BSN 246 HESI Health Assessment Exam (Latest 2024/
2025 Update) Questions and Verified Answers |100%
Correct| Grade A- Nightingale
Which action can be assigned to the unlicensed assistive personnel (UAP)? - ANSWER
Measure the client's urinary output.
What is the best initial response by the nurse? - ANSWER 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.) - ANSWER Pain rating of 6/10 - Heart rate of 102 beats/minute - Blood
pressure of 132/76 mmHg
Which action should the nurse implement first? - ANSWER 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.) -
,ANSWER 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. - ANSWER a
Which is the priority nursing assessment during the first 24-hour postoperative period? -
ANSWER Vital signs
The nurse is teaching the patient about fluid management between dialysis treatments. Which
instruction by the nurse is the most accurate? - ANSWER 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? - ANSWER
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.) -
ANSWER 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 - ANSWER 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? - ANSWER 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.) - ANSWER 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? -
ANSWER 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.) - ANSWER 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.) - ANSWER
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? - ANSWER Call and speak directly
with the healthcare provider (HCP).
Which intervention is most important for the nurse to implement? - ANSWER Hold
the dose of potassium chloride and contact the HCP to report the serum potassium level.
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