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BSN 246 HESI exam with correct answers
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BSN 246 HESI exam with correct answers
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BSN 246 HESI exam with correctanswers
Which action can be assigned to the unlicensed assistive personnel (UAP)?
- .......🔷ANSWERS🔶......✔✔ Measure the client's urinary output.
What is the best initial response by the nurse? - .......🔷ANSWERS🔶......✔✔ Describe the location
and type of pain you are having
Based on the nurse's assessment, which assessment data supports the decision to administer pain
medication as the first intervention? (Select all that apply. One, some, or all options may be correct.)
- .......🔷ANSWERS🔶......✔✔ Pain rating of 6/10 - Heart rate of 102 beats/minute - Blood pressure
of 132/76 mmHg
Which action should the nurse implement first? - .......🔷ANSWERS🔶......✔✔ Administer an
analgesic.
Which interventions are important to include in the client's plan of care while receiving multiple
immunosuppressants? (Select all that apply. One, some, or all options may be correct.)
- .......🔷ANSWERS🔶......✔✔ Instruct client to wear a mask when walking in the halls. - Instruct
visitors that fresh flowers should not be taken into the room. - Monitor immunosuppression drug
levels regularly.
Which intervention should the nurse ensure is included in the plan of care during the immediate
postoperative period?
a. Monitor Judy's urinary output hourly using an urimeter.
b. Assess Judy's surgical incision every shift.
c. Monitor Judy's nasogastric tube every 4 hours.
d. Encourage Judy to use the incentive spirometer daily. - .......🔷ANSWERS🔶......✔✔ a
,Which is the priority nursing assessment during the first 24-hour postoperative period?
- .......🔷ANSWERS🔶......✔✔ Vital signs
The nurse is teaching the patient about fluid management between dialysis treatments. Which
instruction by the nurse is the most accurate? - .......🔷ANSWERS🔶......✔✔ Limit fluids in between
treatments to minimize the amount of fluid that needs to be removed during dialysis.
Which expected outcome should be included in the nurse's teaching plan?
- .......🔷ANSWERS🔶......✔✔ Client will avoid canned and processed foods.
The nurse assesses the dialysis graft. Which assessment should be reported to the healthcare
provider (HCP) immediately? (Select all that apply. One, some, or all options may be correct.)
- .......🔷ANSWERS🔶......✔✔ Yellow, purulent drainage from graft incision site. - Absence of a thrill
over the graft site. - Capillary refill >10 seconds in the hand where the graft is placed.
Which intervention should the nurse ensure has been include in the client's plan of care? (Select all
that apply. One, some, or all options may be correct.)
A. Instruct lab personnel to obtain blood specimens from the dual-lumen catheter.
B. Perform sterile dressing changes at the dual-lumen catheter site.
C. Empty and record the drainage from the graft tubing regularly.
D. Regularly rotate IV insertion sites above and below the graft site.
E. Assess Judy's distal pulses and circulation in the arm with the access
- .......🔷ANSWERS🔶......✔✔ B. Perform sterile dressing changes at the dual lumen catheter site - E.
Assess the client's distal pulses and circulation in the arm with the access.
The nurse documents the assessment of the arteriovenous (AV) graft. Which documentation best
describes a properly functioning AV graft? - .......🔷ANSWERS🔶......✔✔ Thrill present and palpated
The client asks the nurse to clarify what palliative care involves. Which explanation provides the
client the best education regarding palliative care? (Select all that apply. One, some, or all options
may be correct.) - .......🔷ANSWERS🔶......✔✔ Palliative care provides relief from symptoms
including pain. - Palliative care supports holistic care and improves quality of life. -
,What complication would the client be most concerned about if choosing peritoneal dialysis?
- .......🔷ANSWERS🔶......✔✔ Abdominal infection/Peritonitis
The nurse prepares and instructs the client for hemodialysis. Which statements by the client indicate
the need for further education? (Select all that apply. One, some, or all options may be correct.)
- .......🔷ANSWERS🔶......✔✔ Hemodialysis will help restore kidney function back to a normal level.
- Bowel or bladder perforation may occur with hemodialysis catheter placement.
What action should the nurse take based on the response from the healthcare provider (HCP) phone
call? (Select all that apply. One, some, or all options may be correct.) - .......🔷ANSWERS🔶......✔✔
Document both phone calls and the HCP's prescriptions. - Notify the charge nurse and activate the
chain of command - Hold the potassium chloride
Which intervention should the nurse implement? - .......🔷ANSWERS🔶......✔✔ Call and speak
directly with the healthcare provider (HCP).
Which intervention is most important for the nurse to implement? - .......🔷ANSWERS🔶......✔✔
Hold the dose of potassium chloride and contact the HCP to report the serum potassium level.
Based on these problems, which nursing intervention should be included in the client's plan of care?
- .......🔷ANSWERS🔶......✔✔ Encourage the client to ask questions and discuss fears about
diagnosis
Which assessment data indicates to the nurse that the desired outcome of the epoetin alfa has been
achieved? - .......🔷ANSWERS🔶......✔✔ Conjunctival sac returns to a reddish pink color
Which assessment should the nurse perform to determine if the desired outcome of the losartan has
been achieved? - .......🔷ANSWERS🔶......✔✔ Blood pressure
Which assessment finding indicates to the nurse that the desired outcome of the calcium acetate has
been achieved? - .......🔷ANSWERS🔶......✔✔ Serum phosphorous of 4.0 mg/dL (1.29 mmol/L)5
, After the nurse completes the assessment, what findings are most important to report to the
healthcare provider (HCP) ? (Select all that apply. One, some, or all options may be correct.)
- .......🔷ANSWERS🔶......✔✔ Blood pressure of 178/92 mmHg - Respiratory rate of 28 breaths per
minute- Bibasilar crackles - Edema
The client's hemoglobin level is 7.8 g/dL (78 g/L). What action should the nurse take?
- .......🔷ANSWERS🔶......✔✔ Obtain an order to start an erythropoietin stimulating agent (ESA)
What assessment data supports the diagnosis of acute organ rejection? (Select all that apply. One,
some, or all options may be correct.) - .......🔷ANSWERS🔶......✔✔ - Blood pressure of 178/96 mm
Hg.
- Sub therapeutic immunosuppression levels
- Acute pain rated 6/10
- Temperature of 100.6 F(38.1 C).
- BUN of 56 mg/dL (19.99 mmol/L)
- Creatinine of 1.9 mg/dL (167.96 mcmol/L
What is the correct interpretation of these ABG's? - .......🔷ANSWERS🔶......✔✔ Metabolic acidosis
(compensated)
Which lab value would the nurse be MOST concerned about? - .......🔷ANSWERS🔶......✔✔
Glomerular filtration rate (GFR) of 9mL/min/1.73m2.
The nurse is teaching the client about progression of chronic kidney disease (CKD). Which
evaluation statement documented by the nurse indicates the client's understanding of the disease
process? - .......🔷ANSWERS🔶......✔✔ The client acknowledges that renal replacement therapy will
need to be initiated immediately to rid the body of waste and maintain fluid balance.
Based on the client's symptoms, what should the nurse suspect? - .......🔷ANSWERS🔶......✔✔ The
client has uremia and may need to start dialysis.
Which additional symptoms should the nurse ask about? (Select all that apply. One, some, or all
options may be correct.) - .......🔷ANSWERS🔶......✔✔ - Nausea - Decreased attention span - Itching
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