BSN HESI 266 EXAM QUESTIONS
WITH CORRECT DETAILED
ANSWERS
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?
a. Activity level of bowel sounds.
b. Eating patterns of dietary intake.
c. Level and amount of physical activity
d. Color and consistency of feces - Answer-b. Eating patterns of dietary intake.
An older adult client with a long hist
ory 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?
a. Apply a tight flow venturi mask.
b. Encourage client to drink water.
c. Assist client to an upright position.
d. Administer a prescribed sedative - 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?
a. Monitor the client's intravenous site hourly during the treatment
b. Keep the head of the bed
elevated until the treatment is completed.
c. Instruct the client to drink plenty of fluids during the treatment.
,d. Administer an antiemetic before starting the 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 opt
ion that applies. To repeat the video, click the play button again.)
a. Continue with the insulin injection.
b. Keep the skin flat rather than bunched.
c. Lie down flat for better skin exposure.
d. Select a different injection site - 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.
a. Oxygen saturation
b. Pain scale
c. Lung sounds
d. Urinary output
e. Skin elasticity - Answer-a. Oxygen saturation
c. Lung sounds
d. Urinary output
(LOU)
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?
a. White blood cell (WBC) count
b. Hematocrit.
c. Platelet count.
d. Blood pH level - 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?
a. Red blood cell count.
b. Platelet count.
c. White blood cell count.
d. Hemoglobin levels. - 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?
a. Monitoring catheter drainage (pic one says this)
b. irrigation the catheter manually.
c. Decreasing the flow rate.
d. Discounting infusing solution. - Answer-a. Monitoring catheter drainage (pic one says
this)
The nurse is preparing a client for surgery who was admitted to the emergency center
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?
a. Notify the healthcare provider of the client's medication history.
WITH CORRECT DETAILED
ANSWERS
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?
a. Activity level of bowel sounds.
b. Eating patterns of dietary intake.
c. Level and amount of physical activity
d. Color and consistency of feces - Answer-b. Eating patterns of dietary intake.
An older adult client with a long hist
ory 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?
a. Apply a tight flow venturi mask.
b. Encourage client to drink water.
c. Assist client to an upright position.
d. Administer a prescribed sedative - 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?
a. Monitor the client's intravenous site hourly during the treatment
b. Keep the head of the bed
elevated until the treatment is completed.
c. Instruct the client to drink plenty of fluids during the treatment.
,d. Administer an antiemetic before starting the 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 opt
ion that applies. To repeat the video, click the play button again.)
a. Continue with the insulin injection.
b. Keep the skin flat rather than bunched.
c. Lie down flat for better skin exposure.
d. Select a different injection site - 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.
a. Oxygen saturation
b. Pain scale
c. Lung sounds
d. Urinary output
e. Skin elasticity - Answer-a. Oxygen saturation
c. Lung sounds
d. Urinary output
(LOU)
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?
a. White blood cell (WBC) count
b. Hematocrit.
c. Platelet count.
d. Blood pH level - 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?
a. Red blood cell count.
b. Platelet count.
c. White blood cell count.
d. Hemoglobin levels. - 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?
a. Monitoring catheter drainage (pic one says this)
b. irrigation the catheter manually.
c. Decreasing the flow rate.
d. Discounting infusing solution. - Answer-a. Monitoring catheter drainage (pic one says
this)
The nurse is preparing a client for surgery who was admitted to the emergency center
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?
a. Notify the healthcare provider of the client's medication history.
