BSN 366 / BSN366: HESI Exam RN
Exit – Nightingale | Latest Update
Question:
A client who is receiving zidovudine reports the appearance of pinpoint,
red, brown spots on the skin. Which result should the nurse report to the
healthcare provider?
A) Skin biopsy.
B) Complete blood count.
C) Allergy test.
D) Electromyography.
Answer:
B) Complete blood count.
Rationale:
Zidovudine is an antiretroviral medication used to in the treatment of HIV infection. One
of the potential side effects of zidovudine is hematological toxicity, including anemia
(low rbc count) and neutropenia (low wbc count). The appearance of pinpoint, red,
round spots on the skin could be indicative of petechiae, which are small hemorrhages
caused by leakage of blood into the skin. Petechiae can occur due to low platelet
counts, a component of the CBC. Monitoring the CBC is important for clients receiving
zidovudine to identify any potential adverse affects on blood cell counts.
,Question:
Nurse is caring for a client with a sexually transmitted infections syphilis.
The client reports having had prior sexually transmitted infections. Which
response should the nurse provide?
A) Notify that persons with STDs are reported to local health departments.
B) Answer questions directly and correct any misinformation.
C) Provide counseling that most contraceptives protect against infection.
D) Discuss that partners without similar symptoms may not be infected.
Answer:
B) Answer questions directly and correct any misinformation.
Rationale:
Syphilis and other STIs are important public health concerns. The nurse
should provide accurate information, answer questions, and correct any
misconceptions the client might have. This approach supports the clients
knowledge and understanding of their health condition and prevents the
spread of misinformation.
Question:
Which instruction should the nurse delegate to an unlicensed assistive
personnel?
A) Call the pharmacy to obtain clients new antibiotic dose.
,B) Observe the clients gate to determine the need for assistance.
C) Bring a sterile chest drainage unit from central supply to the unit.
D) Evaluate a client's urinary catheter for proper drainage.
Answer:
C) Bring a sterile chest drainage unit from central supply to the unit.
Rationale:
This task is appropriate to delegate to a UAP. It involves transporting an
item from one location to another, which does not require clinical judgment
or assessment.
Question:
The nurse on a medical surgical unit receives a report from a post
anesthesia care unit nurse for a client who is being transferred following a
right hemicolectomy. The PACU nurse reports, the client has an IV infusion
of 1000 mL of lactated ringers infusing at 125 mL per hour into the left
wrist with 300 mL remaining. Prescriptions and food morphine sulfate 2 mg
IV every 2 to 4 hours for pain. Last administer 30 minutes ago, and aspirin
4 mg IV every eight hours for nausea, last administered 15 minutes ago.
Which additional information is most important for the nurse to obtain in
the report?
A) History of vomiting at home for three days prior to surgery.
B) Peripheral pulse is present with full range of motion of both legs.
C) Soft abdomen, absent bowel sounds, no bleeding on dressing.
, D) Declining to take ice chips for complaints of dry mouth.
Answer:
C) Soft abdomen, absent bowel sounds, no bleeding on dressing.
Rationale:
While all options are important to consider, the most critical information in this scenario
is assessing peripheral pulses and the range of motion of both legs. A right
hemicolectomy involves abdominal surgery and decreased or absent peripheral pulses
along with a limited range of motion could indicate impaired circulation, thrombosis, or
other post-operative complications. These findings might necessitate prompt
intervention to prevent potential complications.
Question:
When the parents of a six-year-old boy with a brain tumor are told that his
condition is terminal, the mother shouts at the father, "this is your fault! It
never would have happened if we had sought treatment sooner!" Which
intervention is best for the Nursing information?
A) Refer the parents to the chaplain to provide grief counseling.
B) I'm sure the parents that a terminal diagnosis was inevitable.
C) Explain to the parents that anger is a common response to grief.
D) Tell the parents that blaming each other will not change the situation.
Answer:
C) Explain to the parents that anger is a common response to grief.
Exit – Nightingale | Latest Update
Question:
A client who is receiving zidovudine reports the appearance of pinpoint,
red, brown spots on the skin. Which result should the nurse report to the
healthcare provider?
A) Skin biopsy.
B) Complete blood count.
C) Allergy test.
D) Electromyography.
Answer:
B) Complete blood count.
Rationale:
Zidovudine is an antiretroviral medication used to in the treatment of HIV infection. One
of the potential side effects of zidovudine is hematological toxicity, including anemia
(low rbc count) and neutropenia (low wbc count). The appearance of pinpoint, red,
round spots on the skin could be indicative of petechiae, which are small hemorrhages
caused by leakage of blood into the skin. Petechiae can occur due to low platelet
counts, a component of the CBC. Monitoring the CBC is important for clients receiving
zidovudine to identify any potential adverse affects on blood cell counts.
,Question:
Nurse is caring for a client with a sexually transmitted infections syphilis.
The client reports having had prior sexually transmitted infections. Which
response should the nurse provide?
A) Notify that persons with STDs are reported to local health departments.
B) Answer questions directly and correct any misinformation.
C) Provide counseling that most contraceptives protect against infection.
D) Discuss that partners without similar symptoms may not be infected.
Answer:
B) Answer questions directly and correct any misinformation.
Rationale:
Syphilis and other STIs are important public health concerns. The nurse
should provide accurate information, answer questions, and correct any
misconceptions the client might have. This approach supports the clients
knowledge and understanding of their health condition and prevents the
spread of misinformation.
Question:
Which instruction should the nurse delegate to an unlicensed assistive
personnel?
A) Call the pharmacy to obtain clients new antibiotic dose.
,B) Observe the clients gate to determine the need for assistance.
C) Bring a sterile chest drainage unit from central supply to the unit.
D) Evaluate a client's urinary catheter for proper drainage.
Answer:
C) Bring a sterile chest drainage unit from central supply to the unit.
Rationale:
This task is appropriate to delegate to a UAP. It involves transporting an
item from one location to another, which does not require clinical judgment
or assessment.
Question:
The nurse on a medical surgical unit receives a report from a post
anesthesia care unit nurse for a client who is being transferred following a
right hemicolectomy. The PACU nurse reports, the client has an IV infusion
of 1000 mL of lactated ringers infusing at 125 mL per hour into the left
wrist with 300 mL remaining. Prescriptions and food morphine sulfate 2 mg
IV every 2 to 4 hours for pain. Last administer 30 minutes ago, and aspirin
4 mg IV every eight hours for nausea, last administered 15 minutes ago.
Which additional information is most important for the nurse to obtain in
the report?
A) History of vomiting at home for three days prior to surgery.
B) Peripheral pulse is present with full range of motion of both legs.
C) Soft abdomen, absent bowel sounds, no bleeding on dressing.
, D) Declining to take ice chips for complaints of dry mouth.
Answer:
C) Soft abdomen, absent bowel sounds, no bleeding on dressing.
Rationale:
While all options are important to consider, the most critical information in this scenario
is assessing peripheral pulses and the range of motion of both legs. A right
hemicolectomy involves abdominal surgery and decreased or absent peripheral pulses
along with a limited range of motion could indicate impaired circulation, thrombosis, or
other post-operative complications. These findings might necessitate prompt
intervention to prevent potential complications.
Question:
When the parents of a six-year-old boy with a brain tumor are told that his
condition is terminal, the mother shouts at the father, "this is your fault! It
never would have happened if we had sought treatment sooner!" Which
intervention is best for the Nursing information?
A) Refer the parents to the chaplain to provide grief counseling.
B) I'm sure the parents that a terminal diagnosis was inevitable.
C) Explain to the parents that anger is a common response to grief.
D) Tell the parents that blaming each other will not change the situation.
Answer:
C) Explain to the parents that anger is a common response to grief.
