BSN 366 HESI - PRACTICE TEST EXAM QUESTIONS AND ANSWERS GRADED A+
1. A client is admitted to the hospital for alcohol dependency.
What is the priority nursing intervention during the first 48
hours following admission?
A. Administer thiamine (B1) to prevent Korsakoff's syndrome.
B. Monitor for increased blood pressure and pulse.
C. Administer a PRN benzodiazepine as needed for anxiety.
D. Encourage fluid intake of non-caffeinated
beverages. Submit: B. Monitor for increased blood
pressure and pulse.
Rationale
Clients with alcohol dependency experience withdrawal symptoms, which include
elevated blood pressure, pulse, and temperature, so monitoring these physical
parameters has the highest priority. Administering thamine will prevent Korsakott's
syndrome (secondary dementia caused by thiamine deficiency, associated with
malnutrition secondary to excessive alcohol intake, but this intervention does not
have the priority of monitoring vital signs.
,2. A child with Tetrology of Fallot suffers a hypercyanotic
episode. Which im-mediate action by the nurse can lessen the
symptoms of this "TET spell?"
A. Remove child's constrictive clothing.
B. Place child in knee-chest position.
C. Have child stop all current activity.
D. Administer a dose of digoxin stat.: B. Place child in knee-chest
position.
Rationale
The child should be placed on his or her back in the knee-to-chest position to
increase blood vessel resistance. The increased pressure reduces the rush of blood
through the septal hole and improves blood circulation. Removing tight clothing has
nominal ettects in hypercyanosis. Stopping current activity is self-regulating. A dose
of digoxin is not indicated for immediate relief of "tet spells." It is used to improve
cardiac output.
3. The nurse is assessing a client and identifies the presence of
petechiae. Which documentation best describes this
finding?
A. Purplish-red pinpoint lesions of the skin.
B. Purple to bluish discoloration of the skin.
C. Small circumscribed elevations containing purulent fluid.
D. Generalized reddish discoloration of an area of skin.: A. Purplish-
red pinpoint lesions
,of the skin.
Rationale
Petechiae are described as purplish to red, non-blanchable, pinpoint lesions that
are tiny hemorrhages within the dermal or submucosal layers. Purplish skin
discoloration describes ecchymosis caused by trauma to the underlying blood
vessels. Small elevations conting pus describes pustules. Generalize red skin area is
nonspecific and incomplete.
4. Which information should the nurse give a client with chronic
kidney disease (CKD)?
A. Restrict calcium-rich foods.
B. Obtain monthly B12 injections.
C. Avoid salt substitutes.
D. Increase daily intake of fiber.: C. Avoid salt substitutes.
Rationale
A client with CKD should restrict sodium and potassium dietary intake, and salt
substitutes usually contain potassium, so they should avoid using them. Hypocalcemia
is a complication of CKD and calcium supplements are often needed. Anemia related
to CKD is treated with iron, folic acid, and erythropoietin, not B12 injections.
Although increasing fiber is a common dietary recommendation, it not an essential
part of client teaching for CKD.
5. A nurse is answering questions about breast cancer at a
hospital-sponsored community health fair. A woman asks the
nurse to explain the use of tamox-ifen (Nolvadex). Which
, response should the nurse provide?
A. Low doses of tamoxifen prevent menopausal hot flashes.
B. An option used to reduce the risk of breast cancer for all
women.
C. This anti-estrogen drug inhibits malignancy growth.
D. Part of a combination of chemotherapeutic agents used to treat
tumors.: C. This anti-estrogen drug inhibits malignancy growth.
Rationale
Tamoxifen (Nolvadex) is used in postmenopausal women with breast cancer to
prevent and treat recurrent cancer and inhibit the growth-stimulating ettects of
estrogen by blocking estrogen receptor sites on malignant cells. A side ettect of
tamoxifen is hot flashes, which is related to the decreased estrogen. Tamoxifen is
used for women with estrogen
1. A client is admitted to the hospital for alcohol dependency.
What is the priority nursing intervention during the first 48
hours following admission?
A. Administer thiamine (B1) to prevent Korsakoff's syndrome.
B. Monitor for increased blood pressure and pulse.
C. Administer a PRN benzodiazepine as needed for anxiety.
D. Encourage fluid intake of non-caffeinated
beverages. Submit: B. Monitor for increased blood
pressure and pulse.
Rationale
Clients with alcohol dependency experience withdrawal symptoms, which include
elevated blood pressure, pulse, and temperature, so monitoring these physical
parameters has the highest priority. Administering thamine will prevent Korsakott's
syndrome (secondary dementia caused by thiamine deficiency, associated with
malnutrition secondary to excessive alcohol intake, but this intervention does not
have the priority of monitoring vital signs.
,2. A child with Tetrology of Fallot suffers a hypercyanotic
episode. Which im-mediate action by the nurse can lessen the
symptoms of this "TET spell?"
A. Remove child's constrictive clothing.
B. Place child in knee-chest position.
C. Have child stop all current activity.
D. Administer a dose of digoxin stat.: B. Place child in knee-chest
position.
Rationale
The child should be placed on his or her back in the knee-to-chest position to
increase blood vessel resistance. The increased pressure reduces the rush of blood
through the septal hole and improves blood circulation. Removing tight clothing has
nominal ettects in hypercyanosis. Stopping current activity is self-regulating. A dose
of digoxin is not indicated for immediate relief of "tet spells." It is used to improve
cardiac output.
3. The nurse is assessing a client and identifies the presence of
petechiae. Which documentation best describes this
finding?
A. Purplish-red pinpoint lesions of the skin.
B. Purple to bluish discoloration of the skin.
C. Small circumscribed elevations containing purulent fluid.
D. Generalized reddish discoloration of an area of skin.: A. Purplish-
red pinpoint lesions
,of the skin.
Rationale
Petechiae are described as purplish to red, non-blanchable, pinpoint lesions that
are tiny hemorrhages within the dermal or submucosal layers. Purplish skin
discoloration describes ecchymosis caused by trauma to the underlying blood
vessels. Small elevations conting pus describes pustules. Generalize red skin area is
nonspecific and incomplete.
4. Which information should the nurse give a client with chronic
kidney disease (CKD)?
A. Restrict calcium-rich foods.
B. Obtain monthly B12 injections.
C. Avoid salt substitutes.
D. Increase daily intake of fiber.: C. Avoid salt substitutes.
Rationale
A client with CKD should restrict sodium and potassium dietary intake, and salt
substitutes usually contain potassium, so they should avoid using them. Hypocalcemia
is a complication of CKD and calcium supplements are often needed. Anemia related
to CKD is treated with iron, folic acid, and erythropoietin, not B12 injections.
Although increasing fiber is a common dietary recommendation, it not an essential
part of client teaching for CKD.
5. A nurse is answering questions about breast cancer at a
hospital-sponsored community health fair. A woman asks the
nurse to explain the use of tamox-ifen (Nolvadex). Which
, response should the nurse provide?
A. Low doses of tamoxifen prevent menopausal hot flashes.
B. An option used to reduce the risk of breast cancer for all
women.
C. This anti-estrogen drug inhibits malignancy growth.
D. Part of a combination of chemotherapeutic agents used to treat
tumors.: C. This anti-estrogen drug inhibits malignancy growth.
Rationale
Tamoxifen (Nolvadex) is used in postmenopausal women with breast cancer to
prevent and treat recurrent cancer and inhibit the growth-stimulating ettects of
estrogen by blocking estrogen receptor sites on malignant cells. A side ettect of
tamoxifen is hot flashes, which is related to the decreased estrogen. Tamoxifen is
used for women with estrogen
