BSN 225 HESI V2
It is most important for the nurse to recalculate the Braden scale score for a client who
has developed which problem? - CORRECT ANSWER-Urinary Incontinence
At 0100 on a client's second postoperative night, the client states being unable to sleep
and plans to read until feeling sleepy. Which action should the nurse implement? -
CORRECT ANSWER-Bring the client a prescribed PRN sedative-hypnotic.
Which statement by a client indicates to the nurse that the client understands how a
newly prescribed transdermal medication will be administered? - CORRECT ANSWER-
The medicine will be applied directly on my skin.
While electronically scanning the clients armband at the bedside prior to administering
pain medication, the nurse observes the power flickers and the computer screen goes
blank. The computer fails to reboot and the screen remains dark. Which action should
the nurse do first? - CORRECT ANSWER-Notify information services department of this
situation.
When conducting diet teaching for a client who is experiencing episodes of vomiting, the
nurse recommends that the client consume only clear liquids. Which choices by the
client indicate effective learning? (Select all that apply) - CORRECT ANSWER--
Carbonated ginger ale
- Warm chicken broth
- Filtered apple juice
A client with rheumatoid arthritis (RA) is experiencing chronic pain in both hands and
wrists. Which information about the client is most important for the nurse to obtain when
planning care? - CORRECT ANSWER-The ability to perform activities of daily living.
The nurse is preparing a teaching plan for a client with low back pain. Which sleeping
position should be included in the teaching? - CORRECT ANSWER-Side-lying with hip
and knees flexed.
The nurse is interviewing a client with lower abdominal pain and dyspnea, and needs to
question the client about sexual activity. Which approach is best for the nurse to use? -
CORRECT ANSWER-Begin with questions that are less sensitive in nature.
The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff,
the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?
- CORRECT ANSWER-Inflate blood pressure cuff to 120 mm Hg.
A male client presents to the clinic: Stating that he has a high stress job and is having
difficulty falling asleep at night. He has tried over the counter medication, including
, herbals. The client is reporting a constant headache and is seeking medication to help
him sleep. Which intervention should the nurse implement? - CORRECT ANSWER-
Determine the clients sleep and activity pattern.
A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA),
which resulted in paralysis of the right arm. When the nurse enters the room, the client
is struggling to put on a shirt, and curses the nurse. Which response is best for the
nurse to provide? - CORRECT ANSWER-Dressing must be a frustrating experience for
you.
A young adult client is seen in the emergency department for a minor injury following a
motor vehicle collision. The client states being very angry at the person who hit the car.
Which is the best nursing response? - CORRECT ANSWER-You are upset this incident
has brought you here.
When assessing a client that starts to wheeze, which related data should the nurse
obtain? - CORRECT ANSWER-Precipitation factors
A client has a total serum calcium level of 7.0 mg/dL (1.75mmol/L). Based on this
information, which action is most important for the nurse to include while measuring the
clients vital signs? - CORRECT ANSWER-Note the rhythm of the pulse.
A surgical incision that is healing by secondary intention develops a thick tan exudate.
Which action should the nurse take first. - CORRECT ANSWER-Obtain a wound
culture.
The nurse is planning to use simulation to teach a group of newly hired unlicensed
assistive personnel (UAP). In developing the teaching session, what should the nurse
do first? - CORRECT ANSWER-Determine the learning objectives.
The nurse implements a change in the approach to client care after gathering evidence
in support of the new approach. Which action should the nurse take next? - CORRECT
ANSWER-Evaluate the effectiveness of the change.
An elderly client with Alzheimer's disease is being discharged with several prescriptions
and the nurse plans to teach the daughter, who is the client's primary caregiver, about
drug administration. What is the best method to use in evaluating the daughter's
understanding? - CORRECT ANSWER-Ask the daughter to repeat the dosage and
methods for administrating to assess her understanding.
The nurse is caring for a hospitalized client who was place in restraints due to
confusion. The family removes the restraints while they are with the client. When the
family leaves, which action should the nurse take first? - CORRECT ANSWER-
Reassess the client to determine the need for continuing restraints.
It is most important for the nurse to recalculate the Braden scale score for a client who
has developed which problem? - CORRECT ANSWER-Urinary Incontinence
At 0100 on a client's second postoperative night, the client states being unable to sleep
and plans to read until feeling sleepy. Which action should the nurse implement? -
CORRECT ANSWER-Bring the client a prescribed PRN sedative-hypnotic.
Which statement by a client indicates to the nurse that the client understands how a
newly prescribed transdermal medication will be administered? - CORRECT ANSWER-
The medicine will be applied directly on my skin.
While electronically scanning the clients armband at the bedside prior to administering
pain medication, the nurse observes the power flickers and the computer screen goes
blank. The computer fails to reboot and the screen remains dark. Which action should
the nurse do first? - CORRECT ANSWER-Notify information services department of this
situation.
When conducting diet teaching for a client who is experiencing episodes of vomiting, the
nurse recommends that the client consume only clear liquids. Which choices by the
client indicate effective learning? (Select all that apply) - CORRECT ANSWER--
Carbonated ginger ale
- Warm chicken broth
- Filtered apple juice
A client with rheumatoid arthritis (RA) is experiencing chronic pain in both hands and
wrists. Which information about the client is most important for the nurse to obtain when
planning care? - CORRECT ANSWER-The ability to perform activities of daily living.
The nurse is preparing a teaching plan for a client with low back pain. Which sleeping
position should be included in the teaching? - CORRECT ANSWER-Side-lying with hip
and knees flexed.
The nurse is interviewing a client with lower abdominal pain and dyspnea, and needs to
question the client about sexual activity. Which approach is best for the nurse to use? -
CORRECT ANSWER-Begin with questions that are less sensitive in nature.
The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff,
the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?
- CORRECT ANSWER-Inflate blood pressure cuff to 120 mm Hg.
A male client presents to the clinic: Stating that he has a high stress job and is having
difficulty falling asleep at night. He has tried over the counter medication, including
, herbals. The client is reporting a constant headache and is seeking medication to help
him sleep. Which intervention should the nurse implement? - CORRECT ANSWER-
Determine the clients sleep and activity pattern.
A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA),
which resulted in paralysis of the right arm. When the nurse enters the room, the client
is struggling to put on a shirt, and curses the nurse. Which response is best for the
nurse to provide? - CORRECT ANSWER-Dressing must be a frustrating experience for
you.
A young adult client is seen in the emergency department for a minor injury following a
motor vehicle collision. The client states being very angry at the person who hit the car.
Which is the best nursing response? - CORRECT ANSWER-You are upset this incident
has brought you here.
When assessing a client that starts to wheeze, which related data should the nurse
obtain? - CORRECT ANSWER-Precipitation factors
A client has a total serum calcium level of 7.0 mg/dL (1.75mmol/L). Based on this
information, which action is most important for the nurse to include while measuring the
clients vital signs? - CORRECT ANSWER-Note the rhythm of the pulse.
A surgical incision that is healing by secondary intention develops a thick tan exudate.
Which action should the nurse take first. - CORRECT ANSWER-Obtain a wound
culture.
The nurse is planning to use simulation to teach a group of newly hired unlicensed
assistive personnel (UAP). In developing the teaching session, what should the nurse
do first? - CORRECT ANSWER-Determine the learning objectives.
The nurse implements a change in the approach to client care after gathering evidence
in support of the new approach. Which action should the nurse take next? - CORRECT
ANSWER-Evaluate the effectiveness of the change.
An elderly client with Alzheimer's disease is being discharged with several prescriptions
and the nurse plans to teach the daughter, who is the client's primary caregiver, about
drug administration. What is the best method to use in evaluating the daughter's
understanding? - CORRECT ANSWER-Ask the daughter to repeat the dosage and
methods for administrating to assess her understanding.
The nurse is caring for a hospitalized client who was place in restraints due to
confusion. The family removes the restraints while they are with the client. When the
family leaves, which action should the nurse take first? - CORRECT ANSWER-
Reassess the client to determine the need for continuing restraints.
