BSN 266 HESI WITH ACCURATE
ANSWERS AND QUESTIONS FORMAT
- D Enjoys fat-free yogurt as an occasional snack food.
Question 1 of 55
The nurse is evaluating a client's understanding about the DASH (Dietary Approaches to
Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the
eating plan?
- A Uses only lactose-free dairy products.
- B Carefully cleans and peels all fresh fruit and vegetables.
- C No longer incudes grains in daily diet.
- D Enjoys fat-free yogurt as an occasional snack food.
- A Further decline in level of consciousness.
Question 2 of 55
A client who has a history of hypothyroidism was initially admitted with lethargy and
confusion. Which additional finding warrants the most immediate action by the nurse?
[Hematocrit (Reference Range: Male: 42% to 52% (0.42 to 0.52 volume fraction)]
- A Further decline in level of consciousness.
- B Hematocrit of 30% (0.30 volume fraction)
- C Cold and dry skin.
- D Facial puffiness and periorbital edema
,- B Full thickness.
Question 3 of 55
The nurse is caring for a client with a burn that is severely edematous with a wound bed
that is brown and yellow in appearance. The client expresses feeling no pain. Which
classification of burn depth should the nurse document?
- A Deep full-thickness.
- B Full thickness.
- C Deep partial-thickness.
- D Superficial partial-thickness.
- A Urinary output.
- B Oxygen saturation.
- D Lung sounds.
Orthopneic position, sometimes called tripod position, is a sitting position where an
individual leans slightly forward with their arms propped up on an overbed table or their
knees.
Orthopnea is the sensation of breathlessness in the recumbent (lying down) position,
relieved by sitting or standing.
Question 4 of 55
An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to
breathe is admitted for further treatment. Initial assessment includes a heart rate 128
,beats/minute and irregular, respirations 38 breaths/minute, blood pressure 168/100 mm
Hg, wheezes and crackles in all lung fields. An hour after the administration of furosemide
60 mg intravenous (IV), which assessment(s) should the nurse obtain to determine the
client's response to treatment? (Select all that apply.)
- A Urinary output.
- B Oxygen saturation.
- C Pain scale.
- D Lung sounds.
- E Skin elasticity.
- B Crohn's disease with colectomy.
Question # 5
Rationale - B Crohn's disease with colectomy.
The nurse should recognize that clients with extensive intra-abdominal surgical history are
not candidates for peritoneal dialysis, as these clients may have decreased peritoneal
membrane surface areas and scar tissue formation, which would make it insufficient for
adequate dialysis exchange.
Question 5 of 55
, A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which
condition entered on the client's medical record should the nurse recognize as a
contraindication for peritoneal dialysis?
- A Nephrotic syndrome history.
- B Crohn's disease with colectomy.
- C Type 2 diabetes mellitus.
- D Latent hepatitis C.
- D Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
The three main things that the liver produces are albumin, bile (digestive enzymes), and
prothrombin (clotting factors).
Albumin plays many important roles including maintenance of appropriate osmotic
pressure, binding and transport of various substances like hormones, drugs etc. in blood,
and neutralisation of free radicals. It prevents fluid from leaking out of blood vessels into
your tissues. Albumin is also responsible for transporting vitamins, enzymes and hormones
throughout your body. Albumin makes up 50% of the proteins found in your plasma.
Question 6 of 55
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs,
and massive ascites. Which mechanism contributes to edema and ascites in clients with
cirrhosis?
- A Decreased portacaval pressure with greater collateral circulation.
- B Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
- C Decreased renin-angiotensin response related to an increase in renal blood flow.
- D Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
ANSWERS AND QUESTIONS FORMAT
- D Enjoys fat-free yogurt as an occasional snack food.
Question 1 of 55
The nurse is evaluating a client's understanding about the DASH (Dietary Approaches to
Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the
eating plan?
- A Uses only lactose-free dairy products.
- B Carefully cleans and peels all fresh fruit and vegetables.
- C No longer incudes grains in daily diet.
- D Enjoys fat-free yogurt as an occasional snack food.
- A Further decline in level of consciousness.
Question 2 of 55
A client who has a history of hypothyroidism was initially admitted with lethargy and
confusion. Which additional finding warrants the most immediate action by the nurse?
[Hematocrit (Reference Range: Male: 42% to 52% (0.42 to 0.52 volume fraction)]
- A Further decline in level of consciousness.
- B Hematocrit of 30% (0.30 volume fraction)
- C Cold and dry skin.
- D Facial puffiness and periorbital edema
,- B Full thickness.
Question 3 of 55
The nurse is caring for a client with a burn that is severely edematous with a wound bed
that is brown and yellow in appearance. The client expresses feeling no pain. Which
classification of burn depth should the nurse document?
- A Deep full-thickness.
- B Full thickness.
- C Deep partial-thickness.
- D Superficial partial-thickness.
- A Urinary output.
- B Oxygen saturation.
- D Lung sounds.
Orthopneic position, sometimes called tripod position, is a sitting position where an
individual leans slightly forward with their arms propped up on an overbed table or their
knees.
Orthopnea is the sensation of breathlessness in the recumbent (lying down) position,
relieved by sitting or standing.
Question 4 of 55
An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to
breathe is admitted for further treatment. Initial assessment includes a heart rate 128
,beats/minute and irregular, respirations 38 breaths/minute, blood pressure 168/100 mm
Hg, wheezes and crackles in all lung fields. An hour after the administration of furosemide
60 mg intravenous (IV), which assessment(s) should the nurse obtain to determine the
client's response to treatment? (Select all that apply.)
- A Urinary output.
- B Oxygen saturation.
- C Pain scale.
- D Lung sounds.
- E Skin elasticity.
- B Crohn's disease with colectomy.
Question # 5
Rationale - B Crohn's disease with colectomy.
The nurse should recognize that clients with extensive intra-abdominal surgical history are
not candidates for peritoneal dialysis, as these clients may have decreased peritoneal
membrane surface areas and scar tissue formation, which would make it insufficient for
adequate dialysis exchange.
Question 5 of 55
, A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which
condition entered on the client's medical record should the nurse recognize as a
contraindication for peritoneal dialysis?
- A Nephrotic syndrome history.
- B Crohn's disease with colectomy.
- C Type 2 diabetes mellitus.
- D Latent hepatitis C.
- D Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
The three main things that the liver produces are albumin, bile (digestive enzymes), and
prothrombin (clotting factors).
Albumin plays many important roles including maintenance of appropriate osmotic
pressure, binding and transport of various substances like hormones, drugs etc. in blood,
and neutralisation of free radicals. It prevents fluid from leaking out of blood vessels into
your tissues. Albumin is also responsible for transporting vitamins, enzymes and hormones
throughout your body. Albumin makes up 50% of the proteins found in your plasma.
Question 6 of 55
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs,
and massive ascites. Which mechanism contributes to edema and ascites in clients with
cirrhosis?
- A Decreased portacaval pressure with greater collateral circulation.
- B Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
- C Decreased renin-angiotensin response related to an increase in renal blood flow.
- D Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
