BSN 246 Hesi Review
The registered nurse (RN) is caring for a client who has taken atenolol for 2 years. The
healthcare provider recently changed the medication to enalaprilto manage the client's
blood pressure. Which instruction should the RN provide the client regarding the new
medication?
-Take the medication at bedtime.
-Report presence of increased bruising.
-Check pulse before taking medication.
-Rise slowly when getting out of bed or chair. - CORRECT ANSWER-Rise slowly when
getting out of bed or chair.
Rationale
The client's new medication is an angiotensin-converting enzyme (ACE) inhibitor, which
has the side effect oforthostatic hypotension. Instructing the client to rise slowly from a
sitting or lying down position is important to teach the client to avoid dizziness and
potentially falling.
The registered nurse (RN) is making early morning rounds on a group of clients when a
client begins exhibiting symptoms of an acute asthma attack. The RN administers a
PRN prescription for a Beta 2 receptor agonist agent. Which client response should the
RN expect?
Select all that apply
-Tachycardia.
-Increased blood pressure.
-Rapid resolution of wheezing.
-Improved pulse oximetry values.
-Reduce fever airway inflammation. - CORRECT ANSWER-Rapid resolution of
wheezing.
Improved pulse oximetry values.
Rationale
Beta 2 receptor agonist agents should provide immediate return of airflow and resolve
wheezing and improve oxygenation.
An older client is admitted to the hospital with severe diarrhea. The registered nurse
(RN) is completing an assessment and notes the client has dry mucous membranes
and poor skin turgor. Which assessment data should the RN gather to determine if the
client has a fluid volume deficit?
-Lower extremity edema.
-Orthostatic hypotension.
-Elevated blood pressure.
-Cheyne-Stokes respirations. - CORRECT ANSWER-Orthostatic hypotension.
Rationale
, Orthostatic hypotension can be a sign of fluid volume deficit in an older client who has
experienced severe diarrhea.
The registered nurse (RN) is evaluating a client who presents with symptoms of viral
gastroenteritis. Which assessment finding should the RN report to the healthcare
provider?
-Dry mucous membranes and lips.
-Rebound abdominal tenderness over right lower quadrant.
-Dizziness when client ambulates from a sitting position.
-Poor skin turgor over client's wrist. - CORRECT ANSWER-Rebound abdominal
tenderness over right lower quadrant.
Rationale
RLQ rebound abdominal tenderness may be related to acute appendicitis and should be
reported to the healthcare provider.
A client with cirrhosis of the liver asks the registered nurse (RN) to explain how varicose
veins can occur in the esophagus. Which statement should the RN provide to teach the
client about the physiological etiology?
-The enlarged liver presses on the lower half of the esophagus which weakens blood
vessel walls.
-Abnormal vessels form as a result of liver damage that causes chronic low serum
protein levels.
-Esophageal swelling and tissue damage causes blood to circulate blood back through
the stomach.
-Increased portal pressure causes blood flow through liver to be shunted to the
esophageal vessels. - CORRECT ANSWER-Increased portal pressure causes blood
flow through liver to be shunted to the esophageal vessels.
Rationale
Cirrhotic and fibrosed liver damage causes obstructed blood flow through portal vessels
to the liver which increases the portal pressurecausing the blood flow through the liver
to be shunted to the esophageal vessels. The result of this shunting of blood causes the
esophageal vessels (veins) to balloon out and weaken. As the portal hypertension
increases, these esophageal varices can rupture and cause bleeding resulting in bloody
emesis and black tarry stools.
Which action should the registered nurse (RN) implement to complete an assessment
for a client while using an interpreter?
-Ask closed-ended questions with the assistance of the interpreter.
-Maintain eye contact with the client while listening to the translation.
-Instruct interpreter to answer questions from interpreter's point of view.
-Protect the client's privacy by asking a limited number of questions. - CORRECT
ANSWER-Maintain eye contact with the client while listening to the translation.
Rationale
When completing an assessment, the RN should maintain eye contact with the client to
gather additional information from the client's nonverbal cues.
The registered nurse (RN) is caring for a client who has taken atenolol for 2 years. The
healthcare provider recently changed the medication to enalaprilto manage the client's
blood pressure. Which instruction should the RN provide the client regarding the new
medication?
-Take the medication at bedtime.
-Report presence of increased bruising.
-Check pulse before taking medication.
-Rise slowly when getting out of bed or chair. - CORRECT ANSWER-Rise slowly when
getting out of bed or chair.
Rationale
The client's new medication is an angiotensin-converting enzyme (ACE) inhibitor, which
has the side effect oforthostatic hypotension. Instructing the client to rise slowly from a
sitting or lying down position is important to teach the client to avoid dizziness and
potentially falling.
The registered nurse (RN) is making early morning rounds on a group of clients when a
client begins exhibiting symptoms of an acute asthma attack. The RN administers a
PRN prescription for a Beta 2 receptor agonist agent. Which client response should the
RN expect?
Select all that apply
-Tachycardia.
-Increased blood pressure.
-Rapid resolution of wheezing.
-Improved pulse oximetry values.
-Reduce fever airway inflammation. - CORRECT ANSWER-Rapid resolution of
wheezing.
Improved pulse oximetry values.
Rationale
Beta 2 receptor agonist agents should provide immediate return of airflow and resolve
wheezing and improve oxygenation.
An older client is admitted to the hospital with severe diarrhea. The registered nurse
(RN) is completing an assessment and notes the client has dry mucous membranes
and poor skin turgor. Which assessment data should the RN gather to determine if the
client has a fluid volume deficit?
-Lower extremity edema.
-Orthostatic hypotension.
-Elevated blood pressure.
-Cheyne-Stokes respirations. - CORRECT ANSWER-Orthostatic hypotension.
Rationale
, Orthostatic hypotension can be a sign of fluid volume deficit in an older client who has
experienced severe diarrhea.
The registered nurse (RN) is evaluating a client who presents with symptoms of viral
gastroenteritis. Which assessment finding should the RN report to the healthcare
provider?
-Dry mucous membranes and lips.
-Rebound abdominal tenderness over right lower quadrant.
-Dizziness when client ambulates from a sitting position.
-Poor skin turgor over client's wrist. - CORRECT ANSWER-Rebound abdominal
tenderness over right lower quadrant.
Rationale
RLQ rebound abdominal tenderness may be related to acute appendicitis and should be
reported to the healthcare provider.
A client with cirrhosis of the liver asks the registered nurse (RN) to explain how varicose
veins can occur in the esophagus. Which statement should the RN provide to teach the
client about the physiological etiology?
-The enlarged liver presses on the lower half of the esophagus which weakens blood
vessel walls.
-Abnormal vessels form as a result of liver damage that causes chronic low serum
protein levels.
-Esophageal swelling and tissue damage causes blood to circulate blood back through
the stomach.
-Increased portal pressure causes blood flow through liver to be shunted to the
esophageal vessels. - CORRECT ANSWER-Increased portal pressure causes blood
flow through liver to be shunted to the esophageal vessels.
Rationale
Cirrhotic and fibrosed liver damage causes obstructed blood flow through portal vessels
to the liver which increases the portal pressurecausing the blood flow through the liver
to be shunted to the esophageal vessels. The result of this shunting of blood causes the
esophageal vessels (veins) to balloon out and weaken. As the portal hypertension
increases, these esophageal varices can rupture and cause bleeding resulting in bloody
emesis and black tarry stools.
Which action should the registered nurse (RN) implement to complete an assessment
for a client while using an interpreter?
-Ask closed-ended questions with the assistance of the interpreter.
-Maintain eye contact with the client while listening to the translation.
-Instruct interpreter to answer questions from interpreter's point of view.
-Protect the client's privacy by asking a limited number of questions. - CORRECT
ANSWER-Maintain eye contact with the client while listening to the translation.
Rationale
When completing an assessment, the RN should maintain eye contact with the client to
gather additional information from the client's nonverbal cues.
