BSN HESI
BSN 266--
HESIconsolidated.pdfhttps://www.stuvia.com/user/passnursingnow
266-- consolidated.pdfhttps://www.stuvia.com/user/passnursingnow
https://www.stuvia.com/user/passnursingnow
BSN HESI 266-- consolidated
A client experiences an AOB incompatibility reaction after multiple blood
transfusions. Which finding should the nurse report immediately to the health
care provider?
a. low back pain and hypotension
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
d. arthritic joint changes and chronic pain
a. low back pain and hypotension
When conducting discharge teaching for a client diagnosed with diverticulosis,
which diet instruction should the nurse include?
a. Have small frequent meals and sit up for at least two hours after meals.
b. Eat a bland diet and avoid spicy foods.
c. Eat a high-fiber diet and increase fluid intake.
d. Eat a soft diet with increased intake of milk and milk products
c. Eat a high-fiber diet and increase fluid intake.
The nurse observes an increased number of blood clots in the drainage tubing of
a client with continuous bladder irrigation following a transurethral resection of
the prostate (TURP). What is the best initial nursing action?
a. Provide additional oral fluid intake
b. Measure the client's intake and output.
c. Increase the flow of the bladder irrigation
d. Administer a PRN dose of an antispasmodic agent
c. Increase the flow of the bladder irrigation
https://www.stuvia.com/user/passnursingnow
BSN HESI
https://www.stuvia.com/user/passnursingnow
266-- consolidatedhttps://www.stuvia.com/user/passnursingnow
,BSN HESI
BSN 266--
HESIconsolidated.pdfhttps://www.stuvia.com/user/passnursingnow
266-- consolidated.pdfhttps://www.stuvia.com/user/passnursingnow
https://www.stuvia.com/user/passnursingnow
A client with lung cancer who wears subcutaneous morphine sulfate patch for
pain is short of breath and is difficult to arouse. When performing a head to toe
assessment, the nurse discovers four analgesic patches on the client's body.
Which intervention should the nurse implement first?
A. Remove all of the morphine patches
B. Administer a narcotic antagonist
C. Apply oxygen per face mask
D. Measure the client's blood pressure
B. Administer a narcotic antagonist
After falling down the basement steps, a client is brought to the emergency room.
X-ray confirms that the client's right leg is fractured. Following application of a leg
cast, which assessment finding warrants immediate intervention by the nurse?
a. Circumferential edema of right foot.
b. Complaint of throbbing right leg pain.
c. Right foot pale with sluggish capillary refill.
d. Increased temperature to lower extremity
c. Right foot pale with sluggish capillary refill
The answer indicates a potential problem with the blood circulation in the client's
right foot. When a leg cast is applied, it should not interfere with the blood flow to
the foot. However, if the foot becomes pale and the capillary refill is sluggish, it
suggests that the blood flow might be compromised. Capillary refill is the time
taken for color to return to an external capillary bed after pressure is applied to
cause blanching. Normal capillary refill time is usually less than 2 seconds.
Sluggish or delayed capillary refill can be a sign of peripheral vascular disease,
shock, or hypothermia. In this case, it could be due to the cast being too tight,
causing a reduction in blood flow to the foot. This is a serious condition that
requires immediate intervention by the nurse to prevent further complications
such as tissue necrosis due to lack of oxygen and nutrients. The nurse may need
to adjust or remove the cast to restore proper blood flow.
An overweight, young adult who was recently diagnosed with type 2 diabetes
mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very
weak and jittery. Which actions should the nurse implement?
https://www.stuvia.com/user/passnursingnow
BSN HESI
https://www.stuvia.com/user/passnursingnow
266-- consolidatedhttps://www.stuvia.com/user/passnursingnow
, BSN HESI
BSN 266--
HESIconsolidated.pdfhttps://www.stuvia.com/user/passnursingnow
266-- consolidated.pdfhttps://www.stuvia.com/user/passnursingnow
https://www.stuvia.com/user/passnursingnow
(Select all that apply.)
A. Check his fingerstick glucose level
B. Assess his skin temperature and moisture
C. Measure his pulse and blood pressure
D. Document anxiety on the surgical checklist
E. Administer a PRN dose of regular insulin
A. Check finger stick glucose
B. Assess skin temperature and moisture
C. Measure pulse and blood pressure
ANSWER: (CAM)
A client who underwent cardiac stent placement 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 scheduled every 3-6 hours for a series
of three.
d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring.
d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring
While completing a health assessment for a client with migraine headaches, the
nurse assesses bilateral weakness in the clients hand grips. The client reports
joint pain and trouble twisting a door knob due to weaknesses. Which action
should the nurses take in response to these figures?
a. Implement fall precautions to reduce the 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
d. Consult with the occupational therapist for a functional assessment
https://www.stuvia.com/user/passnursingnow
BSN HESI
https://www.stuvia.com/user/passnursingnow
266-- consolidatedhttps://www.stuvia.com/user/passnursingnow
BSN 266--
HESIconsolidated.pdfhttps://www.stuvia.com/user/passnursingnow
266-- consolidated.pdfhttps://www.stuvia.com/user/passnursingnow
https://www.stuvia.com/user/passnursingnow
BSN HESI 266-- consolidated
A client experiences an AOB incompatibility reaction after multiple blood
transfusions. Which finding should the nurse report immediately to the health
care provider?
a. low back pain and hypotension
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
d. arthritic joint changes and chronic pain
a. low back pain and hypotension
When conducting discharge teaching for a client diagnosed with diverticulosis,
which diet instruction should the nurse include?
a. Have small frequent meals and sit up for at least two hours after meals.
b. Eat a bland diet and avoid spicy foods.
c. Eat a high-fiber diet and increase fluid intake.
d. Eat a soft diet with increased intake of milk and milk products
c. Eat a high-fiber diet and increase fluid intake.
The nurse observes an increased number of blood clots in the drainage tubing of
a client with continuous bladder irrigation following a transurethral resection of
the prostate (TURP). What is the best initial nursing action?
a. Provide additional oral fluid intake
b. Measure the client's intake and output.
c. Increase the flow of the bladder irrigation
d. Administer a PRN dose of an antispasmodic agent
c. Increase the flow of the bladder irrigation
https://www.stuvia.com/user/passnursingnow
BSN HESI
https://www.stuvia.com/user/passnursingnow
266-- consolidatedhttps://www.stuvia.com/user/passnursingnow
,BSN HESI
BSN 266--
HESIconsolidated.pdfhttps://www.stuvia.com/user/passnursingnow
266-- consolidated.pdfhttps://www.stuvia.com/user/passnursingnow
https://www.stuvia.com/user/passnursingnow
A client with lung cancer who wears subcutaneous morphine sulfate patch for
pain is short of breath and is difficult to arouse. When performing a head to toe
assessment, the nurse discovers four analgesic patches on the client's body.
Which intervention should the nurse implement first?
A. Remove all of the morphine patches
B. Administer a narcotic antagonist
C. Apply oxygen per face mask
D. Measure the client's blood pressure
B. Administer a narcotic antagonist
After falling down the basement steps, a client is brought to the emergency room.
X-ray confirms that the client's right leg is fractured. Following application of a leg
cast, which assessment finding warrants immediate intervention by the nurse?
a. Circumferential edema of right foot.
b. Complaint of throbbing right leg pain.
c. Right foot pale with sluggish capillary refill.
d. Increased temperature to lower extremity
c. Right foot pale with sluggish capillary refill
The answer indicates a potential problem with the blood circulation in the client's
right foot. When a leg cast is applied, it should not interfere with the blood flow to
the foot. However, if the foot becomes pale and the capillary refill is sluggish, it
suggests that the blood flow might be compromised. Capillary refill is the time
taken for color to return to an external capillary bed after pressure is applied to
cause blanching. Normal capillary refill time is usually less than 2 seconds.
Sluggish or delayed capillary refill can be a sign of peripheral vascular disease,
shock, or hypothermia. In this case, it could be due to the cast being too tight,
causing a reduction in blood flow to the foot. This is a serious condition that
requires immediate intervention by the nurse to prevent further complications
such as tissue necrosis due to lack of oxygen and nutrients. The nurse may need
to adjust or remove the cast to restore proper blood flow.
An overweight, young adult who was recently diagnosed with type 2 diabetes
mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very
weak and jittery. Which actions should the nurse implement?
https://www.stuvia.com/user/passnursingnow
BSN HESI
https://www.stuvia.com/user/passnursingnow
266-- consolidatedhttps://www.stuvia.com/user/passnursingnow
, BSN HESI
BSN 266--
HESIconsolidated.pdfhttps://www.stuvia.com/user/passnursingnow
266-- consolidated.pdfhttps://www.stuvia.com/user/passnursingnow
https://www.stuvia.com/user/passnursingnow
(Select all that apply.)
A. Check his fingerstick glucose level
B. Assess his skin temperature and moisture
C. Measure his pulse and blood pressure
D. Document anxiety on the surgical checklist
E. Administer a PRN dose of regular insulin
A. Check finger stick glucose
B. Assess skin temperature and moisture
C. Measure pulse and blood pressure
ANSWER: (CAM)
A client who underwent cardiac stent placement 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 scheduled every 3-6 hours for a series
of three.
d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring.
d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring
While completing a health assessment for a client with migraine headaches, the
nurse assesses bilateral weakness in the clients hand grips. The client reports
joint pain and trouble twisting a door knob due to weaknesses. Which action
should the nurses take in response to these figures?
a. Implement fall precautions to reduce the 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
d. Consult with the occupational therapist for a functional assessment
https://www.stuvia.com/user/passnursingnow
BSN HESI
https://www.stuvia.com/user/passnursingnow
266-- consolidatedhttps://www.stuvia.com/user/passnursingnow
