BSN 266 HESI EXAM
Questions and Answers
1.Question 1 of 55
The nurse is evaluating a client's understanding about the DASH (Dietary
Approaches to Stop Hypertension) eating plan. Which behavior indicates
that the client is adhering to the eating plan?
- A Uses only lactose-free dairy products.
- B Carefully cleans and peels all fresh fruit and vegetables.
- C No longer incudes grains in daily diet.
- D Enjoys fat-free yogurt as an occasional snack food.
Answer - D Enjoys fat-free yogurt as an occasional snack food.
2.Question 2 of 55
A client who has a history of hypothyroidism was initially admitted with
lethargy and confusion. Which additional finding warrants the most
immediate action by the nurse? [Hematocrit (Reference Range Male 42% to
52% (0.42 to 0.52 volume fraction)]
- A Further decline in level of consciousness.
- B Hematocrit of 30% (0.30 volume fraction)
- C Cold and dry skin.
- D Facial puffiness and periorbital edema
,Answer - A Further decline in level of con- sciousness.
3.Question 3 of 55
The nurse is caring for a client with a burn that is severely edematous with a
wound bed that is brown and yellow in appearance. The client expresses
feel- ing no pain. Which classification of burn depth should the nurse
document?
- A Deep full-thickness.
- B Full thickness.
- C Deep partial-thickness.
- D Superficial partial-thickness.
Answer - B Full thickness.
4.Question 4 of 55
An older client who is agitated, dyspneic, orthopneic, and using acces-
sory muscles to breathe is admitted for further treatment. Initial assess-
ment includes a heart rate 128 beats/minute and irregular, respirations 38
breaths/minute, blood pressure 168/100 mm Hg, wheezes and crackles in
all
lung fields. An hour after the administration of furosemide 60 mg
intravenous (IV), which assessment(s) should the nurse obtain to determine
the client's response to treatment? (Select all that apply.)
- A Urinary output.
- B Oxygen saturation.
- C Pain scale.
,- D Lung sounds.
- E Skin elasticity.
Answer - A Urinary output.
- B Oxygen saturation.
- D Lung sounds.
Orthopneic position, sometimes called tripod position, is a sitting
position where an individual leans slightly forward with their arms
propped up on an overbed table or their knees.
Orthopnea is the sensation of breathlessness in the recumbent (lying
down) posi- tion, relieved by sitting or standing.
5.Question 5 of 55
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 Crohn's disease with colectomy.
- C Type 2 diabetes mellitus.
- D Latent hepatitis C.
Answer - B Crohn's disease with colectomy.
Question # 5
Rationale - B Crohn's disease with colectomy.
, The nurse should recognize that clients with extensive intra-abdominal
surgical his- tory are not candidates for peritoneal dialysis, as these
clients may have decreased peritoneal membrane surface areas and
scar tissue formation, which would make it insufficient for adequate
dialysis exchange.
6.Question 6 of 55
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 Decreased portacaval pressure with greater collateral circulation.
- B Hyperaldosteronism causing an increased sodium reabsorption in
renal tubules.
- C Decreased renin-angiotensin response related to an increase in renal
blood flow.
- D Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
Answer - D Hypoalbuminemia that results in a decreased colloidal
oncotic pressure.
The three main things that the liver produces are albumin, bile
(digestive enzymes), and prothrombin (clotting factors).
Albumin plays many important roles including maintenance of
appropriate osmotic pressure, binding and transport of various
substances like hormones, drugs etc. in blood, and neutralisation of
free radicals. It prevents fluid from leaking out of
Questions and Answers
1.Question 1 of 55
The nurse is evaluating a client's understanding about the DASH (Dietary
Approaches to Stop Hypertension) eating plan. Which behavior indicates
that the client is adhering to the eating plan?
- A Uses only lactose-free dairy products.
- B Carefully cleans and peels all fresh fruit and vegetables.
- C No longer incudes grains in daily diet.
- D Enjoys fat-free yogurt as an occasional snack food.
Answer - D Enjoys fat-free yogurt as an occasional snack food.
2.Question 2 of 55
A client who has a history of hypothyroidism was initially admitted with
lethargy and confusion. Which additional finding warrants the most
immediate action by the nurse? [Hematocrit (Reference Range Male 42% to
52% (0.42 to 0.52 volume fraction)]
- A Further decline in level of consciousness.
- B Hematocrit of 30% (0.30 volume fraction)
- C Cold and dry skin.
- D Facial puffiness and periorbital edema
,Answer - A Further decline in level of con- sciousness.
3.Question 3 of 55
The nurse is caring for a client with a burn that is severely edematous with a
wound bed that is brown and yellow in appearance. The client expresses
feel- ing no pain. Which classification of burn depth should the nurse
document?
- A Deep full-thickness.
- B Full thickness.
- C Deep partial-thickness.
- D Superficial partial-thickness.
Answer - B Full thickness.
4.Question 4 of 55
An older client who is agitated, dyspneic, orthopneic, and using acces-
sory muscles to breathe is admitted for further treatment. Initial assess-
ment includes a heart rate 128 beats/minute and irregular, respirations 38
breaths/minute, blood pressure 168/100 mm Hg, wheezes and crackles in
all
lung fields. An hour after the administration of furosemide 60 mg
intravenous (IV), which assessment(s) should the nurse obtain to determine
the client's response to treatment? (Select all that apply.)
- A Urinary output.
- B Oxygen saturation.
- C Pain scale.
,- D Lung sounds.
- E Skin elasticity.
Answer - A Urinary output.
- B Oxygen saturation.
- D Lung sounds.
Orthopneic position, sometimes called tripod position, is a sitting
position where an individual leans slightly forward with their arms
propped up on an overbed table or their knees.
Orthopnea is the sensation of breathlessness in the recumbent (lying
down) posi- tion, relieved by sitting or standing.
5.Question 5 of 55
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 Crohn's disease with colectomy.
- C Type 2 diabetes mellitus.
- D Latent hepatitis C.
Answer - B Crohn's disease with colectomy.
Question # 5
Rationale - B Crohn's disease with colectomy.
, The nurse should recognize that clients with extensive intra-abdominal
surgical his- tory are not candidates for peritoneal dialysis, as these
clients may have decreased peritoneal membrane surface areas and
scar tissue formation, which would make it insufficient for adequate
dialysis exchange.
6.Question 6 of 55
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 Decreased portacaval pressure with greater collateral circulation.
- B Hyperaldosteronism causing an increased sodium reabsorption in
renal tubules.
- C Decreased renin-angiotensin response related to an increase in renal
blood flow.
- D Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
Answer - D Hypoalbuminemia that results in a decreased colloidal
oncotic pressure.
The three main things that the liver produces are albumin, bile
(digestive enzymes), and prothrombin (clotting factors).
Albumin plays many important roles including maintenance of
appropriate osmotic pressure, binding and transport of various
substances like hormones, drugs etc. in blood, and neutralisation of
free radicals. It prevents fluid from leaking out of
