HESI BSN 225 Exam with |! |! |! |! |!
precise detailed solutions |! |!
A client with chronic renal disease is admitted to the hospital for evaluation
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prior to a surgical procedure. Which laboratory test indicates the client's
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protein status for the longest length of time?
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a. Transferrin
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b. Prealbumin
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c. Serum albumin
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d. Urine urea nitrogen - Correct answer ✔c. Serum albumin
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Rationale: Serum albumin has a long half-life and is the best long-term
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indicator of the body's entry into a catabolic state following protein depletion
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from malnutrition or stress of chronic illness (C).
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The nurse is digitally removing a fecal impaction for a client. The nurse
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should stop the procedure and take corrective action if which client reaction
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is noted?
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a. Temperature increases from 98.8 to 99.0 F.
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b. Pulse rate decreases from 78 to 52 beats/min.
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c. Respiratory rate increases from 16 to 24 breaths/min.
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d. Blood pressure increases from 110/84 to 118/88 mm/Hg. - Correct answer
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✔b. Pulse rate decreases from 78 to 52 beats/min.
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, Rationale: Parasympathetic reaction can occur as a result of digital
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stimulation of the anal sphincter, which should be stopped if the client
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experiences a vagal response, such as bradycardia (B). |! |! |! |! |! |! |!
Which statement is an example of a correctly written nursing diagnosis
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statement?
a. Altered tissue perfusion related to congestive heart failure.
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b. Altered urinary elimination related to urinary tract infection.
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c. Risk for impaired tissue integrity related to client's refusal to turn.
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d. Ineffective coping related to response to positive biopsy test results. -
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Correct answer ✔d. Ineffective coping related to response to positive biopsy
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test results.
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Rationale: The first part of the nursing diagnosis statement is the "diagnostic
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label" and is followed by "related to" the cause, which should direct the nurse
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to the appropriate interventions.
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The daughter of an older woman who became depressed following the death
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of her husband asks, "My mother was always well-adjusted until my father
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died. Will she tend to be sick from now on?" Which response is best for the
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
nurse to provide? |! |!
a. "She is almost sure to be less able to adapt than before."
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b. "It's highly likely that she will recover and return to her pre-illness state."
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c. "If you can interest her in something besides religion, it will help her stay
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well."
d. "Cultural strains contribute to each woman's tendencies for recurrences of
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depression." - Correct answer ✔b. "It's highly likely that she will recover and
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return to her pre-illness state."
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precise detailed solutions |! |!
A client with chronic renal disease is admitted to the hospital for evaluation
|! |! |! |! |! |! |! |! |! |! |! |! |!
prior to a surgical procedure. Which laboratory test indicates the client's
|! |! |! |! |! |! |! |! |! |! |!
protein status for the longest length of time?
|! |! |! |! |! |! |!
a. Transferrin
|!
b. Prealbumin
|!
c. Serum albumin
|! |!
d. Urine urea nitrogen - Correct answer ✔c. Serum albumin
|! |! |! |! |! |! |! |! |!
Rationale: Serum albumin has a long half-life and is the best long-term
|! |! |! |! |! |! |! |! |! |! |! |!
indicator of the body's entry into a catabolic state following protein depletion
|! |! |! |! |! |! |! |! |! |! |! |!
from malnutrition or stress of chronic illness (C).
|! |! |! |! |! |! |!
The nurse is digitally removing a fecal impaction for a client. The nurse
|! |! |! |! |! |! |! |! |! |! |! |! |!
should stop the procedure and take corrective action if which client reaction
|! |! |! |! |! |! |! |! |! |! |! |!
is noted?
|!
a. Temperature increases from 98.8 to 99.0 F.
|! |! |! |! |! |! |!
b. Pulse rate decreases from 78 to 52 beats/min.
|! |! |! |! |! |! |! |!
c. Respiratory rate increases from 16 to 24 breaths/min.
|! |! |! |! |! |! |! |!
d. Blood pressure increases from 110/84 to 118/88 mm/Hg. - Correct answer
|! |! |! |! |! |! |! |! |! |! |! |!
✔b. Pulse rate decreases from 78 to 52 beats/min.
|! |! |! |! |! |! |! |!
, Rationale: Parasympathetic reaction can occur as a result of digital
|! |! |! |! |! |! |! |! |! |!
stimulation of the anal sphincter, which should be stopped if the client
|! |! |! |! |! |! |! |! |! |! |! |!
experiences a vagal response, such as bradycardia (B). |! |! |! |! |! |! |!
Which statement is an example of a correctly written nursing diagnosis
|! |! |! |! |! |! |! |! |! |! |!
statement?
a. Altered tissue perfusion related to congestive heart failure.
|! |! |! |! |! |! |! |!
b. Altered urinary elimination related to urinary tract infection.
|! |! |! |! |! |! |! |!
c. Risk for impaired tissue integrity related to client's refusal to turn.
|! |! |! |! |! |! |! |! |! |! |!
d. Ineffective coping related to response to positive biopsy test results. -
|! |! |! |! |! |! |! |! |! |! |! |!
Correct answer ✔d. Ineffective coping related to response to positive biopsy
|! |! |! |! |! |! |! |! |! |! |!
test results.
|!
Rationale: The first part of the nursing diagnosis statement is the "diagnostic
|! |! |! |! |! |! |! |! |! |! |! |!
label" and is followed by "related to" the cause, which should direct the nurse
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
to the appropriate interventions.
|! |! |!
The daughter of an older woman who became depressed following the death
|! |! |! |! |! |! |! |! |! |! |! |!
of her husband asks, "My mother was always well-adjusted until my father
|! |! |! |! |! |! |! |! |! |! |! |!
died. Will she tend to be sick from now on?" Which response is best for the
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
nurse to provide? |! |!
a. "She is almost sure to be less able to adapt than before."
|! |! |! |! |! |! |! |! |! |! |! |!
b. "It's highly likely that she will recover and return to her pre-illness state."
|! |! |! |! |! |! |! |! |! |! |! |! |!
c. "If you can interest her in something besides religion, it will help her stay
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
well."
d. "Cultural strains contribute to each woman's tendencies for recurrences of
|! |! |! |! |! |! |! |! |! |! |!
depression." - Correct answer ✔b. "It's highly likely that she will recover and
|! |! |! |! |! |! |! |! |! |! |! |! |!
return to her pre-illness state."
|! |! |! |!
