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BSN246
HESI 1
| Question | Answer |
|---|---|
| While caring for a client who has esophageal varices, which nursing intervention is most important for the registered nurse (RN) to implement? | Monitor infusing IV fluids and any replacement blood products Rationale Maintaining hemodynamic stability in a client with esophageal varicescan precipitatea life-threatening crisis if esophageal varies leak or rupture and can result in hemorrhage. |
| (RN) is making early morning rounds on a group of clients when a client begins exhibiting symptoms of an acute asthma attack. The RN administers a PRN prescription for a Beta 2 receptor agonist agent. Which client response should the RN expect? | Rapid resolution of wheezing, improved pulse oximetry values Rationale Beta 2 receptor agonist agents should provide immediate return of airflow and resolve wheezing and improve oxygenation. |
| A client with progressive hearing loss appears distressed when the registered nurse (RN) asks open-ended questions about the client's health history. Which forms of communication should the RN use? | Face the client so can see the RN mouth, check if the hearing aids are working, reduce environmental noise surrounding |
| A client is newly diagnosed with diverticulosis. The registered nurse (RN)is assessing the client's basic knowledge about the disease process. Which statement by the client conveys the client's understanding of the etiology of diverticula? | constipation causes weakening of colon wall which results in out-pouching sacs increases intestinal pressure that weakens the intestinal walls |
| The registered nurse (RN) is caring for a client with tuberculosis (TB) who is taking a combination drug regimen. The client complains about taking "so many pills." What information should the RN provide to the client about the prescribed treatement? | the development of resistant strains of TB are decreases with a combination of drugs |
| The registered nurse (RN) is caring for a client with peptic ulcer disease (PUD). What assessment should the RN identify and document that is consistent with PUD? (Select all that apply). | Hematemesis, gastric pain on and empty stomach |
| Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock? | lethargy |
| Which action should the registered nurse (RN) implement to complete an assessment for a client while using an interpreter? | maintain eye contact with the client listening to the translation |
| A client with cirrhosis of the liver asks the registered nurse (RN) to explain how varicose veins can occur in the esophagus. Which statement should the RN provide to teach the client about the physiological etiology? | increased portal pressure causes blood flow through liver to be shunted to the esophageal |
| The registered nurse (RN) is teaching a client who is being discharged after treatment of tuberculosis (TB). Which cultural issues should the RN assess when preparing the client for discharge? (Select all that apply.) | native language, education level |
| (RN) is assessing a male arrives with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. Which condition should the RN ask the client about his medical history | Ulcerative colitis |
| Pt awaking in the middle of the night with difficulty breathing and shortness of breath related to paroxysmal nocturnal dyspnea. Which underlying condition should the registered nurse (RN) identify in the client's history? | Heart failure Rationale Paroxysmal nocturnal dyspnea is classic sign of heart failure and is secondary to fluid overload associated with heart failure which causes pulmonary edema. |
| The registered nurse (RN) is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the RN to report the healthcare provider? | Dyspnea |
| admitted to the hospital with severe diarrhea (RN) is completing an assessment and notes the client has dry mucous membranes and poor skin turgor. Which assessment data should the RN gather to determine if the client has a fluid volume deficit? | Orthostatic hypotension |
| (RN) to inquire about a possible reaction after taking amoxicillin for 5 days. She reports having vaginal discomfort, itching, and a white discharge. The RN should discuss which action with the client? | Consult with healthcare provider about another treatment for his effect |
| The registered nurse (RN) is teaching a client who is newly diagnosed with emphysema how to perform pursed lip breathing. What is the primary reason for teaching the client this method of breathing? | Promotes CO2 elimination |
| The registered nurse (RN) is interviewing a female client who states she has a persistent productive cough during the winter caused by bronchitis. Which additional finding should the RN assess for bronchitis? | Phlegm production and wheezing |
| (RN) is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the RN that the client is stabilizing? | urine output of 40 ml/hr |
| (RN) reviews the new prescription, phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess? | Consumption of any alcohol or tyramine-rich foods |
| (RN) is caring for a client who has taken atenolol for 2 years. The healthcare provider recently changed the medication to enalaprilto manage the client's blood pressure. Which instruction should the RN provide the client regarding the new medication? | rise slowly when getting out of bed or chair |
| diagnosed with Sarcoidosis. (RN) that she does not understand why she has this. When teaching about the occurrence of sarcoidosis, the RN should include that sarcoidosis most commonly occurs with which ethnic group of women? | African American women |
| (RN) is assessing common complications related to a client's recent diagnosis, systemic lupus erythematosus (SLE). Which symptom should the RN instruct the client to report immediately? | Fever related to infection |
| (EMR)(RN) assesses a client who is at risk for a possible interaction with an over-the-counter (OTC) decongestant. Which client health history should the RN report to the healthcare provider concerning the OTC medication? (Select all that apply). | Closed angle glaucoma, chronic HTN |
| 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, skin cool to touch |
| (RN) notifies the spouse of a client who was admitted to hospice with shallow respirations, .After receiving this information, the client's spouse begins vacuuming around the bed. Which stage of grief is the spouse displaying during the visit? | Denial |
| (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? | The client is treating the nurse with respect |
| (RN) places an ice pack on a middle school student who comes to the school clinic complaining of a sprained ankle. Which therapeutic response should the RN anticipate? | reduced pain and minimized bruising |
| (RN) is caring for an older client who has been bedridden for two weeks. Which assessment findings indicate to the RN that the client is developing a complication related to immobility? | stiffness in the right ankle |
| (RN) is caring for a client with acute pancreatitis and assesses the admission laboratory results. What laboratory value should the RN anticipate being elevated with this diagnosis? | Amylase |
| RN) is caring for a client who has a closed head injury from a motor vehicle collision. Which finding should the RN assess the client for the risk of diabetes insipidus (DI)? | polydipsia |
| (RN) is performing a mini-mental state examination (MMSE) for a client who is being admitted to an assisted living community. Which communication techniques should the RN implement to decrease anxiety in the client? (Select all that apply.) | use simple sentences during examination, reduce environmental detractors during the exam, ask ? one at a time to decrease confusion |
| (RN) is caring for a client with a newly placed nasogastric tube (NGT). Once the placement of the NG tube is verified by x-ray, which technique should the RN use as a reliable method to ensure the NGT is not displaced? | check pH of aspirated stomach contents obtained from the NGT |
| After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the client. Which nursing intervention is most important for the RN to implement? | evaluate VS q10-20 min for 2 hr after procedure |
| (RN) is caring for a young adult who is having an oral glucose tolerance tests (OGTT). Which laboratory result should the RN assess as a normal value for the two hour postprandial result? | 140mg/dl |
| (RN) uses the mini-mental state examination (MMSE) when assessing a client for admission to an assisted living facility. Which finding is the RN assessing when requesting the client to count by 7s? | attention to detail |
| (RN) assesses a client's results for arterial blood gases who has emphysema. Which finding is consistent with respiratory acidosis? | pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/l |
| (RN) did not note that a prescription dose was recently changed and did not note the updated medication administration record (MAR). After giving the client the original dose, the RN reports the medication error to the nurse manager. What consequences | a medication error report will be completed and risk management will be notified |
| (RN) is assessing a client who was discharged home after management of chronic hypertension. Which equipment should the RN instruct the client to use at home? | Sphygmomanometer (bp cuff) |
| RN) recognizes which client group is at the greatest risk for developing a urinary tract infection (UTI)? (Rank from highest risk to lowest risk.) | Older females, school-age females, older males, adolescent males |
| lient who is uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after using the inhaler. Which action should the registered nurse (RN) implement first? | withhold meds and report symptoms and VS to hcp |
| (RN) is administering haloperidol 0.5 mg IM PRN to a client for the first time. What side effects should the RN assess the client for during the initial dose? | Dystonia Rationale Dystonia can be a sudden adverse reaction to this psychotropic medication which should be discontinued to resolve dystonia, and the healthcare provider notified immediately. |
| An infant with heart failure receives a prescription, digoxin 35 mcg PO. The registered nurse (RN) calcuates the desired dose for administration using the available concentration of digoxin labeled, 0.05 mg/mL. | 0.7ml |
| (RN) is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the RN after the removal of the chest tube? | prepare the client for chest X-ray @ bedside |
| (RN) is evaluating a client who presents with symptoms of viral gastroenteritis. Which assessment finding should the RN report to the healthcare provider? | rebound abdominal tenderness over right lower quadrant |
| A Muslim male client refuses to let the female registered nurse (RN) listen to his breath sounds during the examination. How should the RN respond? | request a male nurse or healthcare provider to perform the exam |
| (RN) is developing the plan of care for a client who is admitted for alcohol detoxification. Which goal should be most important for the RN to primarily focus the client's care? | the client will remain free from injury |
| (RN) is caring for a client with aplastic anemia who is hospitalized for weight loss and generalized weakness. Labs show (WBC) of 2,500/mm3 and a platelet 160,000/mm3. intervention is the primary focus | maintain strict protective precautions |
| chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be elevated if the client experienced myocardial damage? | Serum troponin |
| client is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the humerus. The family ask the RN what this means. Which type of fracture should the RN explain from these findings? | a frature that bends or splinters part of the bone |
| admitted for dehydration, weight loss, and a flat affect. After reviewing the client's history, (RN) discovers that the client's spouse died 2 weeks ago. interventions should the RN implement to help the client begin the process of dealing with loss? | Establish trust by creating an safe atmosphere for sharing, help the client identify ways to adapt lifestyle to accommodate loss, explore ways to assist the client to make new emotional investments |
Created by:
shelby.eldredge