in the tubing, the nurse Rationale
determines that a client who has An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly
returned from the post-anesthesia care (1 ml/kg/hour). Dark, concentrated, and low volume of urine output should be
has a dark, concentrated urinary reported to the surgeon.
output of 54 ml for the last 2 hours.
What priority nursing action should be
implemented?
A. Report the findings to the surgeon.
B.Irrigate the indwelling urinary catheter.
C.Apply manual pressure to the bladder.
D.Increase the IV flow rate for 15 minutes.
A male client who smokes two packs of B, C and
cigarettes a day states he understands that D
smoking cigarettes is contributing to the Rationale
difficulty that he and his wife are having Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is
in getting pregnant and wants to know if also negatively affected by low testerone levels and obesity.
other factors could be contributing to
their difficulty. What information is best
for the nurse to provide? (Select all that
apply.) Select all that apply
A. Marijuana cigarettes do not affect
sperm count.
B.Alcohol consumption can cause
erectile dysfunction.
C. Low testosterone levels affect sperm
production.
D.Cessation of smoking improves
general health and fertility.
E.Obesity has no effect on sperm
production.
A client with gastroesophageal reflux D. Raising the head of the bed on blocks.
disease (GERD) has been experiencing Rationale
severe reflux during sleep. Which Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce
recommendation by the nurse is most reflux and subsequent aspiration is the most non-pharmacological effective
effective to assist the client? recommendation for a client experiencing severe gastroesophageal reflux during
A. Losing weight. sleep.
B.Decreasing caffeine intake.
C. Avoiding large meals.
D.Raising the head of the bed on blocks.
A 51-year-old truck driver who smokes A. Information about smoking cessation.
two packs of cigarettes a day and is 30 Rationale
pounds overweight is diagnosed with Smoking has been associated with ulcer formation, and stopping or decreasing the
having a gastric ulcer. What content is number of cigarettes smoked per day is an important aspect of ulcer management.
most important for the nurse to include
in the discharge teaching for this
client?
A. Information about smoking cessation.
B.Diet instructions for a low-residue diet.
C. Instructions on a weight-loss program.
D. The importance of increasing
milk in the diet.
, What types of medications should the D. Bronchodilators and steroids.
nurse expect to administer to a client Rationale
during an acute respiratory distress Besides supplemental oxygen, this client with ARDS needs medications to widen
episode? air passages, increase air space, and reduce alveolar membrane inflammation, such
A. Vasodilators and hormones. as bronchodilators and steroids.
B. Analgesics and sedatives.
C.Anticoagulants and expectorants.
D.Bronchodilators and steroids.
A female client is brought to the clinic D. Collect further data to determine whether self-neglect is occurring.
by her daughter for a flu shot. She has Rationale
lost significant weight since the last visit. She Changes in weight and hygiene may be indicators of self-neglect or neglect
has poor personal hygiene and by family members. Further assessment is needed before notifying social
inadequate clothing for the weather. services or discussing a need for counseling.
The client states that she lives alone and
denies problems or concerns. What
action should the nurse implement?
A. Notify social services immediately
of suspected elderly abuse.
B.Discuss the need for mental
health counseling with the
daughter.
C. Explain to the client that she needs
to take better care of herself.
D.Collect further data to determine
whether self-neglect is occurring.
The nurse is assisting a client out of bed for D. Allow the client to sit with the bed in a high Fowler's position.
the first time after surgery. What action Rationale
should the nurse do first? The first step is to raise the head of the bed to a high Fowler's position, which allow
A. Place a chair at a right angle to venous return to compensate from lying flat and the vasodilation effects of
the bedside. perioperative drugs. This helps prevent the client from becoming light-headed and
B.Encourage deep breathing prior to decreases the chance of a client fall.
standing.
C. Help the client to sit and dangle legs on
the side of the bed.
D. Allow the client to sit with the bed
in a
high Fowler's position.
A 32-year-old female client complains B. Inability to get pregnant.
of severe abdominal pain each month Rationale
before her menstrual period, painful Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common
intercourse, and painful defecation. symptoms of endometriosis, which is the abnormal displacement of endometrial
Which additional history should the tissue in the dependent areas of the pelvic peritoneum. A history of infertility is
nurse obtain that is consistent with the another common finding associated with endometriosis.
client's complaints?
A. Frequent urinary tract infections.
B.Inability to get pregnant.
C. Premenstrual syndrome.
D.Chronic use of laxatives.
