BSN 266 HESI V2 UPDATED MED SURG EXAM (NEW
UPDATE) QUESTIONS AND ANSWERS |GRADE A|
100% CORRECT (COMPLETE ANSWERS) -
NIGHTINGALE
Neutrophil count- The patient is experiencing infection, so a nurse should review
the neutrophil count before contacting the HCP. - ANSWER-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. -
ANSWER-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. -
ANSWER-Best position for respiratory distress?
High risk for injury - ANSWER-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. - ANSWER-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 - ANSWER-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.
- ANSWER-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) - ANSWER-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. - ANSWER-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. - ANSWER-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. - ANSWER-Acute Kidney Injury due to aminoglycoside antibiotic
UPDATE) QUESTIONS AND ANSWERS |GRADE A|
100% CORRECT (COMPLETE ANSWERS) -
NIGHTINGALE
Neutrophil count- The patient is experiencing infection, so a nurse should review
the neutrophil count before contacting the HCP. - ANSWER-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. -
ANSWER-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. -
ANSWER-Best position for respiratory distress?
High risk for injury - ANSWER-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. - ANSWER-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 - ANSWER-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.
- ANSWER-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) - ANSWER-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. - ANSWER-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. - ANSWER-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. - ANSWER-Acute Kidney Injury due to aminoglycoside antibiotic
