BSN
246
Practice
HESI
(1
&
2)
The
registered
nurse
(RN)
is
caring
for
a
young
adult
who
is
having
an
oral
glucose
tolerance
tests
(OGTT).
Which
laboratory
result
should
the
RN
assess
as
a
normal
value
for
the
two
hour
postprandial
result?
140
mg/dl.
160
mg/dl.
180
mg/dl.
200
mg/dl.
140
mg/dl.
Rationale
The
two
hour
postprandial
level
should
be
less
140
mg/dl
for
a
young
adult
client.
The
registered
nurse
(RN)
is
caring
for
a
client
who
has
a
closed
head
injury
from
a
motor
vehicle
collision.
Which
finding
should
the
RN
assess
the
client
for
the
risk
of
diabetes
insipidus
(DI)?
High
fever .
Low
blood
pressure.
Muscle
rigidity .
Polydipsia.
Polydipsia.
Rationale
A
characteristic
finding
of
DI
is
excretion
of
large
quantities
of
urine
(5
to
20L/day),
and
most
clients
compensate
for
fluid
loss
by
drinking
large
amounts
of
water
(polydipsia).
DI
can
occur
when
there
has
been
damage
or
injury
to
the
pituitary
gland
or
hypothalamus
as
a
result
of
head
trauma,
tumor
or
an
illness
such
as
meningitis.
This
damage
interrupts
the
ADH
production,
storage
and
release
causing
the
excessive
urination
and
thirst.
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Full
screen 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.
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.
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.
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. 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.
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.
Move
to
another
question
if
the
client
seems
confused.
Reduce
environmental
detractors
during
the
examination.
Allow
family
to
answer
for
the
client
to
decrease
frustration.
Ask
questions
one
at
a
time
to
decrease
confusion.
Use
simple
sentences
during
the
examination.
Reduce
environmental
detractors
during
the
examination.
Ask
questions
one
at
a
time
to
decrease
confusion.
Rationale
Communication
techniques
for
clients
with
cognitive
impairments
should
be
simple,
without
environmental
distractions,
and
direct.
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?
Fever
related
to
infection.
Weight
loss
and
anorexia.
Depressed
mood.
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