BSN 266 HESI V1 Questions with 100% Verified
Answers |Well Explained|
An adult who was recently diagnosed with glaucoma tells the nurse, "It feels like I
am driving through a tunnel." The client expresses great concern about going blind.
Which nursing instruction is most important for the nurses to provide this client?
A. Maintain prescribed eye drop regimen.
B. Eat a diet high in carotene.
C. Wear prescription glasses.
D. Avoid frequent eye pressure measurement. - ANSWER -A. Maintain prescribed
eye drop regimen.
Explanation: Maintaining a prescribed eye drop regimen is crucial for managing
glaucoma and preventing further vision loss. While the other suggestions might be
helpful for overall eye health, adherence to the prescribed eye drop regimen is the
most important action to help prevent the progression of glaucoma.
Which information should the nurse include on the teaching plan of a client
diagnosed with gastroesophageal reflux disease (GERD)?
A. Adjust food intake to three full meals per day and no snacks.
B. Sleep without pillows at night to maintain neck alignment.
C. Minimize symptoms by wearing loose, comfortable clothing.
D. Avoid participation in any aerobic exercise programs. - ANSWER -C.
Minimize symptoms by wearing loose, comfortable clothing.
Explanation: Wearing loose, comfortable clothing can help minimize GERD
symptoms by reducing pressure on the abdomen and lower esophageal sphincter.
Other lifestyle changes, such as smaller, more frequent meals, elevating the head of
the bed, and avoiding foods that trigger symptoms, are also important for
managing GERD.
A client arrives to the emergency department reporting an intermittent fever and
night sweats for the past 3 weeks and has developed a productive cough containing
small amounts of blood. Which intervention should the nurse prioritize?
,A. Move into airborne isolation.
B. Collect specimens for blood cultures.
C. Arrange transport for radiographic imaging.
D. Obtain a sputum sample. - ANSWER -A. Move into airborne isolation.
Explanation: The client's symptoms (intermittent fever, night sweats, productive
cough with blood) are suggestive of tuberculosis (TB). The nurse should prioritize
placing the client in airborne isolation to prevent the potential spread of TB to
others while awaiting further assessment and testing.
A client receives a prescription for 1 liter of Ringer's intravenously to be infused
over 6 hours. How many mL/hr should the nurse program the infusion pump to
deliver? (Enter numerical value only. If rounding is required, round to the nearest
whole number.)
________ mL - ANSWER -167
A client with eczema is applying 10% urea cream onto the affected skin areas.
Which finding reflects the expected therapeutic response?
A. Hydration of affected dry skin areas.
B. Reduced pain in eczematous areas.
C. Decreased weeping of ulcerations in affected areas.
D. Healing with a return to normal skin appearance. - ANSWER -A. Hydration of
affected dry skin areas.
Explanation: Urea cream is a moisturizing agent that helps hydrate and soften dry,
rough skin in clients with eczema. The expected therapeutic response would be
hydration of the affected dry skin areas. While the cream may also help alleviate
some symptoms, such as itching or pain, its primary purpose is to moisturize the
skin.
The nurse is caring for a client with chronic pancreatitis who reports persistent
gnawing abdominal pain. To help the client manage the pain, which assessment
data is most improtant for the nurse ot obtain?
A. Activity level of bowel sounds.
B. Eating patterns of dietary restrictions.
C. Level and amount of physical activity.
, D. Color and consistency of feces. - ANSWER -B. Eating patterns of dietary
restrictions.
Explanation: In clients with chronic pancreatitis, the nurse should assess eating
patterns of dietary intake to help manage persistent abdominal pain. The pain is
often related to the type and amount of food consumed, and adjusting the diet can
help alleviate discomfort. Clients are usually advised to eat smaller, more frequent
meals, and avoid high-fat foods.
A client with hyperparathyroidism reports a sudden onset of severe flank pain.
Which intervention should the nurse include in the client's plan of care?
A. Implement seizure precautions.
B. Initiate cardiac telemetry.
C. Administer a PRN dose of a laxative.
D. Begin straining all urine. - ANSWER -D. Begin straining all urine.
Explanation: Sudden onset of severe flank pain in a client with
hyperparathyroidism may indicate the presence of kidney stones. The nurse should
include straining all urine in the client's plan of care to collect any passed stones
for analysis and to monitor the progress of stone passage.
After falling down the basement steps, a client is brought to the emergency room.
X-ray confirms that the client's right leg is fractured. Following application of a leg
cast, which assessment finding warrants immediate intervention by the nurse?
A. Circumferential edema of right foot.
B. Complaint of throbbing right leg pain.
C. Right foot pale with sluggish capillary refill.
D. Increased temperature to lower extremity. - ANSWER -C. Right foot pale with
sluggish capillary refill.
Explanation: A pale right foot with sluggish capillary refill following the
application of a leg cast may indicate compromised blood flow to the extremity,
which requires immediate intervention by the nurse. The other findings are
expected after a fracture and cast application, but do not warrant immediate
intervention.
An older adult client with a long history of chronic obstructive pulmonary disease
(COPD) is admitted with progressive shortness of breath and a persistent cough.
Answers |Well Explained|
An adult who was recently diagnosed with glaucoma tells the nurse, "It feels like I
am driving through a tunnel." The client expresses great concern about going blind.
Which nursing instruction is most important for the nurses to provide this client?
A. Maintain prescribed eye drop regimen.
B. Eat a diet high in carotene.
C. Wear prescription glasses.
D. Avoid frequent eye pressure measurement. - ANSWER -A. Maintain prescribed
eye drop regimen.
Explanation: Maintaining a prescribed eye drop regimen is crucial for managing
glaucoma and preventing further vision loss. While the other suggestions might be
helpful for overall eye health, adherence to the prescribed eye drop regimen is the
most important action to help prevent the progression of glaucoma.
Which information should the nurse include on the teaching plan of a client
diagnosed with gastroesophageal reflux disease (GERD)?
A. Adjust food intake to three full meals per day and no snacks.
B. Sleep without pillows at night to maintain neck alignment.
C. Minimize symptoms by wearing loose, comfortable clothing.
D. Avoid participation in any aerobic exercise programs. - ANSWER -C.
Minimize symptoms by wearing loose, comfortable clothing.
Explanation: Wearing loose, comfortable clothing can help minimize GERD
symptoms by reducing pressure on the abdomen and lower esophageal sphincter.
Other lifestyle changes, such as smaller, more frequent meals, elevating the head of
the bed, and avoiding foods that trigger symptoms, are also important for
managing GERD.
A client arrives to the emergency department reporting an intermittent fever and
night sweats for the past 3 weeks and has developed a productive cough containing
small amounts of blood. Which intervention should the nurse prioritize?
,A. Move into airborne isolation.
B. Collect specimens for blood cultures.
C. Arrange transport for radiographic imaging.
D. Obtain a sputum sample. - ANSWER -A. Move into airborne isolation.
Explanation: The client's symptoms (intermittent fever, night sweats, productive
cough with blood) are suggestive of tuberculosis (TB). The nurse should prioritize
placing the client in airborne isolation to prevent the potential spread of TB to
others while awaiting further assessment and testing.
A client receives a prescription for 1 liter of Ringer's intravenously to be infused
over 6 hours. How many mL/hr should the nurse program the infusion pump to
deliver? (Enter numerical value only. If rounding is required, round to the nearest
whole number.)
________ mL - ANSWER -167
A client with eczema is applying 10% urea cream onto the affected skin areas.
Which finding reflects the expected therapeutic response?
A. Hydration of affected dry skin areas.
B. Reduced pain in eczematous areas.
C. Decreased weeping of ulcerations in affected areas.
D. Healing with a return to normal skin appearance. - ANSWER -A. Hydration of
affected dry skin areas.
Explanation: Urea cream is a moisturizing agent that helps hydrate and soften dry,
rough skin in clients with eczema. The expected therapeutic response would be
hydration of the affected dry skin areas. While the cream may also help alleviate
some symptoms, such as itching or pain, its primary purpose is to moisturize the
skin.
The nurse is caring for a client with chronic pancreatitis who reports persistent
gnawing abdominal pain. To help the client manage the pain, which assessment
data is most improtant for the nurse ot obtain?
A. Activity level of bowel sounds.
B. Eating patterns of dietary restrictions.
C. Level and amount of physical activity.
, D. Color and consistency of feces. - ANSWER -B. Eating patterns of dietary
restrictions.
Explanation: In clients with chronic pancreatitis, the nurse should assess eating
patterns of dietary intake to help manage persistent abdominal pain. The pain is
often related to the type and amount of food consumed, and adjusting the diet can
help alleviate discomfort. Clients are usually advised to eat smaller, more frequent
meals, and avoid high-fat foods.
A client with hyperparathyroidism reports a sudden onset of severe flank pain.
Which intervention should the nurse include in the client's plan of care?
A. Implement seizure precautions.
B. Initiate cardiac telemetry.
C. Administer a PRN dose of a laxative.
D. Begin straining all urine. - ANSWER -D. Begin straining all urine.
Explanation: Sudden onset of severe flank pain in a client with
hyperparathyroidism may indicate the presence of kidney stones. The nurse should
include straining all urine in the client's plan of care to collect any passed stones
for analysis and to monitor the progress of stone passage.
After falling down the basement steps, a client is brought to the emergency room.
X-ray confirms that the client's right leg is fractured. Following application of a leg
cast, which assessment finding warrants immediate intervention by the nurse?
A. Circumferential edema of right foot.
B. Complaint of throbbing right leg pain.
C. Right foot pale with sluggish capillary refill.
D. Increased temperature to lower extremity. - ANSWER -C. Right foot pale with
sluggish capillary refill.
Explanation: A pale right foot with sluggish capillary refill following the
application of a leg cast may indicate compromised blood flow to the extremity,
which requires immediate intervention by the nurse. The other findings are
expected after a fracture and cast application, but do not warrant immediate
intervention.
An older adult client with a long history of chronic obstructive pulmonary disease
(COPD) is admitted with progressive shortness of breath and a persistent cough.
