BSN 266 HESI V2 question and answer already
passed
Neutrophil count- The patient is experiencing infection, so a nurse should review the neutrophil count
before contacting the HCP. - ✔✔While caring for a client with full thickness burns covering 40% of the
body, the nurse observes purulent drainage from the wounds. Before reporting the finding, what is the
best lab value to evaluate?
Demonstrate the use of visual scanning during meals to the client and family. - ✔✔An older woman who
experienced a cerebrovascular accident (CVA) has difficulty with visual perception and she only eats half
of the food on her meal tray. Her family expresses concern about her nutritional status. How should the
nurse respond to the family's concern?
High Fowler's Position- High fowlers helps to decrease venous return, which decreases fluid volume in
the heart that results in decreased cardiac workload. - ✔✔Best position for respiratory distress?
High risk for injury - ✔✔A patient with peripheral artery disease has marked peripheral neuropath. An
appropriate nursing diagnosis for the patient is
Check feet every day for cuts or injuries. - ✔✔Type 2 diabetes patient discharge teaching patient and
family
Institute Contact precautions for staff and visitors
Send wound drainage for culture and sensitivity
Monitor the clients WBC count - ✔✔Plan of care for patient with skin lesions of lower extremities with
possible MRSA. SATA
Hematemesis- - Contact HCP if blood is visible in body fluids such as hematemesis. - ✔✔A patient with
, acute anterior wall MI 1 week ago is given low-dose aspirin. The medication is related to which problem
and HCP should be notified?
Elevated blood urea nitrogen (BUN) - ✔✔For a patient with SLE exacerbation what is the most important
to report which assessment finding?
Rate of pain on a scale from 0-10. - ✔✔Before selecting a medication to administer, which action should
the nurse implement in the post-op patient who reports incisional pain and has 2 PRN analgesia
available in MAR?
Keep patient NPO- Patient should be kept NPO until procedure is successfully completed. The patient
should not take anything by mouth. - ✔✔Patient had bariatric surgery 2 months ago who developed
post-op strictures who is experiencing nausea and vomiting and anorexia who is admitted for fluid
resuscitation. Which intervention should the nurse implement?
Vital sign changes and ECGs- Priority parameters are vital sign changes related to hypovolemia and ECG
changes due to serum electrolyte loss, which can be life threatening. - ✔✔Acute Kidney Injury due to
aminoglycoside antibiotic moved from oliguric phase to the diuretic phase. Which parameters are most
important to monitor?
Nuts, chocolate, dark greens, and spinach. - ✔✔Patient has a calcium oxalate renal stone. Which food
are you going to teach the patient to avoid?
Pancreatitis- complications include pancreatitis that may manifest with upper left quadrant or
mid-epigastric pain which radiates to the back and accompanied by nausea, vomiting, and fever. - ✔✔A
patient had a cholecystectomy 2 days ago, the patient is febrile, abdominal pain radiating to the back
and has had 3 episodes of vomiting in the last 8 hours. The patient is exhibiting symptoms for which
condition?
Uncompensated Metabolic Alkalosis - ✔✔Patient has a bowel obstruction and ABGs read ph- 7.50
PaCO2-42 and HCO3-33. How would you define this acid base balance?
passed
Neutrophil count- The patient is experiencing infection, so a nurse should review the neutrophil count
before contacting the HCP. - ✔✔While caring for a client with full thickness burns covering 40% of the
body, the nurse observes purulent drainage from the wounds. Before reporting the finding, what is the
best lab value to evaluate?
Demonstrate the use of visual scanning during meals to the client and family. - ✔✔An older woman who
experienced a cerebrovascular accident (CVA) has difficulty with visual perception and she only eats half
of the food on her meal tray. Her family expresses concern about her nutritional status. How should the
nurse respond to the family's concern?
High Fowler's Position- High fowlers helps to decrease venous return, which decreases fluid volume in
the heart that results in decreased cardiac workload. - ✔✔Best position for respiratory distress?
High risk for injury - ✔✔A patient with peripheral artery disease has marked peripheral neuropath. An
appropriate nursing diagnosis for the patient is
Check feet every day for cuts or injuries. - ✔✔Type 2 diabetes patient discharge teaching patient and
family
Institute Contact precautions for staff and visitors
Send wound drainage for culture and sensitivity
Monitor the clients WBC count - ✔✔Plan of care for patient with skin lesions of lower extremities with
possible MRSA. SATA
Hematemesis- - Contact HCP if blood is visible in body fluids such as hematemesis. - ✔✔A patient with
, acute anterior wall MI 1 week ago is given low-dose aspirin. The medication is related to which problem
and HCP should be notified?
Elevated blood urea nitrogen (BUN) - ✔✔For a patient with SLE exacerbation what is the most important
to report which assessment finding?
Rate of pain on a scale from 0-10. - ✔✔Before selecting a medication to administer, which action should
the nurse implement in the post-op patient who reports incisional pain and has 2 PRN analgesia
available in MAR?
Keep patient NPO- Patient should be kept NPO until procedure is successfully completed. The patient
should not take anything by mouth. - ✔✔Patient had bariatric surgery 2 months ago who developed
post-op strictures who is experiencing nausea and vomiting and anorexia who is admitted for fluid
resuscitation. Which intervention should the nurse implement?
Vital sign changes and ECGs- Priority parameters are vital sign changes related to hypovolemia and ECG
changes due to serum electrolyte loss, which can be life threatening. - ✔✔Acute Kidney Injury due to
aminoglycoside antibiotic moved from oliguric phase to the diuretic phase. Which parameters are most
important to monitor?
Nuts, chocolate, dark greens, and spinach. - ✔✔Patient has a calcium oxalate renal stone. Which food
are you going to teach the patient to avoid?
Pancreatitis- complications include pancreatitis that may manifest with upper left quadrant or
mid-epigastric pain which radiates to the back and accompanied by nausea, vomiting, and fever. - ✔✔A
patient had a cholecystectomy 2 days ago, the patient is febrile, abdominal pain radiating to the back
and has had 3 episodes of vomiting in the last 8 hours. The patient is exhibiting symptoms for which
condition?
Uncompensated Metabolic Alkalosis - ✔✔Patient has a bowel obstruction and ABGs read ph- 7.50
PaCO2-42 and HCO3-33. How would you define this acid base balance?
