BSN 225 - HESI FUNDAMENTALS EXAM QUESTIONS AND ANSWERS 2023

BSN 225 - HESI FUNDAMENTALS EXAM QUESTIONS AND ANSWERS 2023 The nurse is caring for a client on hospice who was started on a 25 mcg/hr Fentanyl patch yesterday at 0800. The nurse completes an assessment today at 2000 and reviews the following assessment data: Yesterday 0800 BP 98/60 HR 110 RR 24 O2SAT 94% PAIN 6/10 INTERVENTIONS Fentanyl patch 25mcg/hr applied Yesterday 2000 100/55 100 20 95% 2/10 Reposition, visiting with family Today 0800 92/40 104 24 92% 4/10 Ice pack applied Today 2000 100/65 110 24 94% 7/10 Which intervention is best for the nurse to provide? a. explain that the fentanyl patch takes time to become effective, and they should experience relief soon. b. offer to administer 5mg of morphine orally as prescribed for breakthrough pain c. reposition the client and offer to give a back rub. d. call the provider to provide an update on the client's condition b. offer to administer 5mg of morphine orally as prescribed for breakthrough pain Rationale: A fentanyl patch is effective for 72 hours before it needs to be replaced. This breakthrough pain is evidenced by a decline in pain rating followed by an elevated pain rating during the time that the fentanyl patch should still be effective. When changing a client's post-op wound dressing, the nurse notes yellow purulent drainage. What action should the nurse take? a. Notify the healthcare provider. b. Cover the wound with clean gauze and secure. c. Irrigate the wound with sterile water and leave open to air. d. Irrigate the wound with normal saline and pack with gauze. a. Notify the healthcare provider. Rationale: Yellow purulent drainage is an indication of an infection. This finding should be reported to the healthcare provider for assessment and intervention. Choices B, C, and D are all incorrect because the priority action is to notify the healthcare provider of the status of the wound. Further wound management (cultures, irrigation, or no irrigation, packing or no packing, antibiotics, etc.) should be determined after assessment of the site by the surgical team. Irrigating the wound before assessment has been completed may interfere with medical decision-making and hsould be avoided. The healthcare provider prescribes enteral feeds of Jevity 1.2 cal at 66mL/hour over 20 hours, and free water flushes of 225 mL q 4 hours x 24 hr via nasogastric tube. How many mL of total fluid will the client receive in 24 hours? (Enter numerical value only. If rounding is required, round to one decimal place.) 2670 mL Rationale: 66mL/hour x 20 hours = 1320 mL Then it is necessary to calculate the amount of fluid from the free water flushes. Free water flushes every 4 hours for 24 hours = 6 flushes 225 mL x 65 flushes = 1350 mL Finally, add the two sums together: 1320 mL + 1350 mL = 2670 mL in 24 hours The nurse prepares to administer a medication that comes in tablet for through a client's gastrostomy tube. Which actions should the nurse implement? (Select all that apply) a. Position client in Fowler's position b. Aspirate gastric contents at the start and end of the procedure c. Mix crushed medication with tube feeding d. Pour dissolved medication into a syringe and inject into G tube e. Flush tube with 30 cc of lukewarm water prior and after the medication administration a. Position client in Fowler's position e. Flush tube with 30 cc of lukewarm water prior to and after the medication administration Rationale: Choices A and E describe the correct execution of the listed steps of medication administration. Fowler's position promotes the downward flow of the medication into the stomach and decreases the risk for medication reflux and aspiration. The client should be maintained in Fowler's position during the procedure and for 30 minutes after the medication administration. The tube should be flushed before and after the medication administration to clean the tubing and prevent blockage. Lukewarm water (room temperature) should be used to prevent abdominal cramping. To prevent volume overload, no more than 30 ml should be administered per flush. The nurse should follow a specific protocol to promote client safety and medication efficacy when providing medication using a G-tube. The appropriate steps include: 1. positioning the client in Fowler's position 2. verifying tube placement and GI function through aspiration of stomach contents 3. flushing the tube with water prior to medication administration 4. preparing the medication by crushing and dissolving it into water 5. allowing the solution to drain into the G-tube by gravity 6. flushing the tube with water after the medication administration 7. reclamping the tube after the administration is completed and the tube has been flushed. The nurse notes that a client who is receiving oxygen by nasal cannula continues to remove the oxygen prongs from the nares. What action should the nurse take? a. tape the oxygen tubing to the client's nares b. assess why the client removes the nasal cannula c. increase the oxygen flow rate d. change the nasal cannula to a mask b. assess why the client removes the nasal cannula Rationale: Using the nursing process, the nurse would first assess why the client is removing the nasal cannula from the nares. Nasal prongs can cause discomfort in the nose or around the ears. If the client reports discomfort, the nurse can troubleshoot based on their symptoms to ensure proper oxygen delivery (e.g., if nasal irritation is present, the air can be humidified, etc.) The nurse is concerned that a blood pressure reading is dangerously elevated for an obese client. What should the nurse do first before contacting the health care provider with the reading? a. reassess the blood pressure using a larger cuff b. reassess the blood pressure using a smaller cuff c. reassess the blood pressure while the client is standing d. reassess the blood pressure while the client is lying down a. reassess the blood pressure using a larger cuff Rationale: Blood pressure cuffs are sensitive and will provide either falsely high or falsely low readings if an incorrect size is used. since the client is obese and the reading was dangerously elevated, the nurse should first assure that the correct size of cuff was used for the reading and then reassess the client's blood pressure. The nurse should use a larger cuff to accurately assess this client's blood pressure. BP - 136/80 mmHg HR - 88 beats/min RespR - 20 breaths/min O2% sat - 92 % on 2L O2 Temp - 37 C (99.6 F) oral A client with tracheostomy is admitted with pneumonia. The client has a productive cough with thick yellow sputum, bilateral crackles on lung auscultation, and vital sign as listed above. When creating this client's care plan, which client outcome should be the nurse identify as a priority? a. client will be able to effectively cough secretions via tracheostomy b. client will have clear lungs sounds c. client will be afebrile d. client will have oxygen saturation greater than 90% during hospitalization a. client will be able to effectively cough secretions via tracheostomy Rationale: A tracheostomy is an opening in the trachea that bypasses an obstructed upper airway. There are multiple indications for and types of tracheostomies but regardless of these variations, the nurse should focus care planning using the ABC (airway, breathing, circulation) framework, combined with the nursing process. The first step is assessment, during which the nurse has gathered data related to cough, lung sounds, and vital signs. Next, the nurse should analyzed this data, noting abnormal findings and looking for patterns. In this scenario, the nurse should notice that the client has many abnormal data points related to patent airway and compromised respiratory system and will build the care plan from these abnormal data points. An adult client is prescribed to receive 2.5 mL of medication through an IM injection. The nurse should select which site to provide this medication? a. dorsogluteal site b. ventrogluteal site c. deltoid site d. abdomen b. ventrogluteal site Rationale: The ventrogluteal site is the preferred site for IM injections because the injection area is free of major nerves and blood vessels and has only a narrow layer of fat of consistent thinness (which guarantees that the needle injects the drug into the muscle instead of the subQ fat layer). The ventrogluteal site can hold large volumes and is considered to be the sagest site for IM injections overall. The nurse is assisting a client who has been on bedrest for several days to move from sitting on the side of the bed to a standing position. As the client begins to stand, the client complains of being dizzy and then loses consciousness. What should the nurse do? a. call for help while maintaining the client in a standing position. b. assist the client to the floor c. guide the client's body back into the bed d. lift the client to the chair c. guide the client's body back into the bed Rationale: Orthostatic hypotension is a common problem affecting the elderly population, esp. after several days of bedrest. The resulting decrease in blood flow to the brain can cause lightheadedness or even loss of consciousness. Since the client has lost consciousness, the safest action would be for the nurse to guide the client's body back into the bed. The home health nurse is visiting a client with chronic pain who has a history of depression. The client sates, "What is the point of therapy? My pain will never get any better and I will not be able to do the things I used to." The nurse adds an outcome to the client's care plan to describe and plan for two future orientated goals. Indicate the step of the nursing process that the nurse has completed. a. assessment b. analysis c. plan d. intervention e. evaluation c. plan Rationale: The nursing process is essential to providing nursing care. By using a system and applying it to every client interaction, the nurse can ensure that client goals are clearly defined, correct interventions are implemented, and measurements are taken to ensure that goals are met. The nurse creates an incident note for a client following a fall. Which entry should be corrected because it appears on The Joint Commission's published list of "DO NOT USE" abbreviations and documentations? PROGRESS NOTE Date: 10/30/2020 Time: 11:20 am Nursing Note: Client found on floor next to the toilet in the bathroom. Client had been ambulating with SBA but stated that he felt dizzy and lost his balance. Had been on floor approx. 5 minutes. Assisted to wheelchair. VS stable. Completed full assessment. Obtained BG-225. C/O pain to right great toe where a small laceration was noted, bandage applied. Pain rated as 6/10 to right hip and RLQ. Assisted client back to bed. Administered 2.0 mg morphine IV and client was transported to CT scan for evaluation of injuries. The Joint Commission has issued warnings regarding medical abbreviations and documentations since 2001. The "DO NOT USE" list was implemented in 2004 following sentinel events that occurred around misinterpreted medical abbreviations. The list applies to all forms of communications between healthcare providers, including handwritten notes, computer entries, and pre-printed forms. The entry that should be corrected is "2.0 mg morphine" because the trailing 0 in this entry is on the "DO NOT USE" list. The decimal point can be problematic if the reader does not see it and interprets the dose as 20 mg rather than 2mg. The Joint Commission also requires a leading 0 when working with fractional doses (0.2 mg is correct vs. .2 mg, which is incorrect). While rounding on the unit, the nurse manager notices a potentially offensive tattoo visible on a staff nurse's forearm. The nurse should complete the additional actions in which sequence? (Arrange from first on top to last on bottom). 1. provide the nurse with a long-sleeved scrub jacket to wear for the remainder of the shift. 2. review the hospital policy regarding covering of tattoos with the nurse. 3. document the encounter in the nurse's staff file. 4. have the nurse complete the task they were doing when the manager noted the tattoo. 4. have the nurse complete the task they were doing when the manager noted the tattoo. 2. review the hospital policy regarding covering of tattoos with the nurse. 1. provide the nurse with a long-sleeved scrub jacket to wear for the remainder of the shift. 3. document the encounter in the nurse's staff file. Rationale: Typical hospital policy is that tattoos, particularly offensive ones, should be covered while at work. The nurse should be allowed to complete their current task to avoid disrupting client care, drawing attention to the issue, or cause an unnecessarily uncomfortable situation for the nurse or client. The manager should then review the hospital policy regarding tattoos with the nurse so that the nurse understands why they are in violation. Next, the nurse manager should provide the nurse with a scrub jacket to cover the tattoo. Once the encounter with the nurse is over, the manager should document the accident in the nurse's staff file. The nurse is evaluating the outcomes of care provided to a client. When conducting this evaluation, the nurse should utilize which variable? a. data collected during the initial assessment b. actions implemented during care c. goals established according to prioritized nursing diagnoses d. laboratory data c. goals established according to prioritized nursing diagnoses The nursing process is essential to providing nursing care. By using a system and applying it to every client interaction, the nurse can ensure that client goal are clearly defined, correct interventions are implemented, and measurements are taken to ensure that goals are met. Evaluation is the final step of the nursing process. This step involves evaluating the outcomes of care. In order to evaluate client outcomes, the nurse should utilize the goals established according to prioritized nursing diagnoses (in the planning phase of the nursing process). The nurse should then see if the interventions that were implemented (in the intervention phase of the nursing process) were successful in reaching those goals. While caring for a 76-year-old client on supplemental oxygen via nasal cannula, the nurse notes the client's pulse oximetry reading is 88%. After assessing the client's airway and breathing, in what sequence should the nurse perform these actions? (Arrange from first on top to last on bottom). 1. Notify the healthcare provider 2. Reposition the pulse oximeter probe 3. Check patency of oxygen tubing and nasal cannula 4. Reassess pulse oximetry reading 5. Verify oxygen flow rate and FiO2 2. Reposition the pulse oximeter probe 4. Reassess pulse oximetry reading 3. Check patency of oxygen tubing and nasal cannula 5. Verify oxygen flow rate and FiO2 1. Notify the healthcare provider The nurse is emptying the urinary collection bag for a client with a history of HIV who has an intake and output order. In which sequence should the nurse perform the following actions after the urinary collection bag has been drained into the urine receptacle? (Arrange from first on top to last on bottom). 1. remove personal protective equipment 2. ensure the urinary collection bag is placed below the client's bladder 3. empty the urine receptacle 4. document the amount of urine collected on the bedside computer 5. wash hands with soap and water 2. ensure the urinary collection bag is placed below the client's bladder 3. empty the urine receptacle 1. remove personal protective equipment 5. wash hands with soap and water 4. document the amount of urine collected on the bedside computer The nurse receives an order for 0.5mg/kg of oral dexamethasone for a child with viral croup. The child weighs 28 lbs. Dexamethasone is available from the pharmacy in 1 mg/1mL vial. Which device should the nurse use to correctly prepare this dose of medication? a. a 60 ml irrigation syringe b. an oral medication cup c. a parenteral medication syringe d. an oral medication syringe d. an oral medication syringe During early morning rounds a client tells the nurse that last night was his first night in the hospital and he was unable to sleep due to the numerous interruptions and alarms. What action should the nurse take? (Select all that apply.) a. give the client a sleeping pill and allow him to rest until later in the afternoon b. turn down the volume from the tv and dim the overhead lights c. turn off alarms on the client monitor and IV poles d. get the client extra pillows and blankets and help them get into a comfortable position e. reschedule the morning ADLs until medications are due after lunch. d. get the client extra pillows and blankets and help them get into a comfortable position e. reschedule the morning ADLs until medications are due after lunch. Rationale: Appropriate interventions for this client include: helping clients position comfortably and providing extra pillow and blankets as needed can make clients more comfortable and likely to fall asleep. Also planning to consolidate tasks and activities for the day to minimize interruptions will allow clients to get some much needed rest. While the nurse is brushing the teeth of an unconscious client, the client begins to cough. What should the nurse do? a. suction the mouth with a tonsilar suction catheter b. flush the mouth with water c. finish brushing the teeth with glycerine swabs d. lower the head of the bed a. suction the mouth with a tonsilar suction catheter Rationale: When brushing the teeth of an unconscious client, the nurse should have a suction device available to use in the event the client begins to cough. Suction is used to prevent aspiration.