BSN 266 HESI Updated Questions & Answers |
Nursing Study Guide| Well Explained and
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An older adult client with a long history of chronic obstructive
pulmonary disease (COPD) is admitted with progressive shortness of
breath and a persistent cough. She is anxious and is complaining of
a dry mouth. Which intervention should the nurse implement?
A. Administer a prescribed sedative
B. Assist client to an upright position
C. Encourage client to drink water
D. Apply a high flow venturi mask
ANS: B. Assist client to an upright position
A client with multiple sclerosis (MS) is admitted to the medical unit,
The client reports fatigue, muscle weakness, and diplopia. Which
action should the nurse implement to reduce the clients risk for
falls? SATA
A. Provide assistance to bedside commode
B. Provide frequent rest periods.
C. Offer to assist with warm baths in the morning
D. Monitor pulse ox during activities
E. Teach to patch one eye while walking
ANS:
,A. Provide assistance to bedside commode\
C. Schedule frequent rest periods.
E. Teach to patch one eye while walking
A client arrives to the ED following a motor vehicle collision, The
nurse observes the client experiencing increasing dyspnea and
notes absent breath sounds on the left side, which procedure should
the nurse prepare for the client?
A. Bronchoscopy
B. Chest tube insertion
C. Endotracheal intubation
D. Pulmonary function test
ANS: B. Chest tube insertion
Following a transurethral resection of the prostate (TURP) a client is
discharged from the hospital with an indwelling urinary catheter,
Which instruction is most important for the nurse to include in the
discharge teaching plan?
A. Eliminate all spicy foods from your diet
B. Drink 3 liters of water each day
C. Clamp the catheter when taking a shower
D. Avoid driving a car for 2 weeks
ANS: B. Drink 3 liters of water each day
An adult woman with Graves disease is admitted with severe
dehydration and malnutrition, She is currently restless and refusing
to eat. Which action is most important for the nurse to implement?
A. Teach client relaxation techniques
B. Determine the clients food preferences
C. Maintain a patent Intravenous site
D. Keep room temperature cool
ANS: C. Maintain a paten intravenous site
A client tells the clinic nurse about experiencing burning on
urination, and assessment reveals that the client had sexual
,intercourse four days ago with a person who was a casual
acquaintance, Which action should the nurse implement?
A. Obtain a specimen of urethral drainage for culture
B. Observe the perineal area for a chancre like lesion
C. Identify all sexual partners in the last four days.
D. Assess for perineal itching erythema and excoriation
ANS: A. Obtain a specimen of urethral drainage for culture
The nurse is caring for a client admitted to the hospital with a
tentative diagnosis of bacterial meningitis, which diagnostic
procedure should the nurse prepare the client for?
A. Lumbar puncture
B. Skull radiography
C. MRI
D. CT
ANS: A Lumbar puncture
An older adult client with long term type 2 DM is seen in the clinic for
a routine health assessment, which assessment would the nurse
complete to determine if a patient with type 2 DM is experiencing
long term complications? SATA
A. Sensation in feet and legs
B. Skin condition of lower extremities
C. Visual acuity
D Serum creatinine and blood urea nitrogen (BUN)
E. Signs of respiratory tract infection
ANS:
A. Sensation in feet and legs
B. Skin condition of lower extremities
C. Visual acuity
D. Serum Creatinine and blood urea nitrogen (BUN)
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 a client with cirrhosis?
A. Decreased portacaval pressure with greater collateral circulation
B. Hypoalbuminemia that results in decreased colloidal oncotic
pressure
C. Decreased renin angiotensin response related to an increase in
renal blood flow
D. Hyperaldosteronism causing an increased sodium absorption in
renal tubes
ANS:
B. Hypoalbuminemia that results in decreased colloidal oncotic
pressure
Hypoalbuminemia that results in a decreased colloidal oncotic
pressure, this is correct, in cirrhosis liver damage leads to
decreased synthesis of albumin, Albumin plays a crucial role in
maintaining colloidal oncotic pressure and when it is decreased
(hypoalbuminemia) fluid is more likely to leak out of blood vessels
resulting n edema, the same mechanism contributes to the
development of ascites in the abdominal cavity.
D: Incorrect hyperaldosteronism is characterized by an excess of
aldosterone a hormone that regulates sodium and water balance in
cirrhosis sodium retention is often related to other mechanisms such
as portal hypertension and hypoalbuminemia rather than
hyperaldosteronism.
C. Cirrhosis is more commonly associated with an activated renin
angiotensin aldosterone system, leading to increased sodium and
water retention, the increased renin angiotensin response is a
compensatory mechanism to maintain perfusion in the setting o
cirrhosis and does not contribute to decreased renal blood flow
The nurse is planning care for an older adult client who experiences
a cerebrovascular accident several weeks ago. The client has
Nursing Study Guide| Well Explained and
Analysed|100% Guarantee Pass| Graded A+
,Rationalized ,Latest Exam and Brand new
Version!!!
An older adult client with a long history of chronic obstructive
pulmonary disease (COPD) is admitted with progressive shortness of
breath and a persistent cough. She is anxious and is complaining of
a dry mouth. Which intervention should the nurse implement?
A. Administer a prescribed sedative
B. Assist client to an upright position
C. Encourage client to drink water
D. Apply a high flow venturi mask
ANS: B. Assist client to an upright position
A client with multiple sclerosis (MS) is admitted to the medical unit,
The client reports fatigue, muscle weakness, and diplopia. Which
action should the nurse implement to reduce the clients risk for
falls? SATA
A. Provide assistance to bedside commode
B. Provide frequent rest periods.
C. Offer to assist with warm baths in the morning
D. Monitor pulse ox during activities
E. Teach to patch one eye while walking
ANS:
,A. Provide assistance to bedside commode\
C. Schedule frequent rest periods.
E. Teach to patch one eye while walking
A client arrives to the ED following a motor vehicle collision, The
nurse observes the client experiencing increasing dyspnea and
notes absent breath sounds on the left side, which procedure should
the nurse prepare for the client?
A. Bronchoscopy
B. Chest tube insertion
C. Endotracheal intubation
D. Pulmonary function test
ANS: B. Chest tube insertion
Following a transurethral resection of the prostate (TURP) a client is
discharged from the hospital with an indwelling urinary catheter,
Which instruction is most important for the nurse to include in the
discharge teaching plan?
A. Eliminate all spicy foods from your diet
B. Drink 3 liters of water each day
C. Clamp the catheter when taking a shower
D. Avoid driving a car for 2 weeks
ANS: B. Drink 3 liters of water each day
An adult woman with Graves disease is admitted with severe
dehydration and malnutrition, She is currently restless and refusing
to eat. Which action is most important for the nurse to implement?
A. Teach client relaxation techniques
B. Determine the clients food preferences
C. Maintain a patent Intravenous site
D. Keep room temperature cool
ANS: C. Maintain a paten intravenous site
A client tells the clinic nurse about experiencing burning on
urination, and assessment reveals that the client had sexual
,intercourse four days ago with a person who was a casual
acquaintance, Which action should the nurse implement?
A. Obtain a specimen of urethral drainage for culture
B. Observe the perineal area for a chancre like lesion
C. Identify all sexual partners in the last four days.
D. Assess for perineal itching erythema and excoriation
ANS: A. Obtain a specimen of urethral drainage for culture
The nurse is caring for a client admitted to the hospital with a
tentative diagnosis of bacterial meningitis, which diagnostic
procedure should the nurse prepare the client for?
A. Lumbar puncture
B. Skull radiography
C. MRI
D. CT
ANS: A Lumbar puncture
An older adult client with long term type 2 DM is seen in the clinic for
a routine health assessment, which assessment would the nurse
complete to determine if a patient with type 2 DM is experiencing
long term complications? SATA
A. Sensation in feet and legs
B. Skin condition of lower extremities
C. Visual acuity
D Serum creatinine and blood urea nitrogen (BUN)
E. Signs of respiratory tract infection
ANS:
A. Sensation in feet and legs
B. Skin condition of lower extremities
C. Visual acuity
D. Serum Creatinine and blood urea nitrogen (BUN)
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 a client with cirrhosis?
A. Decreased portacaval pressure with greater collateral circulation
B. Hypoalbuminemia that results in decreased colloidal oncotic
pressure
C. Decreased renin angiotensin response related to an increase in
renal blood flow
D. Hyperaldosteronism causing an increased sodium absorption in
renal tubes
ANS:
B. Hypoalbuminemia that results in decreased colloidal oncotic
pressure
Hypoalbuminemia that results in a decreased colloidal oncotic
pressure, this is correct, in cirrhosis liver damage leads to
decreased synthesis of albumin, Albumin plays a crucial role in
maintaining colloidal oncotic pressure and when it is decreased
(hypoalbuminemia) fluid is more likely to leak out of blood vessels
resulting n edema, the same mechanism contributes to the
development of ascites in the abdominal cavity.
D: Incorrect hyperaldosteronism is characterized by an excess of
aldosterone a hormone that regulates sodium and water balance in
cirrhosis sodium retention is often related to other mechanisms such
as portal hypertension and hypoalbuminemia rather than
hyperaldosteronism.
C. Cirrhosis is more commonly associated with an activated renin
angiotensin aldosterone system, leading to increased sodium and
water retention, the increased renin angiotensin response is a
compensatory mechanism to maintain perfusion in the setting o
cirrhosis and does not contribute to decreased renal blood flow
The nurse is planning care for an older adult client who experiences
a cerebrovascular accident several weeks ago. The client has
