HESI REVIEW BSN 266
ACCURATE ACTUAL EXAM
WITH FREQUENTLY TESTED
QUESTIONS AND STUDY
GUIDE\EXPERT VERIFIED
FOR GUARANTEED
PASS\ALREADY GRADED A+
The nurse is caring for a client with a small bowel obstruction. The client is vomiting foul-smelling
fecal-like material. What action should the nurse implement?
A. Administer antiemetics every 2 to 3 hours.
B. Position on the left side with knees drawn up.
C. Encourage ice chips sparingly.
D. Give IV fluids with electrolytes
D
Rationale
When the bowel is obstructed, electrolytes and fluids are not absorbed, so parenteral fluids with
sodium chloride, bicarbonate, and potassium should be administered to prevent electrolyte
imbalance and dehydration
The nurse is assessing a client with a chest tube that is attached to suction and a closed drainage
system. Which finding is most important for the nurse to further assess?
A. Upper chest subcutaneous emphysema.
B. Tidaling (fluctuation) of fluid in the water-seal chamber.
,C. Constant air bubbling in the suction-control chamber.
D. Pain rated "8" (0-10) at the insertion site.
A
Rationale
Subcutaneous emphysema is a complication and indicates air is leaking beneath the skin surrounding
the chest tube
The nurse is preparing discharge instructions for a client who is going home with a surgical wound on
the coccyx that is healing by secondary intention. What is the priority nursing diagnosis that should
guide the discharge instruction plan?
A. Acute pain.
B. Risk for infection.
C. Disturbed body image.
D. Risk for deficient fluid volume.
B
Rationale
A wound healing by secondary intention is an open wound at risk for infection, and the location of the
wound near the anal area increases the risk for infection even more.
A couple trying to cope with an infertility problem wants to know what can be done to preserve
emotional equilibrium. What is the best response for the nurse to provide?
A. "Tell your friends and family so that they can help you."
B. "Get involved with a support group. I will give you some names."
C. "Talk only to other friends who are infertile since only they can help."
D. "Start adoption proceedings immediately since obtaining an infant is very difficult."
B
Rationale
A support group provides a safe haven for the couple to share their feelings and experience and gain
insight from others dealing with the same experience and let's them know they are not alone in their
situation.
Which client should the nurse assess first?
A. A 27-year-old complaining of severe back pain.
B. A 63-year-old complaining of foot and ankle pain.
,C. A 49-year-old with pancreatitis complained of unrelenting abdominal pain.
D. A 55-year-old newly admitted client complained of jaw pain and indigestion.
D
Rationale
The 55-year-old client should be assessed first to rule out cardiac involvement because jaw pain and
indigestion are common descriptors of myocardial injury
An 85-year-old male client comes to the clinic for his annual physical exam and renewal of
antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which
additional assessment should the nurse complete?
A. Palpate the pedal pulse volume.
B. Count the brachial pulse rate.
C. Measure the blood pressure.
D. Assess for a carotid bruit.
C
Rationale
Elderly clients who take antihypertensive medications often experience side effects, such as
hypotension, which causes tachycardia, a compensatory mechanism to maintain adequate cardiac
output, so the client's blood pressure should be measured.
The nurse is providing discharge instructions to a client who has undergone a left orchiectomy for
testicular cancer. Which statement indicates that the client understands his post-operative care and
prognosis?
A. "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle."
B. "I should wear an athletic supporter and cup to prevent testicular cancer in my remaining testicle."
C. "I should always use a condom because I am at increased risk for acquiring a sexually transmitted
disease."
D. "I should make sure my sons know how to perform TSE because they are at increased risk for this
type of cancer."
A
Rationale
Although testicular cancer protocols, such as surgery, radiation, or chemotherapy, focus on the
primary site of testicular cancer, these treatments do not reduce the risk of testicular cancer in the
remaining testicle, so early recognition is the best prevention. The client's understanding is reflected
, in the statement to perform monthly TSE for changes in size, shape, or consistency of the testis that
may indicate early cancer.
A client is admitted after blunt abdominal injury. Which assessment finding requires immediate action
by the nurse?
A. Radiating abdominal pain with left lower quadrant palpation.
B. Grimacing after palpation of the right hypochondriac region.
C. Rebound tenderness with abdominal palpation.
D. Bluish periumbilical skin discoloration
D
Rationale
immediate action is indicated for intraperitoneal hemorrhage which causes periumbilical discoloration
(D) and indicates the presence of a splenic rupture, a life-threatening complication of blunt abdominal
injury. (A, B, and C) indicate inflammation of the appendix or gallbladder but do not represent an
acute finding as a result of blunt abdominal trauma
A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate
4 mg every 2 hours and a clear liquid diet. The client complains of feeling distended and has sharp,
cramping gas pains. What nursing intervention should be implemented?
A. Obtain a prescription for a laxative.
B. Withhold all oral fluid and food.
C. Assist the client to ambulate in the hall.
D. Administer the prescribed morphine sulfate
C
Rationale
Decreased peristalsis causes postoperative abdominal distention as a result of handling the intestine
during surgery, limited dietary intake before and after surgery, and anesthetic and analgesic agents.
Peristalsis is stimulated, flatus passed and distention minimized by implementing early and frequent
ambulation
During the assessment of a client who is 24 hours post-hemicolectomy with a temporary colostomy,
the nurse determines that the client’s stoma is dry and dark red in color. What action should the nurse
implement?
A. Notify the surgeon.
B. Document the assessment.
C. Secure a colostomy pouch over the stoma.
ACCURATE ACTUAL EXAM
WITH FREQUENTLY TESTED
QUESTIONS AND STUDY
GUIDE\EXPERT VERIFIED
FOR GUARANTEED
PASS\ALREADY GRADED A+
The nurse is caring for a client with a small bowel obstruction. The client is vomiting foul-smelling
fecal-like material. What action should the nurse implement?
A. Administer antiemetics every 2 to 3 hours.
B. Position on the left side with knees drawn up.
C. Encourage ice chips sparingly.
D. Give IV fluids with electrolytes
D
Rationale
When the bowel is obstructed, electrolytes and fluids are not absorbed, so parenteral fluids with
sodium chloride, bicarbonate, and potassium should be administered to prevent electrolyte
imbalance and dehydration
The nurse is assessing a client with a chest tube that is attached to suction and a closed drainage
system. Which finding is most important for the nurse to further assess?
A. Upper chest subcutaneous emphysema.
B. Tidaling (fluctuation) of fluid in the water-seal chamber.
,C. Constant air bubbling in the suction-control chamber.
D. Pain rated "8" (0-10) at the insertion site.
A
Rationale
Subcutaneous emphysema is a complication and indicates air is leaking beneath the skin surrounding
the chest tube
The nurse is preparing discharge instructions for a client who is going home with a surgical wound on
the coccyx that is healing by secondary intention. What is the priority nursing diagnosis that should
guide the discharge instruction plan?
A. Acute pain.
B. Risk for infection.
C. Disturbed body image.
D. Risk for deficient fluid volume.
B
Rationale
A wound healing by secondary intention is an open wound at risk for infection, and the location of the
wound near the anal area increases the risk for infection even more.
A couple trying to cope with an infertility problem wants to know what can be done to preserve
emotional equilibrium. What is the best response for the nurse to provide?
A. "Tell your friends and family so that they can help you."
B. "Get involved with a support group. I will give you some names."
C. "Talk only to other friends who are infertile since only they can help."
D. "Start adoption proceedings immediately since obtaining an infant is very difficult."
B
Rationale
A support group provides a safe haven for the couple to share their feelings and experience and gain
insight from others dealing with the same experience and let's them know they are not alone in their
situation.
Which client should the nurse assess first?
A. A 27-year-old complaining of severe back pain.
B. A 63-year-old complaining of foot and ankle pain.
,C. A 49-year-old with pancreatitis complained of unrelenting abdominal pain.
D. A 55-year-old newly admitted client complained of jaw pain and indigestion.
D
Rationale
The 55-year-old client should be assessed first to rule out cardiac involvement because jaw pain and
indigestion are common descriptors of myocardial injury
An 85-year-old male client comes to the clinic for his annual physical exam and renewal of
antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which
additional assessment should the nurse complete?
A. Palpate the pedal pulse volume.
B. Count the brachial pulse rate.
C. Measure the blood pressure.
D. Assess for a carotid bruit.
C
Rationale
Elderly clients who take antihypertensive medications often experience side effects, such as
hypotension, which causes tachycardia, a compensatory mechanism to maintain adequate cardiac
output, so the client's blood pressure should be measured.
The nurse is providing discharge instructions to a client who has undergone a left orchiectomy for
testicular cancer. Which statement indicates that the client understands his post-operative care and
prognosis?
A. "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle."
B. "I should wear an athletic supporter and cup to prevent testicular cancer in my remaining testicle."
C. "I should always use a condom because I am at increased risk for acquiring a sexually transmitted
disease."
D. "I should make sure my sons know how to perform TSE because they are at increased risk for this
type of cancer."
A
Rationale
Although testicular cancer protocols, such as surgery, radiation, or chemotherapy, focus on the
primary site of testicular cancer, these treatments do not reduce the risk of testicular cancer in the
remaining testicle, so early recognition is the best prevention. The client's understanding is reflected
, in the statement to perform monthly TSE for changes in size, shape, or consistency of the testis that
may indicate early cancer.
A client is admitted after blunt abdominal injury. Which assessment finding requires immediate action
by the nurse?
A. Radiating abdominal pain with left lower quadrant palpation.
B. Grimacing after palpation of the right hypochondriac region.
C. Rebound tenderness with abdominal palpation.
D. Bluish periumbilical skin discoloration
D
Rationale
immediate action is indicated for intraperitoneal hemorrhage which causes periumbilical discoloration
(D) and indicates the presence of a splenic rupture, a life-threatening complication of blunt abdominal
injury. (A, B, and C) indicate inflammation of the appendix or gallbladder but do not represent an
acute finding as a result of blunt abdominal trauma
A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate
4 mg every 2 hours and a clear liquid diet. The client complains of feeling distended and has sharp,
cramping gas pains. What nursing intervention should be implemented?
A. Obtain a prescription for a laxative.
B. Withhold all oral fluid and food.
C. Assist the client to ambulate in the hall.
D. Administer the prescribed morphine sulfate
C
Rationale
Decreased peristalsis causes postoperative abdominal distention as a result of handling the intestine
during surgery, limited dietary intake before and after surgery, and anesthetic and analgesic agents.
Peristalsis is stimulated, flatus passed and distention minimized by implementing early and frequent
ambulation
During the assessment of a client who is 24 hours post-hemicolectomy with a temporary colostomy,
the nurse determines that the client’s stoma is dry and dark red in color. What action should the nurse
implement?
A. Notify the surgeon.
B. Document the assessment.
C. Secure a colostomy pouch over the stoma.
