BSN 246 HESI Health Assessment Exam V2
(Latest Update) Questions & Answers| Grade
A| 100% Correct (Verified Solutions)-
What is the correct interpretation of these ABG's? - ANSWER>>Metabolic acidosis
(compensated)
Which lab value would the nurse be MOST concerned about? -
ANSWER>>Glomerular filtration rate (GFR) of 9mL/min/1.73m2.
The nurse is teaching the client about progression of chronic kidney disease
(CKD). Which evaluation statement documented by the nurse indicates the
client's understanding of the disease process? - ANSWER>>The client
acknowledges that renal replacement therapy will need to be initiated
immediately to rid the body of waste and maintain fluid balance.
Based on the client's symptoms, what should the nurse suspect? - ANSWER>>The
client has uremia and may need to start dialysis.
Which additional symptoms should the nurse ask about? (Select all that apply.
One, some, or all options may be correct.) - ANSWER>>- Nausea - Decreased
attention span - Itching
The nurse reviews the client's medical history. What part of the medical history
should the nurse consider relevant to the client's current history? (Select all that
apply. One, some, or all options may be correct.) - ANSWER>>- Hypertension -
Polycystic kidney disease - Diabetes Mellitus-
,The nurse palpates a weak pedal pulse in the client's right foot. Which assessment
findings should the RN document that are consistent with diminished peripheral
circulation? (Select all that apply.)
Diminished hair on legs
Bruising on extremities
Skin cool to touch
Capillary refill less than 3 seconds
Darkened skin on extremities - ANSWER>>Diminished hair on legs
Skin cool to touch
The registered nurse (RN) uses the mini-mental state examination (MMSE) when
assessing a client for admission to an assisted living facility. Which finding is the
RN assessing when requesting the client to count by 7s?
A. Recall of information.
B. Orientation to surroundings.
C. Attention to details.
D. Ability to follow complex commands. - ANSWER>>C
The registered nurse (RN) palpates a weak pedal pulse in the client's right foot.
Which assessment findings should the RN document that are consistent with
diminished peripheral circulation? (Select all that apply.)
A. Diminished hair on legs.
B. Bruising on extremities.
C. Skin cool to touch.
D. Capillary refill less than 3 seconds.
E. Darkened skin on extremities. - ANSWER>>A, C
,Which action should the registered nurse (RN) implement to complete an
assessment for a client while using an interpreter?
A. Ask closed-ended questions with the assistance of the interpreter.
B. Maintain eye contact with the client while listening to the translation.
C. Instruct interpreter to answer questions from interpreter's point of view.
D. Protect the client's privacy by asking a limited number of questions. -
ANSWER>>B
A client with progressive hearing loss appears distressed when the registered
nurse (RN) asks open-ended questions about the client's health history. Which
forms of communication should the RN use? (Select all that apply.)
A. Face the client so the client can see the RN's mouth.
B. Increase one's speech volume when interacting with the client.
C. Repeat information to the client if misunderstood.
D. Check if the client's hearing aides are working properly.
E. Reduce environmental noise surrounding the client. - ANSWER>>A, D, E
Registered nurse (RN) is performing a mini-mental state examination (MMSE) for
a client who is being admitted to an assisted living community. Which
communication techniques should the RN implement to decrease anxiety in the
client? (Select all that apply.)
A. Use simple sentences during the examination.
B. Move to another question if the client seems confused.
C. Reduce environmental detractors during the examination.
D. Allow family to answer for the client to decrease frustration.
E. Ask questions one at a time to decrease confusion. - ANSWER>>A, C, E
A Muslim male client refuses to let the female registered nurse (RN) listen to his
breath sounds during the examination. How should the RN respond?
A. Explain how the nursing skill will be performed before proceeding.
B. Examine client with an additional healthcare provider for support.
C. Request a male nurse or healthcare provider to perform the exam.
D. Avoid any skills that involve touching the client during the exam. - ANSWER>>C
, A client who is uses ipratropium reports having nausea, blurred vision, headaches,
and insomnia after using the inhaler. Which action should the registered nurse
(RN) implement first?
A. Withhold medication and report symptoms and vital signs to healthcare
provider.
B. Give PRN medication for nausea and vomiting and evaluate client in 30
minutes.
C. Reassure client that the ipratropium given will alleviate the symptoms.
D. Delay administration of ipratropium until next maintenance medication is
scheduled. - ANSWER>>A
While reviewing the client's electronic medical record (EMR), the registered nurse
(RN) assesses a client who is at risk for a possible interaction with an over-the-
counter (OTC) decongestant. Which client health history should the RN report to
the healthcare provider concerning the OTC medication? (Select all that apply).
A. Type I diabetes mellitus (DM).
B. Closed angle glaucoma.
C. Chronic hypertension.
D. Rheumatoid arthritis.
E. Crohn's disease. - ANSWER>>B, C
Which action can be assigned to the unlicensed assistive personnel (UAP)? -
ANSWER>>Measure the client's urinary output.
What is the best initial response by the nurse? - ANSWER>>Describe the location
and type of pain you are having
Based on the nurse's assessment, which assessment data supports the decision to
administer pain medication as the first intervention? (Select all that apply. One,
some, or all options may be correct.) - ANSWER>>Pain rating of 6/10 - Heart rate
of 102 beats/minute - Blood pressure of 132/76 mmHg
(Latest Update) Questions & Answers| Grade
A| 100% Correct (Verified Solutions)-
What is the correct interpretation of these ABG's? - ANSWER>>Metabolic acidosis
(compensated)
Which lab value would the nurse be MOST concerned about? -
ANSWER>>Glomerular filtration rate (GFR) of 9mL/min/1.73m2.
The nurse is teaching the client about progression of chronic kidney disease
(CKD). Which evaluation statement documented by the nurse indicates the
client's understanding of the disease process? - ANSWER>>The client
acknowledges that renal replacement therapy will need to be initiated
immediately to rid the body of waste and maintain fluid balance.
Based on the client's symptoms, what should the nurse suspect? - ANSWER>>The
client has uremia and may need to start dialysis.
Which additional symptoms should the nurse ask about? (Select all that apply.
One, some, or all options may be correct.) - ANSWER>>- Nausea - Decreased
attention span - Itching
The nurse reviews the client's medical history. What part of the medical history
should the nurse consider relevant to the client's current history? (Select all that
apply. One, some, or all options may be correct.) - ANSWER>>- Hypertension -
Polycystic kidney disease - Diabetes Mellitus-
,The nurse palpates a weak pedal pulse in the client's right foot. Which assessment
findings should the RN document that are consistent with diminished peripheral
circulation? (Select all that apply.)
Diminished hair on legs
Bruising on extremities
Skin cool to touch
Capillary refill less than 3 seconds
Darkened skin on extremities - ANSWER>>Diminished hair on legs
Skin cool to touch
The registered nurse (RN) uses the mini-mental state examination (MMSE) when
assessing a client for admission to an assisted living facility. Which finding is the
RN assessing when requesting the client to count by 7s?
A. Recall of information.
B. Orientation to surroundings.
C. Attention to details.
D. Ability to follow complex commands. - ANSWER>>C
The registered nurse (RN) palpates a weak pedal pulse in the client's right foot.
Which assessment findings should the RN document that are consistent with
diminished peripheral circulation? (Select all that apply.)
A. Diminished hair on legs.
B. Bruising on extremities.
C. Skin cool to touch.
D. Capillary refill less than 3 seconds.
E. Darkened skin on extremities. - ANSWER>>A, C
,Which action should the registered nurse (RN) implement to complete an
assessment for a client while using an interpreter?
A. Ask closed-ended questions with the assistance of the interpreter.
B. Maintain eye contact with the client while listening to the translation.
C. Instruct interpreter to answer questions from interpreter's point of view.
D. Protect the client's privacy by asking a limited number of questions. -
ANSWER>>B
A client with progressive hearing loss appears distressed when the registered
nurse (RN) asks open-ended questions about the client's health history. Which
forms of communication should the RN use? (Select all that apply.)
A. Face the client so the client can see the RN's mouth.
B. Increase one's speech volume when interacting with the client.
C. Repeat information to the client if misunderstood.
D. Check if the client's hearing aides are working properly.
E. Reduce environmental noise surrounding the client. - ANSWER>>A, D, E
Registered nurse (RN) is performing a mini-mental state examination (MMSE) for
a client who is being admitted to an assisted living community. Which
communication techniques should the RN implement to decrease anxiety in the
client? (Select all that apply.)
A. Use simple sentences during the examination.
B. Move to another question if the client seems confused.
C. Reduce environmental detractors during the examination.
D. Allow family to answer for the client to decrease frustration.
E. Ask questions one at a time to decrease confusion. - ANSWER>>A, C, E
A Muslim male client refuses to let the female registered nurse (RN) listen to his
breath sounds during the examination. How should the RN respond?
A. Explain how the nursing skill will be performed before proceeding.
B. Examine client with an additional healthcare provider for support.
C. Request a male nurse or healthcare provider to perform the exam.
D. Avoid any skills that involve touching the client during the exam. - ANSWER>>C
, A client who is uses ipratropium reports having nausea, blurred vision, headaches,
and insomnia after using the inhaler. Which action should the registered nurse
(RN) implement first?
A. Withhold medication and report symptoms and vital signs to healthcare
provider.
B. Give PRN medication for nausea and vomiting and evaluate client in 30
minutes.
C. Reassure client that the ipratropium given will alleviate the symptoms.
D. Delay administration of ipratropium until next maintenance medication is
scheduled. - ANSWER>>A
While reviewing the client's electronic medical record (EMR), the registered nurse
(RN) assesses a client who is at risk for a possible interaction with an over-the-
counter (OTC) decongestant. Which client health history should the RN report to
the healthcare provider concerning the OTC medication? (Select all that apply).
A. Type I diabetes mellitus (DM).
B. Closed angle glaucoma.
C. Chronic hypertension.
D. Rheumatoid arthritis.
E. Crohn's disease. - ANSWER>>B, C
Which action can be assigned to the unlicensed assistive personnel (UAP)? -
ANSWER>>Measure the client's urinary output.
What is the best initial response by the nurse? - ANSWER>>Describe the location
and type of pain you are having
Based on the nurse's assessment, which assessment data supports the decision to
administer pain medication as the first intervention? (Select all that apply. One,
some, or all options may be correct.) - ANSWER>>Pain rating of 6/10 - Heart rate
of 102 beats/minute - Blood pressure of 132/76 mmHg
