BSN HESI 266 EXAM WITH ALL CORRECT &
VERIFIED ANSWERS (UPDATED TO PASS)
Client is recovering from a transurethral prostatectomy. Which activity should be limited until after
the first postoperative visit with the healthcare provider? Correct answer-Drink 3L
A client with stage IV bone cancer is admitted to the hospital for a 1-10 scale. Which intervention
should the nurse implement? Correct answer-Administer opioid and non-opioid medications
simultaneously
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 Correct answer-a. low back pain and hypotension
ANSWER: (A) LOW BACK PAIN AND HYPOTENSTION
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 Correct answer-c. Eat a high fiber
diet and increase fluid intake.
ANSWER (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 Correct answer-c. Increase the flow of the
bladder
irrigation
,ANSWER (C) Increase the flow of the bladder irrigation
A client wit lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath
and difficult to arouse. When performing a head
-to-toe assessment, the nurse discovers four analgesic patches on Correct answer-Remove all
morphine patches
Coming down the basement steps, a client is brought to the emergency room X-ray ... cast, which
assessment finding warrants immediate
Intervention by the nurse? Correct answer-Right foot pale with sluggish capillary refill
An overweight, young adult who was
recently Check finger stick glucose 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?
(Select all that apply.)
a. Check finger stick
glucose
b. Assess skin temperature
and moisture
c. Measure pulse and blood
pressure Correct answer-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 r
hythm 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
. Correct answer-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 Correct answer-c. Gather
additional assessment data about the pain and weakness.
The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving psoralen and
ultraviolet A light (PUVA) treatment.
Which assessment finding indicates that the client has been overexposed to the treatment?
a. Thick skin plaques topped by silvery white scales
b. Tenderness upon palpation and generalized erythema
c. Brown, rough, greasy, wart-like papules on the face
d. Requires sunglasses because sunlight hurts eyes Correct answer-b. Tenderness upon palpation
and generalized erythema
An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis
leakage. The client's abdomen is tender to touch, and the vital signs are temperature 101* F (38 3*
C). heart rate 130 beats/minute, Respiratory rate 26 breaths/minute, and blood pressure 100/50
mmHg.
Which intervention is most important for the nurse to include in the client's plan of care?
a. Encourage regular turning.
b. Monitor skin for breakdown.
c. Strict IV fluid replacement
d. Assess wound drainage daily Correct answer-c. Strict IV fluid replacement
A client who was recently diagnosed with Raynaud's disease is concerned about pain management.
Which nursing instructions should the nurse provide?
a. Painful areas should be rubbed gently until the pain subsides.
b. Return appointments will be
needed for IV pain medications.
VERIFIED ANSWERS (UPDATED TO PASS)
Client is recovering from a transurethral prostatectomy. Which activity should be limited until after
the first postoperative visit with the healthcare provider? Correct answer-Drink 3L
A client with stage IV bone cancer is admitted to the hospital for a 1-10 scale. Which intervention
should the nurse implement? Correct answer-Administer opioid and non-opioid medications
simultaneously
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 Correct answer-a. low back pain and hypotension
ANSWER: (A) LOW BACK PAIN AND HYPOTENSTION
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 Correct answer-c. Eat a high fiber
diet and increase fluid intake.
ANSWER (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 Correct answer-c. Increase the flow of the
bladder
irrigation
,ANSWER (C) Increase the flow of the bladder irrigation
A client wit lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath
and difficult to arouse. When performing a head
-to-toe assessment, the nurse discovers four analgesic patches on Correct answer-Remove all
morphine patches
Coming down the basement steps, a client is brought to the emergency room X-ray ... cast, which
assessment finding warrants immediate
Intervention by the nurse? Correct answer-Right foot pale with sluggish capillary refill
An overweight, young adult who was
recently Check finger stick glucose 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?
(Select all that apply.)
a. Check finger stick
glucose
b. Assess skin temperature
and moisture
c. Measure pulse and blood
pressure Correct answer-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 r
hythm 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
. Correct answer-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 Correct answer-c. Gather
additional assessment data about the pain and weakness.
The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving psoralen and
ultraviolet A light (PUVA) treatment.
Which assessment finding indicates that the client has been overexposed to the treatment?
a. Thick skin plaques topped by silvery white scales
b. Tenderness upon palpation and generalized erythema
c. Brown, rough, greasy, wart-like papules on the face
d. Requires sunglasses because sunlight hurts eyes Correct answer-b. Tenderness upon palpation
and generalized erythema
An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis
leakage. The client's abdomen is tender to touch, and the vital signs are temperature 101* F (38 3*
C). heart rate 130 beats/minute, Respiratory rate 26 breaths/minute, and blood pressure 100/50
mmHg.
Which intervention is most important for the nurse to include in the client's plan of care?
a. Encourage regular turning.
b. Monitor skin for breakdown.
c. Strict IV fluid replacement
d. Assess wound drainage daily Correct answer-c. Strict IV fluid replacement
A client who was recently diagnosed with Raynaud's disease is concerned about pain management.
Which nursing instructions should the nurse provide?
a. Painful areas should be rubbed gently until the pain subsides.
b. Return appointments will be
needed for IV pain medications.
