BSN 266 Practice HESI updated questions and answers

A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement? A. Position the head of the bed (HOB) flat. B. Withhold intravenous fluids. C. Administer a bolus of IV fluids. D. Give an antihypertensive medication. - answer ----D. Give an antihypertensive medication. Rationale Most ischemic strokes occur during sleep when baseline blood pressure declines or blood viscosity increases due to minimal fluid intake. Completed strokes usually produce neurologic deficits within an hour, and the client's current elevated blood pressure requires antihypertensive medication. A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia? A. "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant." B. "Alopecia is a common side effect you will experience during long-term steroid therapy." C. "Your hair will grow back completely after your course of chemotherapy is completed." D. "The chemotherapy causes permanent alterations in your hair follicles that lead to hair loss." - answer ----A. "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant." Rationale The common adverse effects of chemotherapy (nausea, vomiting, alopecia, bone marrow depression) are due to chemotherapy's effect on the rapidly reproducing cells, both normal and malignant. After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated