BSN 246 HESI PRACTISE QUESTIONS
Which action can be assigned to the unlicensed assistive personnel (UAP)? - ANSWERSMeasure the
client's urinary output.
What is the best initial response by the nurse? - ANSWERSDescribe 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.) -
ANSWERSPain rating of 6/10 - Heart rate of 102 beats/minute - Blood pressure of 132/76 mmHg
Which action should the nurse implement first? - ANSWERSAdminister an analgesic.
Which interventions are important to include in the client's plan of care while receiving multiple
immunosuppressants? (Select all that apply. One, some, or all options may be correct.) -
ANSWERSInstruct client to wear a mask when walking in the halls. - Instruct visitors that fresh flowers
should not be taken into the room. - Monitor immunosuppression drug levels regularly.
Which intervention should the nurse ensure is included in the plan of care during the immediate
postoperative period?
a. Monitor Judy's urinary output hourly using an urimeter.
b. Assess Judy's surgical incision every shift.
c. Monitor Judy's nasogastric tube every 4 hours.
d. Encourage Judy to use the incentive spirometer daily. - ANSWERSa
Which is the priority nursing assessment during the first 24-hour postoperative period? - ANSWERSVital
signs
,The nurse is teaching the patient about fluid management between dialysis treatments. Which
instruction by the nurse is the most accurate? - ANSWERSLimit fluids in between treatments to minimize
the amount of fluid that needs to be removed during dialysis.
Which expected outcome should be included in the nurse's teaching plan? - ANSWERSClient will avoid
canned and processed foods.
The nurse assesses the dialysis graft. Which assessment should be reported to the healthcare provider
(HCP) immediately? (Select all that apply. One, some, or all options may be correct.) - ANSWERSYellow,
purulent drainage from graft incision site. - Absence of a thrill over the graft site. - Capillary refill >10
seconds in the hand where the graft is placed.
Which intervention should the nurse ensure has been include in the client's plan of care? (Select all that
apply. One, some, or all options may be correct.)
A. Instruct lab personnel to obtain blood specimens from the dual-lumen catheter.
B. Perform sterile dressing changes at the dual-lumen catheter site.
C. Empty and record the drainage from the graft tubing regularly.
D. Regularly rotate IV insertion sites above and below the graft site.
E. Assess Judy's distal pulses and circulation in the arm with the access - ANSWERSB. Perform sterile
dressing changes at the dual lumen catheter site - E. Assess the client's distal pulses and circulation in
the arm with the access.
The nurse documents the assessment of the arteriovenous (AV) graft. Which documentation best
describes a properly functioning AV graft? - ANSWERSThrill present and palpated
The client asks the nurse to clarify what palliative care involves. Which explanation provides the client
the best education regarding palliative care? (Select all that apply. One, some, or all options may be
correct.) - ANSWERSPalliative care provides relief from symptoms including pain. - Palliative care
supports holistic care and improves quality of life. -
What complication would the client be most concerned about if choosing peritoneal dialysis? -
ANSWERSAbdominal infection/Peritonitis
,The nurse prepares and instructs the client for hemodialysis. Which statements by the client indicate the
need for further education? (Select all that apply. One, some, or all options may be correct.) -
ANSWERSHemodialysis will help restore kidney function back to a normal level. - Bowel or bladder
perforation may occur with hemodialysis catheter placement.
What action should the nurse take based on the response from the healthcare provider (HCP) phone
call? (Select all that apply. One, some, or all options may be correct.) - ANSWERSDocument both phone
calls and the HCP's prescriptions. - Notify the charge nurse and activate the chain of command - Hold the
potassium chloride
Which intervention should the nurse implement? - ANSWERSCall and speak directly with the healthcare
provider (HCP).
Which intervention is most important for the nurse to implement? - ANSWERSHold the dose of
potassium chloride and contact the HCP to report the serum potassium level.
Based on these problems, which nursing intervention should be included in the client's plan of care? -
ANSWERSEncourage the client to ask questions and discuss fears about diagnosis
Which assessment data indicates to the nurse that the desired outcome of the epoetin alfa has been
achieved? - ANSWERSConjunctival sac returns to a reddish pink color
Which assessment should the nurse perform to determine if the desired outcome of the losartan has
been achieved? - ANSWERSBlood pressure
Which assessment finding indicates to the nurse that the desired outcome of the calcium acetate has
been achieved? - ANSWERSSerum phosphorous of 4.0 mg/dL (1.29 mmol/L)5
After the nurse completes the assessment, what findings are most important to report to the healthcare
provider (HCP) ? (Select all that apply. One, some, or all options may be correct.) - ANSWERSBlood
pressure of 178/92 mmHg - Respiratory rate of 28 breaths per minute- Bibasilar crackles - Edema
The client's hemoglobin level is 7.8 g/dL (78 g/L). What action should the nurse take? - ANSWERSObtain
an order to start an erythropoietin stimulating agent (ESA)
, What assessment data supports the diagnosis of acute organ rejection? (Select all that apply. One, some,
or all options may be correct.) - ANSWERS- Blood pressure of 178/96 mm Hg.
- Sub therapeutic immunosuppression levels
- Acute pain rated 6/10
- Temperature of 100.6 F(38.1 C).
- BUN of 56 mg/dL (19.99 mmol/L)
- Creatinine of 1.9 mg/dL (167.96 mcmol/L
What is the correct interpretation of these ABG's? - ANSWERSMetabolic acidosis (compensated)
Which lab value would the nurse be MOST concerned about? - ANSWERSGlomerular 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? -
ANSWERSThe 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? - ANSWERSThe 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.) - ANSWERS- 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.) - ANSWERS- 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
Which action can be assigned to the unlicensed assistive personnel (UAP)? - ANSWERSMeasure the
client's urinary output.
What is the best initial response by the nurse? - ANSWERSDescribe 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.) -
ANSWERSPain rating of 6/10 - Heart rate of 102 beats/minute - Blood pressure of 132/76 mmHg
Which action should the nurse implement first? - ANSWERSAdminister an analgesic.
Which interventions are important to include in the client's plan of care while receiving multiple
immunosuppressants? (Select all that apply. One, some, or all options may be correct.) -
ANSWERSInstruct client to wear a mask when walking in the halls. - Instruct visitors that fresh flowers
should not be taken into the room. - Monitor immunosuppression drug levels regularly.
Which intervention should the nurse ensure is included in the plan of care during the immediate
postoperative period?
a. Monitor Judy's urinary output hourly using an urimeter.
b. Assess Judy's surgical incision every shift.
c. Monitor Judy's nasogastric tube every 4 hours.
d. Encourage Judy to use the incentive spirometer daily. - ANSWERSa
Which is the priority nursing assessment during the first 24-hour postoperative period? - ANSWERSVital
signs
,The nurse is teaching the patient about fluid management between dialysis treatments. Which
instruction by the nurse is the most accurate? - ANSWERSLimit fluids in between treatments to minimize
the amount of fluid that needs to be removed during dialysis.
Which expected outcome should be included in the nurse's teaching plan? - ANSWERSClient will avoid
canned and processed foods.
The nurse assesses the dialysis graft. Which assessment should be reported to the healthcare provider
(HCP) immediately? (Select all that apply. One, some, or all options may be correct.) - ANSWERSYellow,
purulent drainage from graft incision site. - Absence of a thrill over the graft site. - Capillary refill >10
seconds in the hand where the graft is placed.
Which intervention should the nurse ensure has been include in the client's plan of care? (Select all that
apply. One, some, or all options may be correct.)
A. Instruct lab personnel to obtain blood specimens from the dual-lumen catheter.
B. Perform sterile dressing changes at the dual-lumen catheter site.
C. Empty and record the drainage from the graft tubing regularly.
D. Regularly rotate IV insertion sites above and below the graft site.
E. Assess Judy's distal pulses and circulation in the arm with the access - ANSWERSB. Perform sterile
dressing changes at the dual lumen catheter site - E. Assess the client's distal pulses and circulation in
the arm with the access.
The nurse documents the assessment of the arteriovenous (AV) graft. Which documentation best
describes a properly functioning AV graft? - ANSWERSThrill present and palpated
The client asks the nurse to clarify what palliative care involves. Which explanation provides the client
the best education regarding palliative care? (Select all that apply. One, some, or all options may be
correct.) - ANSWERSPalliative care provides relief from symptoms including pain. - Palliative care
supports holistic care and improves quality of life. -
What complication would the client be most concerned about if choosing peritoneal dialysis? -
ANSWERSAbdominal infection/Peritonitis
,The nurse prepares and instructs the client for hemodialysis. Which statements by the client indicate the
need for further education? (Select all that apply. One, some, or all options may be correct.) -
ANSWERSHemodialysis will help restore kidney function back to a normal level. - Bowel or bladder
perforation may occur with hemodialysis catheter placement.
What action should the nurse take based on the response from the healthcare provider (HCP) phone
call? (Select all that apply. One, some, or all options may be correct.) - ANSWERSDocument both phone
calls and the HCP's prescriptions. - Notify the charge nurse and activate the chain of command - Hold the
potassium chloride
Which intervention should the nurse implement? - ANSWERSCall and speak directly with the healthcare
provider (HCP).
Which intervention is most important for the nurse to implement? - ANSWERSHold the dose of
potassium chloride and contact the HCP to report the serum potassium level.
Based on these problems, which nursing intervention should be included in the client's plan of care? -
ANSWERSEncourage the client to ask questions and discuss fears about diagnosis
Which assessment data indicates to the nurse that the desired outcome of the epoetin alfa has been
achieved? - ANSWERSConjunctival sac returns to a reddish pink color
Which assessment should the nurse perform to determine if the desired outcome of the losartan has
been achieved? - ANSWERSBlood pressure
Which assessment finding indicates to the nurse that the desired outcome of the calcium acetate has
been achieved? - ANSWERSSerum phosphorous of 4.0 mg/dL (1.29 mmol/L)5
After the nurse completes the assessment, what findings are most important to report to the healthcare
provider (HCP) ? (Select all that apply. One, some, or all options may be correct.) - ANSWERSBlood
pressure of 178/92 mmHg - Respiratory rate of 28 breaths per minute- Bibasilar crackles - Edema
The client's hemoglobin level is 7.8 g/dL (78 g/L). What action should the nurse take? - ANSWERSObtain
an order to start an erythropoietin stimulating agent (ESA)
, What assessment data supports the diagnosis of acute organ rejection? (Select all that apply. One, some,
or all options may be correct.) - ANSWERS- Blood pressure of 178/96 mm Hg.
- Sub therapeutic immunosuppression levels
- Acute pain rated 6/10
- Temperature of 100.6 F(38.1 C).
- BUN of 56 mg/dL (19.99 mmol/L)
- Creatinine of 1.9 mg/dL (167.96 mcmol/L
What is the correct interpretation of these ABG's? - ANSWERSMetabolic acidosis (compensated)
Which lab value would the nurse be MOST concerned about? - ANSWERSGlomerular 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? -
ANSWERSThe 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? - ANSWERSThe 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.) - ANSWERS- 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.) - ANSWERS- 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
