BSN246 | BSN 246 HESI Health
Assessment Exam | Questions and
Answers | Rated A+ | 2024/2025 Guide |
Nightingale
The registered nurse (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?
A. Prepare the client for chest x-ray at the bedside.
B. Review arterial blood gases after removal.
C. Elevate the head of bed to 45 degrees.
D. Assist with disassembling the drainage system.
- Correct Answer - A. Prepare the client for chest x-ray at the bedside.
Rationale
A chest x-ray should be performed immediately after the removal of a
chest tube to ensure lung expansion has been maintained after its
removal.
The registered nurse (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?
A. Reduced pain and minimized brusing.
B. Lowering of body core temperature.
C. Increased circulation around injury.
D. Reabsorption of edema at injury.
,- Correct Answer - A. Reduced pain and minimized brusing.
Rationale
Cold applications produce a topical anesthetic effect to reduce pain as
well as constricts blood vessels to minimize bruising.
A client 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?
A. Withhold medication and report symptoms and vital signs to
healthcare provider.
B. Give PRN medication for nausea and vomiting and evaluate client in
30 minutes.
C. Reassure client that the ipratropium given will alleviate the symptoms.
D. Delay administration of ipratropium until next maintenance medication
is scheduled.
- Correct Answer - A. Withhold medication and report symptoms and
vital signs to healthcare provider.
Rationale
Headache, nausea, blurred vision and insomnia are symptoms of
excessive use of ipratropium, so withholding the medication until the
healthcare provider is notified should be initiated to maintain client
safety.
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?
A. Explain how the nursing skill will be performed before proceeding.
B. Examine client with an additional healthcare provider for support.
C. Request a male nurse or healthcare provider to perform the exam.
,D. Avoid any skills that involve touching the client during the exam. -
Correct Answer - C. Request a male nurse or healthcare provider to
perform the exam.
Rationale
Modesty is an important value in the Muslim community, and Muslims
are reluctant to expose any part of their body to healthcare members.
Muslim clients are accustomed to examination by "same sex" healthcare
providers, so is the best solution for the client.
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?
A. The enlarged liver presses on the lower half of the esophagus which
weakens blood vessel walls.
B. Abnormal vessels form as a result of liver damage that causes chronic
low serum protein levels.
C. Esophageal swelling and tissue damage causes blood to circulate
blood back through the stomach.
D. Increased portal pressure causes blood flow through liver to be
shunted to the esophageal vessels. - Correct Answer - D. Increased
portal pressure causes blood flow through liver to be shunted to the
esophageal vessels.
Rationale
Cirrhotic and fibrosed liver damage causes obstructed blood flow
through portal vessels to the liver which increases the portal
pressurecausing the blood flow through the liver to be shunted to the
, esophageal vessels. The result of this shunting of blood causes the
esophageal vessels (veins) to balloon out and weaken. As the portal
hypertension increases, these esophageal varices can rupture and
cause bleeding resulting in bloody emesis and black tarry stools.
The registered nurse (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?
A. Fever related to infection.
B. Weight loss and anorexia.
C. Depressed mood.
D. Break in tissue integrity. - Correct Answer - A. Fever related to
infection.
Rationale
Secondary infections are a major concern with SLE clients due to the
use of corticosteroids and chemotherapeutic agents, which suppresses
the immune system, so reporting fever and infections should be reported
immediately.
A client with 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?
A. Creatine Kinase (CK-MB).
B. Serum troponin.
C. Myoglobin.
D. Ischemia modified albumin. - Correct Answer - B. Serum troponin.
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