BSN HESI 266 Actual Exam Newest 2024/2025 Questions And
Answers/Graded A+
1. Client is recovering from a transurethral prostatecto- Drink 3L
my. Which activity should be limited until after the first
postoperative visit with the healthcare provider?
2. A client with stage IV bone cancer is admitted to the Administer opi-
hospital for a 1-10 scale. Which intervention should oid and non-opioid
the nurse implement? medications simul-
taneously
3. A client experiences an AOB incompatibility reac- a. low back pain
tion after multiple blood transfusions. Which finding and hypotension
should the nurse report immediately to the health care
provider? ANSWER: (A)
LOW BACK PAIN
a. low back pain and hypotension AND HYPOTEN-
STION
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
d. arthritic joint changes and chronic pain
4. When conducting discharge teaching for a client c. Eat a high fiber
diagnosed with diverticulosis, which diet instruction diet and increase
should the nurse include? fluid intake.
a. Have small frequent meals and sit up for at least two ANSWER (C) EAT
hours after meals. A HIGH-FIBER
DIET AND IN-
b. Eat a bland diet and avoid spicy foods. CREASE FLUID
INTAKE
c. Eat a high fiber diet and increase fluid intake.
d. Eat a soft diet with increased intake of milk and milk
products
5. The nurse observes an increased number of blood c. Increase the
clots in the drainage tubing of a client with continuous flow of the bladder
bladder irrigation following a transurethral resection irrigation
, BSN HESI 266
of the prostate (TURP). What is the best initial nursing
action?
ANSWER (C) In-
a. Provide additional oral fluid intake crease the flow of
the bladder irriga-
b. Measure the client's intake and output. tion
c. Increase the flow of the bladder
irrigation
d. Administer a PRN dose of an antispasmodic agent
6. A client wit lung cancer who wears a subcutaneous Remove all mor-
morphine sulfate patch for pain is short of breath and phine patches
difficult to arouse. When performing a head
-to-toe assessment, the nurse discovers four anal-
gesic patches on
7. Coming down the basement steps, a client is brought Right foot pale
to the emergency room X-ray ... cast, which assess- with sluggish cap-
ment finding warrants immediate illary refill
Intervention by the nurse?
8. An overweight, young adult who was a. Check finger
recently Check finger stick glucose diagnosed with stick
type 2 diabetes mellitus is admitted for a hernia repair. glucose
He tells the nurse that he is feeling very weak and
jittery. b. Assess skin
temperature
Which actions should the nurse implement? and moisture
(Select all that apply.)
c. Measure pulse
a. Check finger stick and blood
glucose pressure
b. Assess skin temperature ANSWER: (CAM)
and moisture
, BSN HESI 266
c. Measure pulse and blood
pressure
9. A client who underwent cardiac stent placement four d. Obtain a
days ago arrives to the 12-lead electro-
emergency department reporting a sudden onset of cardiogram and
chest pressure and begin continuous
shortness of breath. Which action should the nurse cardiac monitoring
take next?
a. Listen for extra heart sounds, murmurs, and r
hythm with the bell of
the stethoscope.
b. Evaluate upper and lower extremities for perfusion,
pulse volume,
and pitting edema.
c. Verify troponin level assessments are scheduled
every 3-6 hours for a series of three.
d. Obtain a 12-lead electrocardiogram and begin con-
tinuous cardiac monitoring
.
10. While completing a health assessment for a client c. Gather addi-
with migraine headaches, the nurse assesses bilateral tional assessment
weakness in the clients hand grips. The client reports data about the
joint pain and trouble twisting a door knob due to pain and weak-
weaknesses. Which action should the nurses take in ness.
response to these figures?
a. Implement fall precautions to reduce the clients risk
of injury.
b. Explain that relief of the migraine pain will reduce
related symptoms.
c. Gather additional assessment data about the pain
Answers/Graded A+
1. Client is recovering from a transurethral prostatecto- Drink 3L
my. Which activity should be limited until after the first
postoperative visit with the healthcare provider?
2. A client with stage IV bone cancer is admitted to the Administer opi-
hospital for a 1-10 scale. Which intervention should oid and non-opioid
the nurse implement? medications simul-
taneously
3. A client experiences an AOB incompatibility reac- a. low back pain
tion after multiple blood transfusions. Which finding and hypotension
should the nurse report immediately to the health care
provider? ANSWER: (A)
LOW BACK PAIN
a. low back pain and hypotension AND HYPOTEN-
STION
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
d. arthritic joint changes and chronic pain
4. When conducting discharge teaching for a client c. Eat a high fiber
diagnosed with diverticulosis, which diet instruction diet and increase
should the nurse include? fluid intake.
a. Have small frequent meals and sit up for at least two ANSWER (C) EAT
hours after meals. A HIGH-FIBER
DIET AND IN-
b. Eat a bland diet and avoid spicy foods. CREASE FLUID
INTAKE
c. Eat a high fiber diet and increase fluid intake.
d. Eat a soft diet with increased intake of milk and milk
products
5. The nurse observes an increased number of blood c. Increase the
clots in the drainage tubing of a client with continuous flow of the bladder
bladder irrigation following a transurethral resection irrigation
, BSN HESI 266
of the prostate (TURP). What is the best initial nursing
action?
ANSWER (C) In-
a. Provide additional oral fluid intake crease the flow of
the bladder irriga-
b. Measure the client's intake and output. tion
c. Increase the flow of the bladder
irrigation
d. Administer a PRN dose of an antispasmodic agent
6. A client wit lung cancer who wears a subcutaneous Remove all mor-
morphine sulfate patch for pain is short of breath and phine patches
difficult to arouse. When performing a head
-to-toe assessment, the nurse discovers four anal-
gesic patches on
7. Coming down the basement steps, a client is brought Right foot pale
to the emergency room X-ray ... cast, which assess- with sluggish cap-
ment finding warrants immediate illary refill
Intervention by the nurse?
8. An overweight, young adult who was a. Check finger
recently Check finger stick glucose diagnosed with stick
type 2 diabetes mellitus is admitted for a hernia repair. glucose
He tells the nurse that he is feeling very weak and
jittery. b. Assess skin
temperature
Which actions should the nurse implement? and moisture
(Select all that apply.)
c. Measure pulse
a. Check finger stick and blood
glucose pressure
b. Assess skin temperature ANSWER: (CAM)
and moisture
, BSN HESI 266
c. Measure pulse and blood
pressure
9. A client who underwent cardiac stent placement four d. Obtain a
days ago arrives to the 12-lead electro-
emergency department reporting a sudden onset of cardiogram and
chest pressure and begin continuous
shortness of breath. Which action should the nurse cardiac monitoring
take next?
a. Listen for extra heart sounds, murmurs, and r
hythm with the bell of
the stethoscope.
b. Evaluate upper and lower extremities for perfusion,
pulse volume,
and pitting edema.
c. Verify troponin level assessments are scheduled
every 3-6 hours for a series of three.
d. Obtain a 12-lead electrocardiogram and begin con-
tinuous cardiac monitoring
.
10. While completing a health assessment for a client c. Gather addi-
with migraine headaches, the nurse assesses bilateral tional assessment
weakness in the clients hand grips. The client reports data about the
joint pain and trouble twisting a door knob due to pain and weak-
weaknesses. Which action should the nurses take in ness.
response to these figures?
a. Implement fall precautions to reduce the clients risk
of injury.
b. Explain that relief of the migraine pain will reduce
related symptoms.
c. Gather additional assessment data about the pain
