Nightingale College

BSN 246 Practice HESI (1 & 2 latest

BSN 246 HESI Health Assessment V 2024

The registered nurse (RN) palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.) A. Diminished hair on legs. B. Bruising on extremities. C. Skin cool to touch. D. Capillary refill less than 3 seconds. E. Darkened skin on extremities. (Ans- A, C Which action should the registered nurse (RN) implement to complete an assessment for a client while using ...

The nurse is assessing a newborn infant. How should the nurse measure the heart rate (HR)? Palpate the radial pulse for 15 seconds and multiply by four. Palpate the brachial pulse for 30 seconds and multiply by two. Auscultate the apical site for 60 seconds. Apply a pulse oximeter to obtain both the HR and SpO2. (Ans- C A 28-year-old is brought to the emergency department. He is disoriented and hallucinating, and vital signs are elevated. The nurse suspects that the patient is experienc...

The RN is caring for a client with acute pancreatitis and assesses the admission laboratory results. What laboratory value should the RN anticipate being elevated with this diagnosis? (Ans- Amylase Question: A client who uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after using the inhaler. Which action should the RN implement first? (AnsWithhold medication and report symptoms and vital signs to healthcare provider - these are symptoms of excessive use...

The nurse is assessing a client for a hip flexion contracture. Which finding indicates a negative Thomas test when the client's right knee is brought toward the chest? A. The left leg internally rotates. B. The left leg rises off the table. C. The left leg remains on the table. D. The left leg externally rotates. (Ans- C. The left leg remains on the table. An adult client is in the clinic for a regular physical examination. The nurse is assessing the client's hydration status by p...

A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to complete a head-to-toe assessment and will begin at the head of the client. Which technique should the nurse use to begin the assessment? A. Inspect the hair and skin. B. Palpate the temperature of the skin. C. Percuss for tenderness. D. Auscultate the temporal arteries. (Ans- A. Inspect the hair and skin. The nurse observes peristaltic movement in the left lower quadrant of a client's ...

A male client is eating at his bedside table and suddenly starts gagging, is unable to talk, and places both hands over his throat. Which action should the practical nurse implement? A. Provide manual ventilation with a mask bag. B. Give five back blows or slaps. C. Use a blind finger sweep inside the mouth. D. Apply successive abdominal thrusts. (Ans- D. Apply successive abdominal thrusts. Rationale: Abdominal thrusts, also known as the Heimlich maneuver (D), should be performed to loo...

The 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? (Ans- Polydipsia A male client is admitted after falling from his bed. The HCP tells the family that he has an incomplete fracture of the humerus. The family ask the RN what this means. Which type of fracture should the RN explain from these findings? (Ans- A fracture that bends or splinters part of the bone The RN i...

A nurse is administering medications to clients on a psychiatric unit. What does the nurse identify as the reason that so many psychiatric clients are given the drug benztropine or trihexyphenidyl in conjunction with the phenothiazine-derivative neuroleptic medications? 1. They reduce postural hypotension. 2. They potentiate the effects of the neuroleptic drug. 3. They combat the extrapyramidal side effects of the neuroleptic drug. 4. They ameliorate the depression that may accompany schi...