BSN 266 Practice HESI Exam Questions With 100% Correct Answers

BSN 266 Practice HESI Exam Questions With 100% Correct Answers A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement? A. Position the head of the bed (HOB) flat. B. Withhold intravenous fluids. C. Administer a bolus of IV fluids. D. Give an antihypertensive medication. - answerD. Give an antihypertensive medication. Rationale Most ischemic strokes occur during sleep when baseline blood pressure declines or blood viscosity increases due to minimal fluid intake. Completed strokes usually produce neurologic deficits within an hour, and the client's current elevated blood pressure requires antihypertensive medication. A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia? A. "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant." B. "Alopecia is a common side effect you will experience during long-term steroid therapy." C. "Your hair will grow back completely after your course of chemotherapy is completed." D. "The chemotherapy causes permanent alterations in your hair follicles that lead to hair loss." - answerA. "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant." Rationale The common adverse effects of chemotherapy (nausea, vomiting, alopecia, bone marrow depression) are due to chemotherapy's effect on the rapidly reproducing cells, both normal and malignant. After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented? A. Report the findings to the surgeon. B. Irrigate the indwelling urinary catheter. C. Apply manual pressure to the bladder. D. Increase the IV flow rate for 15 minutes. - answerA. Report the findings to the surgeon. Rationale An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly (1 ml/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the surgeon. A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if other factors could be contributing to their difficulty. What information is best for the nurse to provide? (Select all that apply.) Select all that apply A. Marijuana cigarettes do not affect sperm count. B. Alcohol consumption can cause erectile dysfunction. C. Low testosterone levels affect sperm production. D. Cessation of smoking improves general health and fertility. E. Obesity has no effect on sperm production. - answerB, C and D Rationale Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively affected by low testerone levels and obesity. A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? A. Losing weight. B. Decreasing caffeine intake. C. Avoiding large meals. D. Raising the head of the bed on blocks. - answerD. Raising the head of the bed on blocks. Rationale Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce reflux and subsequent aspiration is the most non-pharmacological effective recommendation for a client experiencing severe gastroesophageal reflux during sleep.