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BSN HESI 266 - consolidated (Latest UPDATES STUDY) Exam Reviews Questions and Verified Answers 100 Correct Grade A
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BSN HESI 266 - consolidated (Latest UPDATES STUDY) Exam Reviews Questions and Verified Answers 100 Correct Grade A BSN HESI 266-- consolidated Study online at A client experiences an AOB incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immed...

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  • November 13, 2024
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BSN HESI 266-- consolidated
Study online at https://quizlet.com/_e4hdjd

A client experiences an AOB incompati-
bility reaction after multiple blood trans-
fusions. Which finding should the nurse
report immediately to the health care
provider?
a. low back pain and hypotension
a. low back pain and hypotension
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
d. arthritic joint changes and chronic pain
When conducting discharge teaching for
a client diagnosed with diverticulosis,
which diet instruction should the nurse
include?

a. Have small frequent meals and sit up c. Eat a high-fiber diet and increase fluid
for at least two hours after meals. intake.
b. Eat a bland diet and avoid spicy foods.
c. Eat a high-fiber diet and increase fluid
intake.
d. Eat a soft diet with increased intake of
milk and milk products
The nurse observes an increased num-
ber of blood clots in the drainage tubing
of a client with continuous bladder irri-
gation following a transurethral resection
of the prostate (TURP). What is the best
initial nursing action?
c. Increase the flow of the bladder irriga-
tion
a. Provide additional oral fluid intake
b. Measure the client's intake and output.
c. Increase the flow of the bladder irriga-
tion
d. Administer a PRN dose of an antispas-
modic agent
A client with lung cancer who wears
subcutaneous morphine sulfate patch for
pain is short of breath and is difficult


, BSN HESI 266-- consolidated
Study online at https://quizlet.com/_e4hdjd
to arouse. When performing a head to
toe assessment, the nurse discovers four
analgesic patches on the client's body.
Which intervention should the nurse im-
plement first? B. Administer a narcotic antagonist
A. Remove all of the morphine patches
B. Administer a narcotic antagonist
C. Apply oxygen per face mask
D. Measure the client's blood pressure
c. Right foot pale with sluggish capillary
refill

The answer indicates a potential problem
with the blood circulation in the client's
right foot. When a leg cast is applied, it
should not interfere with the blood flow
to the foot. However, if the foot becomes
After falling down the basement steps, a
pale and the capillary refill is sluggish,
client is brought to the emergency room.
it suggests that the blood flow might be
X-ray confirms that the client's right leg is
compromised. Capillary refill is the time
fractured. Following application of a leg
taken for color to return to an exter-
cast, which assessment finding warrants
nal capillary bed after pressure is ap-
immediate intervention by the nurse?
plied to cause blanching. Normal capil-
a. Circumferential edema of right foot.
lary refill time is usually less than 2 sec-
b. Complaint of throbbing right leg pain.
onds. Sluggish or delayed capillary re-
c. Right foot pale with sluggish capillary
fill can be a sign of peripheral vascular
refill.
disease, shock, or hypothermia. In this
d. Increased temperature to lower ex-
case, it could be due to the cast being
tremity
too tight, causing a reduction in blood
flow to the foot. This is a serious condi-
tion that requires immediate intervention
by the nurse to prevent further compli-
cations such as tissue necrosis due to
lack of oxygen and nutrients. The nurse
may need to adjust or remove the cast to
restore proper blood flow.

An overweight, young adult who was re-
cently diagnosed with type 2 diabetes


, BSN HESI 266-- consolidated
Study online at https://quizlet.com/_e4hdjd
mellitus is admitted for a hernia repair.
He tells the nurse that he is feeling very
weak and jittery. Which actions should
the nurse implement?
(Select all that apply.)
A. Check finger stick glucose
B. Assess skin temperature and moisture
A. Check his fingerstick glucose level
C. Measure pulse and blood pressure
B. Assess his skin temperature and
moisture
ANSWER: (CAM)
C. Measure his pulse and blood pressure
D. Document anxiety on the surgical
checklist
E. Administer a PRN dose of regular in-
sulin
A client who underwent cardiac stent
placement four days ago arrives to the
emergency department reporting a sud-
den onset of chest pressure and
shortness of breath. Which action should
the nurse take next?
a. Listen for extra heart sounds, mur-
murs, and rhythm with the bell of
the stethoscope. d. Obtain a 12-lead electrocardiogram
b. Evaluate upper and lower extremities and begin continuous cardiac monitoring
for perfusion, pulse volume,
and pitting edema.
c. Verify troponin level assessments are
scheduled every 3-6 hours for a series of
three.
d. Obtain a 12-lead electrocardiogram
and begin continuous cardiac monitor-
ing.

While completing a health assessment
for a client with migraine headaches, the
nurse assesses bilateral weakness in the
clients hand grips. The client reports joint
pain and trouble twisting a door knob
due to weaknesses. Which action should

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