BSN 266 HESI Exam| Questions and 100% Complete Solutions
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Course
BSN 266 HESI
Institution
BSN 266 HESI
1.An older male client tells the nurse that he is losing sleep because he has to
get up several times at night to go to the bathroom, that he has trouble
starting his urinary system, and that he does not feel like his bladder is ever
completely empty. Which intervention should the nurse implemen...
BSN 266 HESI Exam| Questions and 100%
Complete Solutions
1.An older male client tells the nurse that he is losing sleep because he has to
get up several times at night to go to the bathroom, that he has trouble
starting his urinary system, and that he does not feel like his bladder is ever
completely empty. Which intervention should the nurse implement?
a. Review the client's fluid intake prior to bedtime.
b. Obtain a fingerstick blood glucose level.
c. Palpate the bladder above the symphysis pubis.
d. Collect a urine specimen for culture analysis.
C
Explanation: The client's symptoms suggest possible urinary retention, which is
common in older males with benign prostatic hyperplasia (BPH). Palpating the bladder
above the symphysis pubis can help the nurse assess for bladder distention and
provide information to guide further evaluation and management.
2. The nurse has conducted a cancer prevention community education
program. In evaluating the participants' understanding of the carcinogens,
which statement indicates an accurate understanding?
a. Environmental factors such as sunlight and chemicals can cause
cancer to spread.
b. Carcinogens are substances that contain cancerous cells.
c. Substances that change a cell so that it becomes cancerous
are potential sources of cancer.
d. Carcinogens are in the environment and cannot be avoided.
C
Explanation: Carcinogens are substances that can cause changes in a cell's DNA,
leading to the development of cancer. Understanding that carcinogens are potential
sources of cancer indicates accurate knowledge of this concept.
3.A client with pheochromocytoma reports the onset of a severe headache.
The nurse observes that the client is very diaphoretic. Which assessment data
should the nurse obtain next?
a. Capillary glucose. b.
Oxygen saturation. c.
Body temperature. d.
Blood pressure.
,D
Explanation: Clients with pheochromocytoma can experience paroxysmal episodes
of hypertension due to the release of catecholamines from the tumor. The onset of a
severe headache and diaphoresis in a client with pheochromocytoma may indicate a
hypertensive crisis, so the nurse should obtain the client's blood pressure next.
4.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. Latent hepatitis C.
c. Crohn's disease with colectomy.
d. Type 2 diabetes mellitus.
C
Explanation: Crohn's disease with a history of colectomy is a contraindication for
peritoneal dialysis due to the increased risk of peritonitis and complications related to
abdominal surgery. The other conditions listed do not directly contraindicate peritoneal
dialysis.
5.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. Hypoalbuminemia that results in a decreased colloidal
onoctic pressure.
b. Hyperaldosteronism causing an increased sodium reabsorption
in renal tubules.
c. Decreased renin-angiotensin response related to an increase
in renal blood flow.
d. Decreased portacaval pressure with greater collateral circulation.
B
Explanation: In cirrhosis, the liver's ability to produce albumin is compromised,
leading to hypoalbuminemia. This causes a decrease in colloidal oncotic pressure, allowing
fluid to leak into the interstitial spaces and leading to edema and ascites.
6.When providing care for an unconscious client who has seizures. Which
nursing intervention is most essential?
a. Maintain the client in a semi-Fowler's position.
b. Keep the room at a comfortable temperature.
c. Ensure oral suction is available.
d. Provide frequent mouth care.
, C
Explanation: Ensuring that oral suction is available is essential for an unconscious client
who has seizures. Suctioning can help to maintain a patent airway and prevent
aspiration of secretions during and after a seizure.
7,A client presents to the emergency department reporting chest pain that is
radiation to the left arm, shortness of breath, and diaphoresis. Which medication
should the nurse anticipate being prescribed by the healthcare provider?
a. Fentanyl.
b. Hydromorphone.
c. Oxycodone.
d. Morphine.
D
Explanation: Morphine is commonly used to treat chest pain associated with myocardial
infarction (heart attack) as it provides pain relief, reduces anxiety, and has a
vasodilatory effect that can improve blood flow to the heart. The other medications listed
are not typically the first choice for managing chest pain related to a heart attack.
8.An adult who was recently diagnosed with glaucoma tells the nurse, "It feels
like I am driving through a tunnel." The client expresses great concern
about going blind. Which nursing instruction is most important for the nurses to
provide this client?
a. Maintain prescribed eye drop
regimen. b. Eat a diet high in carotene.
c. Wear prescription glasses.
d. Avoid frequent eye pressure measurement.
A
Explanation: Maintaining a prescribed eye drop regimen is crucial for managing
glaucoma and preventing further vision loss. While the other suggestions might be
helpful for overall eye health, adherence to the prescribed eye drop regimen is the
most important action to help prevent the progression of glaucoma.
20. Which information should the nurse include on the teaching plan of a
client diagnosed with gastroesophageal reflux disease (GERD)?
a. Adjust food intake to three full meals per day and no snacks.
b. Sleep without pillows at night to maintain neck alignment.
c. Minimize symptoms by wearing loose, comfortable clothing.
d. Avoid participation in any aerobic exercise programs.
C
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