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BSN 266 Practice HESI – Questions & Answers 2024
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BSN 266 Practice HESI – Questions &Answers 2024
A client with a completed ischemic stroke has a blood pressure of 180/90
mm Hg. Which action should the nurse implement?
A. Position the head of the bed (HOB) flat.
B. Withhold intravenous fluids.
C. Administer a bolus of IV fluids.
D. Give an antihypertensive medication. - -D. Give an antihypertensive
medication.
Rationale
Most ischemic strokes occur during sleep when baseline blood pressure
declines or blood viscosity increases due to minimal fluid intake. Completed
strokes usually produce neurologic deficits within an hour, and the client's
current elevated blood pressure requires antihypertensive medication.
-A client who is receiving chemotherapy asks the nurse, "Why is so much of
my hair falling out each day?" Which response by the nurse best explains the
reason for alopecia?
A. "Chemotherapy affects the cells of the body that grow rapidly, both
normal and malignant."
B. "Alopecia is a common side effect you will experience during long-term
steroid therapy."
C. "Your hair will grow back completely after your course of chemotherapy is
completed."
D. "The chemotherapy causes permanent alterations in your hair follicles
that lead to hair loss." - -A. "Chemotherapy affects the cells of the body that
grow rapidly, both normal and malignant."
Rationale
The common adverse effects of chemotherapy (nausea, vomiting, alopecia,
bone marrow depression) are due to chemotherapy's effect on the rapidly
reproducing cells, both normal and malignant.
-After checking the urinary drainage system for kinks in the tubing, the
nurse determines that a client who has returned from the post-anesthesia
care has a dark, concentrated urinary output of 54 ml for the last 2 hours.
What priority nursing action should be implemented?
A. Report the findings to the surgeon.
B. Irrigate the indwelling urinary catheter.
C. Apply manual pressure to the bladder.
D. Increase the IV flow rate for 15 minutes. - -A. Report the findings to the
surgeon.
Rationale
,An adult who weighs 132 pounds (60 kg) should produce about 60 ml of
urine hourly (1 ml/kg/hour). Dark, concentrated, and low volume of urine
output should be reported to the surgeon.
-A male client who smokes two packs of cigarettes a day states he
understands that smoking cigarettes is contributing to the difficulty that he
and his wife are having in getting pregnant and wants to know if other
factors could be contributing to their difficulty. What information is best for
the nurse to provide? (Select all that apply.)
Select all that apply
A. Marijuana cigarettes do not affect sperm count.
B. Alcohol consumption can cause erectile dysfunction.
C. Low testosterone levels affect sperm production.
D. Cessation of smoking improves general health and fertility.
E. Obesity has no effect on sperm production. - -B, C and D
Rationale
Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm
count is also negatively affected by low testerone levels and obesity.
-A client with gastroesophageal reflux disease (GERD) has been
experiencing severe reflux during sleep. Which recommendation by the
nurse is most effective to assist the client?
A. Losing weight.
B. Decreasing caffeine intake.
C. Avoiding large meals.
D. Raising the head of the bed on blocks. - -D. Raising the head of the bed
on blocks.
Rationale
Raising the head of the bed on blocks (reverse Trendelenburg position) to
reduce reflux and subsequent aspiration is the most non-pharmacological
effective recommendation for a client experiencing severe gastroesophageal
reflux during sleep.
-A 51-year-old truck driver who smokes two packs of cigarettes a day and is
30 pounds overweight is diagnosed with having a gastric ulcer. What content
is most important for the nurse to include in the discharge teaching for this
client?
A. Information about smoking cessation.
B. Diet instructions for a low-residue diet.
C. Instructions on a weight-loss program.
D. The importance of increasing milk in the diet. - -A. Information about
smoking cessation.
Rationale
,Smoking has been associated with ulcer formation, and stopping or
decreasing the number of cigarettes smoked per day is an important aspect
of ulcer management.
-What types of medications should the nurse expect to administer to a client
during an acute respiratory distress episode?
A. Vasodilators and hormones.
B. Analgesics and sedatives.
C. Anticoagulants and expectorants.
D. Bronchodilators and steroids. - -D. Bronchodilators and steroids.
Rationale
Besides supplemental oxygen, this client with ARDS needs medications to
widen air passages, increase air space, and reduce alveolar membrane
inflammation, such as bronchodilators and steroids.
-A female client is brought to the clinic by her daughter for a flu shot. She
has lost significant weight since the last visit. She has poor personal hygiene
and inadequate clothing for the weather. The client states that she lives
alone and denies problems or concerns. What action should the nurse
implement?
A. Notify social services immediately of suspected elderly abuse.
B. Discuss the need for mental health counseling with the daughter.
C. Explain to the client that she needs to take better care of herself.
D. Collect further data to determine whether self-neglect is occurring. - -D.
Collect further data to determine whether self-neglect is occurring.
Rationale
Changes in weight and hygiene may be indicators of self-neglect or neglect
by family members. Further assessment is needed before notifying social
services or discussing a need for counseling.
-The nurse is assisting a client out of bed for the first time after surgery.
What action should the nurse do first?
A. Place a chair at a right angle to the bedside.
B. Encourage deep breathing prior to standing.
C. Help the client to sit and dangle legs on the side of the bed.
D. Allow the client to sit with the bed in a high Fowler's position. - -D. Allow
the client to sit with the bed in a high Fowler's position.
Rationale
The first step is to raise the head of the bed to a high Fowler's position,
which allow venous return to compensate from lying flat and the vasodilation
effects of perioperative drugs. This helps prevent the client from becoming
light-headed and decreases the chance of a client fall.
-A 32-year-old female client complains of severe abdominal pain each
month before her menstrual period, painful intercourse, and painful
, defecation. Which additional history should the nurse obtain that is
consistent with the client's complaints?
A. Frequent urinary tract infections.
B. Inability to get pregnant.
C. Premenstrual syndrome.
D. Chronic use of laxatives. - -B. Inability to get pregnant.
Rationale
Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common
symptoms of endometriosis, which is the abnormal displacement of
endometrial tissue in the dependent areas of the pelvic peritoneum. A
history of infertility is another common finding associated with
endometriosis.
-The nurse would be correct in withholding a dose of digoxin in a client with
congestive heart failure without specific instruction from the healthcare
provider if the client's
A. serum digoxin level is 1.5.
B. blood pressure is 104/68.
C. serum potassium level is 3.
D. apical pulse is 68/min. - -C. serum potassium level is 3.
Rationale
Hypokalemia can precipitate digitalis toxicity in persons receiving digoxin
which will increase the chance of dangerous dysrhythmias (normal
potassium level is 3.5 to 5.5 mEq/L).
-In assessing cancer risk, the nurse identifies which woman as being at
greatest risk of developing breast cancer?
A. A 35-year-old multipara who never breastfed.
B. A 50-year-old whose mother had unilateral breast cancer.
C. A 55-year-old whose mother-in-law had bilateral breast cancer.
D. A 20-year-old whose menarche occurred at age 9. - -B. A 50-year-old
whose mother had unilateral breast cancer.
Rationale
The most predictive risk factors for development of breast cancer are over
40 years of age and a positive family history (occurrence in the immediate
family, i.e., mother or sister). Other risk factors include nulliparity, no history
of breastfeeding, early menarche and late menopause, but are not
considered as predictive as a positive history of an immediate family
member and over 40 years old.
-A client taking a thiazide diuretic for the past six months has a serum
potassium level of 3. The nurse anticipates which change in prescription for
the client?
A. The dosage of the diuretic will be decreased.
B. The diuretic will be discontinued.
C. A potassium supplement will be prescribed.
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