BSN HESI 266-EXAM CONSOLIDATED
Questions and Answers
1.A client experiences an AOB incompatibility reaction after multiple blood
transfusions. Which finding should the nurse report immediately to the
health care provider?
a. low back pain and hypotension
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
d. arthritic joint changes and chronic pain
Answer a. low back pain and hypotension
2.When conducting discharge teaching for a client diagnosed with
diverticulosis, which diet instruction should the nurse include?
a. Have small frequent meals and sit up for at least two hours after meals.
b. Eat a bland diet and avoid spicy foods.
c. Eat a high-fiber diet and increase fluid intake.
d. Eat a soft diet with increased intake of milk and milk products
Answer c. Eat a high-fiber diet and increase fluid intake.
3.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?
a. Provide additional oral fluid intake
b. Measure the client's intake and output.
c. Increase the flow of the bladder irrigation
d. Administer a PRN dose of an antispasmodic agent
Answer c. Increase the flow of the bladder irrigation
4.A client with lung cancer who wears subcutaneous morphine sulfate
patch for pain is short of breath and is difficult to arouse. When performing
a head to toe assessment, the nurse discovers four analgesic patches on
the client's body. Which intervention should the nurse implement first?
A. Remove all of the morphine patches
B. Administer a narcotic antagonist
C. Apply oxygen per face mask
D. Measure the client's blood pressure
Answer B. Administer a narcotic antagonist
5.After falling down the basement steps, a client is brought to the
emergency room. X-ray confirms that the client's right leg is fractured.
Following applica- tion of a leg cast, which assessment finding warrants
immediate intervention by the nurse?
a. Circumferential edema of right foot.
b. Complaint of throbbing right leg pain.
c. Right foot pale with sluggish capillary refill.
d. Increased temperature to lower extremity
,Answer c. Right foot pale with sluggish capillary refill
The answer indicates a potential problem with the blood circulation in
the client's right foot. When a leg cast is applied, it should not
interfere with the blood flow to the foot. However, if the foot becomes
pale and the capillary refill is sluggish, it suggests that the blood flow
might be compromised. Capillary refill is the time taken for color to
return to an external capillary bed after pressure is applied to
cause blanching. Normal capillary refill time is usually less than 2
seconds. Sluggish or delayed capillary refill can be a sign of peripheral
vascular disease, shock, or hypothermia. In this case, it could be due to
the cast being too tight, causing a reduction in blood flow to the foot.
This is a serious condition that requires immediate intervention by the
nurse to prevent further complications such as tissue necrosis due to
lack of oxygen and nutrients. The nurse may need to adjust or remove
the cast to restore proper blood flow.
6.An overweight, young adult who was recently diagnosed with type 2 di-
abetes 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.)
A. Check his fingerstick glucose level
B. Assess his skin temperature and moisture
C. Measure his pulse and blood pressure
D. Document anxiety on the surgical checklist
, E. Administer a PRN dose of regular insulin
Answer A. Check finger stick glucose
B. Assess skin temperature and moisture
C. Measure pulse and blood pressure
Answer (CAM)
7.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?
a. Listen for extra heart sounds, murmurs, and rhythm with the bell
of the stethoscope.
b. Evaluate upper and lower extremities for perfusion, pulse
volume, and pitting edema.
c.Verify troponin level assessments are scheduled every 3-6 hours for a series
of three.
d. Obtain a 12-lead electrocardiogram and begin continuous cardiac
monitor- ing.
Answer d. Obtain a 12-lead electrocardiogram and begin continuous
cardiac monitor- ing
8.While completing a health assessment for a client with migraine
headaches, the nurse assesses bilateral weakness in the clients hand grips.
Questions and Answers
1.A client experiences an AOB incompatibility reaction after multiple blood
transfusions. Which finding should the nurse report immediately to the
health care provider?
a. low back pain and hypotension
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
d. arthritic joint changes and chronic pain
Answer a. low back pain and hypotension
2.When conducting discharge teaching for a client diagnosed with
diverticulosis, which diet instruction should the nurse include?
a. Have small frequent meals and sit up for at least two hours after meals.
b. Eat a bland diet and avoid spicy foods.
c. Eat a high-fiber diet and increase fluid intake.
d. Eat a soft diet with increased intake of milk and milk products
Answer c. Eat a high-fiber diet and increase fluid intake.
3.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?
a. Provide additional oral fluid intake
b. Measure the client's intake and output.
c. Increase the flow of the bladder irrigation
d. Administer a PRN dose of an antispasmodic agent
Answer c. Increase the flow of the bladder irrigation
4.A client with lung cancer who wears subcutaneous morphine sulfate
patch for pain is short of breath and is difficult to arouse. When performing
a head to toe assessment, the nurse discovers four analgesic patches on
the client's body. Which intervention should the nurse implement first?
A. Remove all of the morphine patches
B. Administer a narcotic antagonist
C. Apply oxygen per face mask
D. Measure the client's blood pressure
Answer B. Administer a narcotic antagonist
5.After falling down the basement steps, a client is brought to the
emergency room. X-ray confirms that the client's right leg is fractured.
Following applica- tion of a leg cast, which assessment finding warrants
immediate intervention by the nurse?
a. Circumferential edema of right foot.
b. Complaint of throbbing right leg pain.
c. Right foot pale with sluggish capillary refill.
d. Increased temperature to lower extremity
,Answer c. Right foot pale with sluggish capillary refill
The answer indicates a potential problem with the blood circulation in
the client's right foot. When a leg cast is applied, it should not
interfere with the blood flow to the foot. However, if the foot becomes
pale and the capillary refill is sluggish, it suggests that the blood flow
might be compromised. Capillary refill is the time taken for color to
return to an external capillary bed after pressure is applied to
cause blanching. Normal capillary refill time is usually less than 2
seconds. Sluggish or delayed capillary refill can be a sign of peripheral
vascular disease, shock, or hypothermia. In this case, it could be due to
the cast being too tight, causing a reduction in blood flow to the foot.
This is a serious condition that requires immediate intervention by the
nurse to prevent further complications such as tissue necrosis due to
lack of oxygen and nutrients. The nurse may need to adjust or remove
the cast to restore proper blood flow.
6.An overweight, young adult who was recently diagnosed with type 2 di-
abetes 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.)
A. Check his fingerstick glucose level
B. Assess his skin temperature and moisture
C. Measure his pulse and blood pressure
D. Document anxiety on the surgical checklist
, E. Administer a PRN dose of regular insulin
Answer A. Check finger stick glucose
B. Assess skin temperature and moisture
C. Measure pulse and blood pressure
Answer (CAM)
7.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?
a. Listen for extra heart sounds, murmurs, and rhythm with the bell
of the stethoscope.
b. Evaluate upper and lower extremities for perfusion, pulse
volume, and pitting edema.
c.Verify troponin level assessments are scheduled every 3-6 hours for a series
of three.
d. Obtain a 12-lead electrocardiogram and begin continuous cardiac
monitor- ing.
Answer d. Obtain a 12-lead electrocardiogram and begin continuous
cardiac monitor- ing
8.While completing a health assessment for a client with migraine
headaches, the nurse assesses bilateral weakness in the clients hand grips.
