While caring for a client with full thickness burns covering 40% of the body, the nurse
observes purulent drainage from the wounds. Before reporting the finding, what is the best
lab value to evaluate?
→ Neutrophil count- The patient is experiencing infection, so a nurse should review the
...
BSN 266 HESI V2 QUESTIONS AND
ANSWERS 2024/2025
While caring for a client with full thickness burns covering 40% of the body, the nurse
observes purulent drainage from the wounds. Before reporting the finding, what is the best
lab value to evaluate?
→ Neutrophil count- The patient is experiencing infection, so a nurse should review the
neutrophil count before contacting the HCP.
An older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual
perception and she only eats half of the food on her meal tray. Her family expresses concern
about her nutritional status. How should the nurse respond to the family's concern?
→ Demonstrate the use of visual scanning during meals to the client and family.
Best position for respiratory distress?
→ High Fowler's Position- High fowlers helps to decrease venous return, which decreases
fluid volume in the heart that results in decreased cardiac workload.
A patient with peripheral artery disease has marked peripheral neuropath. An appropriate
nursing diagnosis for the patient is
→ High risk for injury
Type 2 diabetes patient discharge teaching patient and family
→ Check feet every day for cuts or injuries.
Plan of care for patient with skin lesions of lower extremities with possible MRSA. SATA
→ Institute Contact precautions for staff and visitors
→ Send wound drainage for culture and sensitivity
→ Monitor the clients WBC count
A patient with acute anterior wall MI 1 week ago is given low-dose aspirin. The medication is
related to which problem and HCP should be notified?
→ Hematemesis- - Contact HCP if blood is visible in body fluids such as hematemesis.
For a patient with SLE exacerbation what is the most important to report which assessment
finding?
→ Elevated blood urea nitrogen (BUN)
Before selecting a medication to administer, which action should the nurse implement in the
post-op patient who reports incisional pain and has 2 PRN analgesia available in MAR?
→ Rate of pain on a scale from 0-10.
Patient had bariatric surgery 2 months ago who developed post-op strictures who is
experiencing nausea and vomiting and anorexia who is admitted for fluid resuscitation. Which
intervention should the nurse implement?
→ Keep patient NPO- Patient should be kept NPO until procedure is successfully
completed. The patient should not take anything by mouth.
Acute Kidney Injury due to aminoglycoside antibiotic moved from oliguric phase to the diuretic
phase. Which parameters are most important to monitor?
→ Vital sign changes and ECGs- Priority parameters are vital sign changes related to
hypovolemia and ECG changes due to serum electrolyte loss, which can be life
threatening.
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