BSN HESI 246 ACTUAL EXAM 2024
VERIFIED Q & A| LATEST 100%
CORRECT UPDATE 2025
What is the best initial response by the nurse? -
ANSWER-Describe the location and type of pain you are
having
Based on the nurse's assessment, which assessment data
supports the decision to administer pain medication as the
first intervention? (Select all that apply. One, some, or all
options may be correct.) - ANSWER-Pain rating of 6/10 -
Heart rate of 102 beats/minute - Blood pressure of 132/76
mmHg
Which expected outcome should be included in the
nurse's teaching plan? - ANSWER-Client will avoid
canned and processed foods
Which action can be assigned to the unlicensed assistive
personnel (UAP)? - ANSWER-Measure the client's urinary
output.
,Which action should the nurse implement first? -
ANSWER-Administer an analgesic.
Which interventions are important to include in the client's
plan of care while receiving multiple
immunosuppressants? (Select all that apply. One, some,
or all options may be correct.) - ANSWER-Instruct client to
wear a mask when walking in the halls. - Instruct visitors
that fresh flowers should not be taken into the room. -
Monitor immunosuppression drug levels regularly.
Which intervention should the nurse ensure is included in
the plan of care during the immediate postoperative
period?
a. Monitor Judy's urinary output hourly using an urimeter.
b. Assess Judy's surgical incision every shift.
c. Monitor Judy's nasogastric tube every 4 hours.
d. Encourage Judy to use the incentive spirometer daily. -
ANSWER-a
Which is the priority nursing assessment during the first
24-hour postoperative period? - ANSWER-Vital signs
The nurse is teaching the patient about fluid management
between dialysis treatments. Which instruction by the
nurse is the most accurate? - ANSWER-Limit fluids in
between treatments to minimize the amount of fluid that
needs to be removed during dialysis.
.
,The nurse assesses the dialysis graft. Which assessment
should be reported to the healthcare provider (HCP)
immediately? (Select all that apply. One, some, or all
options may be correct.) - ANSWER-Yellow, purulent
drainage from graft incision site. - Absence of a thrill over
the graft site. - Capillary refill >10 seconds in the hand
where the graft is placed.
Which intervention should the nurse ensure has been
include in the client's plan of care? (Select all that apply.
One, some, or all options may be correct.)
A. Instruct lab personnel to obtain blood specimens from
the dual-lumen catheter.
B. Perform sterile dressing changes at the dual-lumen
catheter site.
C. Empty and record the drainage from the graft tubing
regularly.
D. Regularly rotate IV insertion sites above and below the
graft site.
E. Assess Judy's distal pulses and circulation in the arm
with the access - ANSWER-B. Perform sterile dressing
changes at the dual lumen catheter site - E. Assess the
client's distal pulses and circulation in the arm with the
access.
The nurse documents the assessment of the
arteriovenous (AV) graft. Which documentation best
describes a properly functioning AV graft? - ANSWER-
Thrill present and palpated
, The client asks the nurse to clarify what palliative care
involves. Which explanation provides the client the best
education regarding palliative care? (Select all that apply.
One, some, or all options may be correct.) - ANSWER-
Palliative care provides relief from symptoms including
pain. - Palliative care supports holistic care and improves
quality of life. -
What complication would the client be most concerned
about if choosing peritoneal dialysis? - ANSWER-
Abdominal infection/Peritonitis
The nurse prepares and instructs the client for
hemodialysis. Which statements by the client indicate the
need for further education? (Select all that apply. One,
some, or all options may be correct.) - ANSWER-
Hemodialysis will help restore kidney function back to a
normal level. - Bowel or bladder perforation may occur
with hemodialysis catheter placement.
What action should the nurse take based on the response
from the healthcare provider (HCP) phone call? (Select all
that apply. One, some, or all options may be correct.) -
ANSWER-Document both phone calls and the HCP's
prescriptions. - Notify the charge nurse and activate the
chain of command - Hold the potassium chloride
Which intervention should the nurse implement? -
ANSWER-Call and speak directly with the healthcare
provider (HCP).
VERIFIED Q & A| LATEST 100%
CORRECT UPDATE 2025
What is the best initial response by the nurse? -
ANSWER-Describe the location and type of pain you are
having
Based on the nurse's assessment, which assessment data
supports the decision to administer pain medication as the
first intervention? (Select all that apply. One, some, or all
options may be correct.) - ANSWER-Pain rating of 6/10 -
Heart rate of 102 beats/minute - Blood pressure of 132/76
mmHg
Which expected outcome should be included in the
nurse's teaching plan? - ANSWER-Client will avoid
canned and processed foods
Which action can be assigned to the unlicensed assistive
personnel (UAP)? - ANSWER-Measure the client's urinary
output.
,Which action should the nurse implement first? -
ANSWER-Administer an analgesic.
Which interventions are important to include in the client's
plan of care while receiving multiple
immunosuppressants? (Select all that apply. One, some,
or all options may be correct.) - ANSWER-Instruct client to
wear a mask when walking in the halls. - Instruct visitors
that fresh flowers should not be taken into the room. -
Monitor immunosuppression drug levels regularly.
Which intervention should the nurse ensure is included in
the plan of care during the immediate postoperative
period?
a. Monitor Judy's urinary output hourly using an urimeter.
b. Assess Judy's surgical incision every shift.
c. Monitor Judy's nasogastric tube every 4 hours.
d. Encourage Judy to use the incentive spirometer daily. -
ANSWER-a
Which is the priority nursing assessment during the first
24-hour postoperative period? - ANSWER-Vital signs
The nurse is teaching the patient about fluid management
between dialysis treatments. Which instruction by the
nurse is the most accurate? - ANSWER-Limit fluids in
between treatments to minimize the amount of fluid that
needs to be removed during dialysis.
.
,The nurse assesses the dialysis graft. Which assessment
should be reported to the healthcare provider (HCP)
immediately? (Select all that apply. One, some, or all
options may be correct.) - ANSWER-Yellow, purulent
drainage from graft incision site. - Absence of a thrill over
the graft site. - Capillary refill >10 seconds in the hand
where the graft is placed.
Which intervention should the nurse ensure has been
include in the client's plan of care? (Select all that apply.
One, some, or all options may be correct.)
A. Instruct lab personnel to obtain blood specimens from
the dual-lumen catheter.
B. Perform sterile dressing changes at the dual-lumen
catheter site.
C. Empty and record the drainage from the graft tubing
regularly.
D. Regularly rotate IV insertion sites above and below the
graft site.
E. Assess Judy's distal pulses and circulation in the arm
with the access - ANSWER-B. Perform sterile dressing
changes at the dual lumen catheter site - E. Assess the
client's distal pulses and circulation in the arm with the
access.
The nurse documents the assessment of the
arteriovenous (AV) graft. Which documentation best
describes a properly functioning AV graft? - ANSWER-
Thrill present and palpated
, The client asks the nurse to clarify what palliative care
involves. Which explanation provides the client the best
education regarding palliative care? (Select all that apply.
One, some, or all options may be correct.) - ANSWER-
Palliative care provides relief from symptoms including
pain. - Palliative care supports holistic care and improves
quality of life. -
What complication would the client be most concerned
about if choosing peritoneal dialysis? - ANSWER-
Abdominal infection/Peritonitis
The nurse prepares and instructs the client for
hemodialysis. Which statements by the client indicate the
need for further education? (Select all that apply. One,
some, or all options may be correct.) - ANSWER-
Hemodialysis will help restore kidney function back to a
normal level. - Bowel or bladder perforation may occur
with hemodialysis catheter placement.
What action should the nurse take based on the response
from the healthcare provider (HCP) phone call? (Select all
that apply. One, some, or all options may be correct.) -
ANSWER-Document both phone calls and the HCP's
prescriptions. - Notify the charge nurse and activate the
chain of command - Hold the potassium chloride
Which intervention should the nurse implement? -
ANSWER-Call and speak directly with the healthcare
provider (HCP).
