BSN 225 - HESI FUNDAMENTALS EXAM QUESTIONS AND ANSWERS UPDATED

BSN 225 - HESI FUNDAMENTALS EXAM
QUESTIONS AND ANSWERS UPDATED
BSN 225 - HESI FUNDAMENTALS EXAM
QUESTIONS AND ANSWERS UPDATED

The nurse is caring for a client on hospice who was
started on a 25 mcg/hr Fentanyl patch yesterday at 0800.
The nurse completes an assessment today at 2000 and
reviews the following assessment data:

Yesterday 0800
BP 98/60
HR 110
RR 24
O2SAT 94%
PAIN 6/10
INTERVENTIONS
Fentanyl patch 25mcg/hr applied

Yesterday 2000
100/55
100
20
BSN 225 - HESI FUNDAMENTALS EXAM
QUESTIONS AND ANSWERS UPDATED

, BSN 225 - HESI FUNDAMENTALS EXAM
QUESTIONS AND ANSWERS UPDATED
95%
2/10
Reposition, visiting with family

Today 0800
92/40
104
24
92%
4/10
Ice pack applied

Today 2000
100/65
110
24
94%
7/10


Which intervention is best for the nurse to provide?

BSN 225 - HESI FUNDAMENTALS EXAM
QUESTIONS AND ANSWERS UPDATED

, BSN 225 - HESI FUNDAMENTALS EXAM
QUESTIONS AND ANSWERS UPDATED
a. explain that the fentanyl patch takes time to become
effective, and they should experience relief soon. b.
offer to administer 5mg of morphine orally as
prescribed for breakthrough pain
c. reposition the client and offer to give a back rub.
d. call the provider to provide an update on the client's
condition - ANSWER ->b. offer to administer 5mg of
morphine orally as prescribed for breakthrough pain
Rationale:
A fentanyl patch is effective for 72 hours before it needs
to be replaced. This breakthrough pain is evidenced by a
decline in pain rating followed by an elevated pain rating
during the time that the fentanyl patch should still be
effective.

When changing a client's post-op wound dressing, the
nurse notes yellow purulent drainage. What action
should the nurse take?

a. Notify the healthcare provider.
b. Cover the wound with clean gauze and secure.

BSN 225 - HESI FUNDAMENTALS EXAM
QUESTIONS AND ANSWERS UPDATED

, BSN 225 - HESI FUNDAMENTALS EXAM
QUESTIONS AND ANSWERS UPDATED
c. Irrigate the wound with sterile water and leave open
to air.
d. Irrigate the wound with normal saline and pack with
gauze. - ANSWER ->a. Notify the healthcare provider.

Rationale:
Yellow purulent drainage is an indication of an infection.
This finding should be reported to the healthcare
provider for assessment and intervention.

Choices B, C, and D are all incorrect because the priority
action is to notify the healthcare provider of the status of
the wound. Further wound management (cultures,
irrigation, or no irrigation, packing or no packing,
antibiotics, etc.) should be determined after assessment
of the site by the surgical team. Irrigating the wound
before assessment has been completed may interfere
with medical decision-making and hsould be avoided.

The healthcare provider prescribes enteral feeds of Jevity
1.2 cal at 66mL/hour over 20 hours, and free water
flushes of 225 mL q 4 hours x 24 hr via nasogastric tube.
BSN 225 - HESI FUNDAMENTALS EXAM
QUESTIONS AND ANSWERS UPDATED