BSN 266 HESI Exam with Questions and Answers

BSN 266 HESI Exam with Questions and Answers The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs; heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement? a. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter. b. Medicate for pain and monitor vital signs according to protocol. c. Administer intravenous fluid bolus as prescribed by the healthcare provider. d. Encourage the client to splint the incision with a pillow to cough and deep breathe ANSWER b. Medicate for pain and monitor vital signs according to protocol. While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take? a. Assesses the client's radical pulses and capillary refill time. b. Discuss approaches to chronic pain control with the client. c. Notify the healthcare provider of the finding immediately. d. Review the client's dietary intake of high- protein foods ANSWER b. Discuss approaches to chronic pain control with the client.