Page | 1
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BSN 266 Practice HESI Questions with
Detailed Verified Answers (100% Correct
Answers) /Already Graded A+
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.
Ans: 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."
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Ans: 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 urinary output of 54 ml for the last 2 hours. What priority
nursing action should be implemented?
A. Report the findings to the surgeon.
B. Irrigate the indwelling urinary catheter.
C. Apply manual pressure to the bladder.
D. Increase the IV flow rate for 15 minutes.
Ans: A. Report the findings to the surgeon.
Rationale
An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly (1
ml/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the
surgeon.
A male client who smokes two packs of cigarettes a day states he understands
that smoking cigarettes is contributing to the difficulty that he and his wife are
having in getting pregnant and wants to know if other factors could be
contributing to their difficulty. What information is best for the nurse to provide?
(Select all that apply.)
Select all that apply
A. Marijuana cigarettes do not affect sperm count.
B. Alcohol consumption can cause erectile dysfunction.
C. Low testosterone levels affect sperm production.
D. Cessation of smoking improves general health and fertility.
E. Obesity has no effect on sperm production.
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Ans: B, C and D
Rationale
Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also
negatively affected by low testerone levels and obesity.
A client with gastroesophageal reflux disease (GERD) has been experiencing
severe reflux during sleep. Which recommendation by the nurse is most effective
to assist the client?
A. Losing weight.
B. Decreasing caffeine intake.
C. Avoiding large meals.
D. Raising the head of the bed on blocks.
Ans: D. Raising the head of the bed on blocks.
Rationale
Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce reflux and
subsequent aspiration is the most non-pharmacological effective recommendation for a client
experiencing severe gastroesophageal reflux during sleep.
A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30
pounds overweight is diagnosed with having a gastric ulcer. What content is most
important for the nurse to include in the discharge teaching for this client?
A. Information about smoking cessation.
B. Diet instructions for a low-residue diet.
C. Instructions on a weight-loss program.
D. The importance of increasing milk in the diet.
Ans: A. Information about smoking cessation.
Rationale
Smoking has been associated with ulcer formation, and stopping or decreasing the number of
cigarettes smoked per day is an important aspect of ulcer management.
What types of medications should the nurse expect to administer to a client
during an acute respiratory distress episode?
A. Vasodilators and hormones.
B. Analgesics and sedatives.
C. Anticoagulants and expectorants.
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D. Bronchodilators and steroids.
Ans: D. Bronchodilators and steroids.
Rationale
Besides supplemental oxygen, this client with ARDS needs medications to widen air passages,
increase air space, and reduce alveolar membrane inflammation, such as bronchodilators and
steroids.
A female client is brought to the clinic by her daughter for a flu shot. She has lost
significant weight since the last visit. She has poor personal hygiene and
inadequate clothing for the weather. The client states that she lives alone and
denies problems or concerns. What action should the nurse implement?
A. Notify social services immediately of suspected elderly abuse.
B. Discuss the need for mental health counseling with the daughter.
C. Explain to the client that she needs to take better care of herself.
D. Collect further data to determine whether self-neglect is occurring.
Ans: D. Collect further data to determine whether self-neglect is occurring.
Rationale
Changes in weight and hygiene may be indicators of self-neglect or neglect by family
members. Further assessment is needed before notifying social services or discussing a need
for counseling.
The nurse is assisting a client out of bed for the first time after surgery. What
action should the nurse do first?
A. Place a chair at a right angle to the bedside.
B. Encourage deep breathing prior to standing.
C. Help the client to sit and dangle legs on the side of the bed.
D. Allow the client to sit with the bed in a high Fowler's position.
Ans: D. Allow the client to sit with the bed in a high Fowler's position.
Rationale
The first step is to raise the head of the bed to a high Fowler's position, which allow venous
return to compensate from lying flat and the vasodilation effects of perioperative drugs. This
helps prevent the client from becoming light-headed and decreases the chance of a client fall.
A 32-year-old female client complains of severe abdominal pain each month
before her menstrual period, painful intercourse, and painful defecation. Which
additional history should the nurse obtain that is consistent with the client's
complaints?
Click here for more: Preppass - Stuvia
BSN 266 Practice HESI Questions with
Detailed Verified Answers (100% Correct
Answers) /Already Graded A+
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.
Ans: 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."
,Page | 2
Click here for more: Preppass - Stuvia
Ans: 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 urinary output of 54 ml for the last 2 hours. What priority
nursing action should be implemented?
A. Report the findings to the surgeon.
B. Irrigate the indwelling urinary catheter.
C. Apply manual pressure to the bladder.
D. Increase the IV flow rate for 15 minutes.
Ans: A. Report the findings to the surgeon.
Rationale
An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly (1
ml/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the
surgeon.
A male client who smokes two packs of cigarettes a day states he understands
that smoking cigarettes is contributing to the difficulty that he and his wife are
having in getting pregnant and wants to know if other factors could be
contributing to their difficulty. What information is best for the nurse to provide?
(Select all that apply.)
Select all that apply
A. Marijuana cigarettes do not affect sperm count.
B. Alcohol consumption can cause erectile dysfunction.
C. Low testosterone levels affect sperm production.
D. Cessation of smoking improves general health and fertility.
E. Obesity has no effect on sperm production.
,Page | 3
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Ans: B, C and D
Rationale
Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also
negatively affected by low testerone levels and obesity.
A client with gastroesophageal reflux disease (GERD) has been experiencing
severe reflux during sleep. Which recommendation by the nurse is most effective
to assist the client?
A. Losing weight.
B. Decreasing caffeine intake.
C. Avoiding large meals.
D. Raising the head of the bed on blocks.
Ans: D. Raising the head of the bed on blocks.
Rationale
Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce reflux and
subsequent aspiration is the most non-pharmacological effective recommendation for a client
experiencing severe gastroesophageal reflux during sleep.
A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30
pounds overweight is diagnosed with having a gastric ulcer. What content is most
important for the nurse to include in the discharge teaching for this client?
A. Information about smoking cessation.
B. Diet instructions for a low-residue diet.
C. Instructions on a weight-loss program.
D. The importance of increasing milk in the diet.
Ans: A. Information about smoking cessation.
Rationale
Smoking has been associated with ulcer formation, and stopping or decreasing the number of
cigarettes smoked per day is an important aspect of ulcer management.
What types of medications should the nurse expect to administer to a client
during an acute respiratory distress episode?
A. Vasodilators and hormones.
B. Analgesics and sedatives.
C. Anticoagulants and expectorants.
, Page | 4
Click here for more: Preppass - Stuvia
D. Bronchodilators and steroids.
Ans: D. Bronchodilators and steroids.
Rationale
Besides supplemental oxygen, this client with ARDS needs medications to widen air passages,
increase air space, and reduce alveolar membrane inflammation, such as bronchodilators and
steroids.
A female client is brought to the clinic by her daughter for a flu shot. She has lost
significant weight since the last visit. She has poor personal hygiene and
inadequate clothing for the weather. The client states that she lives alone and
denies problems or concerns. What action should the nurse implement?
A. Notify social services immediately of suspected elderly abuse.
B. Discuss the need for mental health counseling with the daughter.
C. Explain to the client that she needs to take better care of herself.
D. Collect further data to determine whether self-neglect is occurring.
Ans: D. Collect further data to determine whether self-neglect is occurring.
Rationale
Changes in weight and hygiene may be indicators of self-neglect or neglect by family
members. Further assessment is needed before notifying social services or discussing a need
for counseling.
The nurse is assisting a client out of bed for the first time after surgery. What
action should the nurse do first?
A. Place a chair at a right angle to the bedside.
B. Encourage deep breathing prior to standing.
C. Help the client to sit and dangle legs on the side of the bed.
D. Allow the client to sit with the bed in a high Fowler's position.
Ans: D. Allow the client to sit with the bed in a high Fowler's position.
Rationale
The first step is to raise the head of the bed to a high Fowler's position, which allow venous
return to compensate from lying flat and the vasodilation effects of perioperative drugs. This
helps prevent the client from becoming light-headed and decreases the chance of a client fall.
A 32-year-old female client complains of severe abdominal pain each month
before her menstrual period, painful intercourse, and painful defecation. Which
additional history should the nurse obtain that is consistent with the client's
complaints?
