BSN 266 HESI
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1. A client who underwent cardiac stent place- D
ment four days ago arrives to the
emergency department reporting a sudden
onset of chest pressure and
shortness of breath. Which action should the
nurse take next?
a. Listen for extra heart sounds, murmurs, and
rhythm with the bell of
the stethoscope.
b. Evaluate upper and lower extremities for
perfusion, pulse volume,
and pitting edema.
c. Verify troponin level assessments are sched-
uled every 3-6 hours
for a series of three.
d. Obtain a 12- lead electrocardiogram and
begin continuous cardiac
monitoring.
2. A client with type 2 diabetes mellitus arrives to B
the clinic reporting episodes of
weakness and palpitations. Which finding
should the nurse recognize as a
possible complication?
a. anxiety and sighing
b. myalgia in wrists and hands
c. hyperactive bowel sounds
d. dark yellow urine
3. 4While completing a health assessment for a C
client with migraine headaches, Explanation: The nurse should gather
the nurse assesses bilateral weakness in the additional assessment data about the
, BSN 266 HESI
Study online at https://quizlet.com/_dfm7mq
clients hand grips. The client pain and
reports joint pain and trouble twisting a door weakness to better understand the
knob due to weaknesses. Which client's condition and to deter-
action should the nurses take in response to mine if there is an
these figures? underlying issue or if the symptoms
a. Implement fall precautions to reduce the are related to the migraine headaches.
clients risk of injury.
b. Explain that relief of the migraine pain will
reduce related
symptoms.
c. Gather additional assessment data about
the pain and weakness.
d. Consult with the occupational therapist for
a functional assessment
4. 5. A client who has developed acute kidney B
injury (AKI) due to aminoglycoside Explanation: During the diuretic phase
antibiotics has moved from the oliguric phase of AKI, the client may experience in-
to the diuretic phase of AKI. Which creased urine
parameters are most important for the nurse output, which can lead to hypovolemia
to plan to carefully monitor? and electrolyte imbalances. Monitor-
a. Uremic irritation of mucous membranes ing for
and skin surfaces. hypovolemia and ECG changes can
b. Hypovolemia and electrocardiographic help detect any complications or wors-
(ECG) changes. ening of the
c. Side effects of total parental nutrition (TPN) client's condition.
and Intralipids.
d. Elevated creatinine and blood urea nitrogen
(BUN).
5. 6. The nurse is caring for a client diagnosed B
with psoriasis vulgaris who is Explanation: Overexposure to PUVA
, BSN 266 HESI
Study online at https://quizlet.com/_dfm7mq
receiving psoralen and ultraviolet A light treatment can cause skin irritation, ten-
(PUVA) treatment. Which assessment derness,
finding indicates that the client has been over- and erythema. If the client exhibits
exposed to the treatment? these symptoms, the nurse should no-
a. Thick skin plaques topped by silvery white tify the
scales healthcare provider for possible treat-
b. Tenderness upon palpation and generalized ment modifications.
erythema
c. Brown, rough, greasy, wart-like papules on
the face
d. Requires sunglasses because sunlight hurts
eyes
6. 7. An adult client who had a gastric bypass C
surgery 2 weeks ago, is admitted with Explanation: The client's vital
possible anastomosis leakage. The signs indicate possible sepsis or sys-
client's abdomen is tender to touch, and temic infection. Strict
the IV fluid replacement is important to
vital signs are temperature 101* F (38 3* C). maintain adequate circulation, support
heart rate 130 beats/minute, blood
respiratory rate 26 breaths/minute, and blood pressure, and treat potential sepsis.
pressure 100/50 mmHg. Which The other interventions are also essen-
intervention is most important for the nurse to tial but not
include in the client's plan of care? as critical as fluid replacement in this
a. Encourage regular turning. situation.
b. Monitor skin for breakdown.
c. Strict IV fluid replacement.
d. Assess wound drainage daily.
7. 8. A client who was recently diagnosed with D
Raynaud's disease is concerned Explanation: For clients with Ray-
about pain management. Which nursing in- naud's disease, cold tempera-
Study online at https://quizlet.com/_dfm7mq
1. A client who underwent cardiac stent place- D
ment four days ago arrives to the
emergency department reporting a sudden
onset of chest pressure and
shortness of breath. Which action should the
nurse take next?
a. Listen for extra heart sounds, murmurs, and
rhythm with the bell of
the stethoscope.
b. Evaluate upper and lower extremities for
perfusion, pulse volume,
and pitting edema.
c. Verify troponin level assessments are sched-
uled every 3-6 hours
for a series of three.
d. Obtain a 12- lead electrocardiogram and
begin continuous cardiac
monitoring.
2. A client with type 2 diabetes mellitus arrives to B
the clinic reporting episodes of
weakness and palpitations. Which finding
should the nurse recognize as a
possible complication?
a. anxiety and sighing
b. myalgia in wrists and hands
c. hyperactive bowel sounds
d. dark yellow urine
3. 4While completing a health assessment for a C
client with migraine headaches, Explanation: The nurse should gather
the nurse assesses bilateral weakness in the additional assessment data about the
, BSN 266 HESI
Study online at https://quizlet.com/_dfm7mq
clients hand grips. The client pain and
reports joint pain and trouble twisting a door weakness to better understand the
knob due to weaknesses. Which client's condition and to deter-
action should the nurses take in response to mine if there is an
these figures? underlying issue or if the symptoms
a. Implement fall precautions to reduce the are related to the migraine headaches.
clients risk of injury.
b. Explain that relief of the migraine pain will
reduce related
symptoms.
c. Gather additional assessment data about
the pain and weakness.
d. Consult with the occupational therapist for
a functional assessment
4. 5. A client who has developed acute kidney B
injury (AKI) due to aminoglycoside Explanation: During the diuretic phase
antibiotics has moved from the oliguric phase of AKI, the client may experience in-
to the diuretic phase of AKI. Which creased urine
parameters are most important for the nurse output, which can lead to hypovolemia
to plan to carefully monitor? and electrolyte imbalances. Monitor-
a. Uremic irritation of mucous membranes ing for
and skin surfaces. hypovolemia and ECG changes can
b. Hypovolemia and electrocardiographic help detect any complications or wors-
(ECG) changes. ening of the
c. Side effects of total parental nutrition (TPN) client's condition.
and Intralipids.
d. Elevated creatinine and blood urea nitrogen
(BUN).
5. 6. The nurse is caring for a client diagnosed B
with psoriasis vulgaris who is Explanation: Overexposure to PUVA
, BSN 266 HESI
Study online at https://quizlet.com/_dfm7mq
receiving psoralen and ultraviolet A light treatment can cause skin irritation, ten-
(PUVA) treatment. Which assessment derness,
finding indicates that the client has been over- and erythema. If the client exhibits
exposed to the treatment? these symptoms, the nurse should no-
a. Thick skin plaques topped by silvery white tify the
scales healthcare provider for possible treat-
b. Tenderness upon palpation and generalized ment modifications.
erythema
c. Brown, rough, greasy, wart-like papules on
the face
d. Requires sunglasses because sunlight hurts
eyes
6. 7. An adult client who had a gastric bypass C
surgery 2 weeks ago, is admitted with Explanation: The client's vital
possible anastomosis leakage. The signs indicate possible sepsis or sys-
client's abdomen is tender to touch, and temic infection. Strict
the IV fluid replacement is important to
vital signs are temperature 101* F (38 3* C). maintain adequate circulation, support
heart rate 130 beats/minute, blood
respiratory rate 26 breaths/minute, and blood pressure, and treat potential sepsis.
pressure 100/50 mmHg. Which The other interventions are also essen-
intervention is most important for the nurse to tial but not
include in the client's plan of care? as critical as fluid replacement in this
a. Encourage regular turning. situation.
b. Monitor skin for breakdown.
c. Strict IV fluid replacement.
d. Assess wound drainage daily.
7. 8. A client who was recently diagnosed with D
Raynaud's disease is concerned Explanation: For clients with Ray-
about pain management. Which nursing in- naud's disease, cold tempera-
