The registered nurse (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/hour.
Apical pulse 100 and blood pressure 76/42.
Urine specific...
BSN 246 HESI Version 1 & 2 Practice Questions
& Answers
The registered nurse (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/hour.
Apical pulse 100 and blood pressure 76/42.
Urine specific gravity 1.001.
Tented skin on dorsal surface of hands.
(Ans- Urine output of 40 mL/hour.
Rationale
A decrease in urinary output is a sign of dehydration. When the urine
output returns to a normal range, 40 mL/hour, the client's kidneys are
perfusing adequately and indicates the client's status is stablizing.
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?
,Withhold medication and report symptoms and vital signs to healthcare
provider.
Give PRN medication for nausea and vomiting and evaluate client in 30
minutes.
Reassure client that the ipratropium given will alleviate the symptoms.
Delay administration of ipratropium until next maintenance medication
is scheduled.
(Ans- 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.
The registered nurse (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?
Exercise bicycle.
Sphygmomanometer.
Blood glucose monitor.
,Weekly medication box.
(Ans- Sphygmomanometer.
Rationale
Self-awareness is the best way for a client to manage chronic
hypertension, so the client should obtain a sphygmomanometer and
learn how to monitor blood pressure daily and maintain a record.
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?
Decreases respiratory rate.
Increases O2 saturation throughout the body.
Conserves energy while ambulating.
Promotes CO2 elimination.
(Ans- Promotes CO2 elimination.
Rationale
Pursed lip breathing helps eliminate CO2 by increasing positive pressure
within the alveoli increasing the surface area of the alveoli making it
easier for the O2 and CO2 gas exchange to occur .
, The registered nurse (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.
Complaints of nausea or vomiting.
Therapeutic serum drug levels.
Blood pressure and pulse prior to taking each dose.
(Ans- Consumption of any alcohol or tyramine-rich foods
Rationale
The consumption of any type of tyramine containing foods such as aged
cheeses, fermented fruits and vegetables, smoked or cured meats, dark
wines and other alcoholic products should be avoided when a client is
prescribed a MAOIs due to the a food-drug interaction causing a
hypertensive crisis which can lead to a hemorrhagic stroke.
A registered nurse (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.)Select all that apply
Use simple sentences during the examination.
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