BSN HESI 266—CONSOLIDATED EXAM REVIEW
QUESTIONS AND ANSWERS, GRADED A+.
A client experiences an AOB incompatibility reaction after multiple blood transfusions. Which finding
should the nurse report immediately to the health care provider?
a. low back pain and hypotension
b. rhinitis and na...
1 BSN HESI 266—CONSOLIDATED EXAM REVIEW QUESTIONS AND ANSWERS , GRADED A+. A client experiences an AOB incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider? a. low back pain and hypotension b. rhinitis and nasal stuffiness c. delayed painful rash with urticarial d. arthritic joint changes and chronic pain a. low back pain and hypotension When conducting discharge teaching for a client diagnosed with diverticul osis, which diet instruction should the nurse include? a. Have small frequent meals and sit up for at least two hours after meals. b. Eat a bland diet and avoid spicy foods. c. Eat a high -fiber diet and increase fluid intake. d. Eat a soft diet with incre ased intake of milk and milk products c. Eat a high -fiber diet and increase fluid intake. The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best initial nursing action? a. Provide additional oral fluid intake b. Measure the client's intake and output. c. Increase the flow of the bladder irrigation d. Administer a PRN dose of an antispasmodic agent c. Increase the flow of the bladder irrigation A client with lung cancer who wears subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic patches on the clie nt's body. Which intervention should the nurse implement first? A. Remove all of the morphine patches B. Administer a narcotic antagonist C. Apply oxygen per face mask D. Measure the client's blood pressure B. Administer a narcotic antagonist After falling down the basement steps, a client is brought to the emergency room. X -ray confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse? a. Circum ferential edema of right foot. b. Complaint of throbbing right leg pain. c. Right foot pale with sluggish capillary refill. d. Increased temperature to lower extremity c. Right foot pale with sluggish capillary refill The answer indicates a potential prob lem with the blood circulation in the client's right foot. When a leg cast is applied, it should not interfere with the blood flow to the foot. However, if the foot becomes pale and the capillary refill is sluggish, it suggests that the blood flow might be compromised. Capillary refill is the time taken for color to return to an external capillary bed after pressure is applied to cause blanching. Normal capillary refill time is usually less than 2 seconds. Sluggish or delayed capillary refill can be a sign of peripheral vascular disease, shock, or hypothermia. In this case, it could be due to the cast being too tight, causing a reduction in blood flow to the foot. This is a serious condition that requires immediate intervention by the nurse to prevent furthe r complications such as tissue necrosis due to lack of oxygen and nutrients. The nurse may need to adjust or remove the cast to restore proper blood flow. An overweight, young adult who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.) A. Check his fingerstick glucose level B. Assess his skin temperature and moisture C. Measure his pulse and blo od pressure D. Document anxiety on the surgical checklist E. Administer a PRN dose of regular insulin A. Check finger stick glucose B. Assess skin temperature and moisture C. Measure pulse and blood pressure ANSWER: (CAM) A client who underwent cardiac st ent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next? a. Listen for extra heart sounds, murmurs, and rhythm with the bell of the stethosc ope. b. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema. c. Verify troponin level assessments are scheduled every 3 -6 hours for a series of three. d. Obtain a 12 -lead electrocardiogram and begin continuous cardiac monito ring. d. Obtain a 12 -lead electrocardiogram and begin continuous cardiac monitoring While completing a health assessment for a client with migraine headaches, the nurse assesses bilateral weakness in the clients hand grips. The client reports joint pain an d trouble twisting a door knob due to weaknesses. Which action should the nurses take in response to these figures? a. Implement fall precautions to reduce the clients risk of injury. b. Explain that relief of the migraine pain will reduce related symptom s. c. Gather additional assessment data about the pain and weakness. d. Consult with the occupational therapist for a functional assessment d. Consult with the occupational therapist for a functional assessment The nurse is caring for a client diagnosed wi th psoriasis vulgaris who is receiving psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment? a. Thick skin plaques topped by silvery white scales b. Tenderness upon pal pation and generalized erythema c. Brown, rough, greasy, wart -like papules on the face d. Requires sunglasses because sunlight hurts eyes b. Tenderness upon palpation and generalized erythema An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis leakage. The client's abdomen is tender to touch, and the vital signs are temperature 101 F (38 3 C). heart rate 130 beats/minute, Respiratory rate 26 breaths/minute, and blood pressure 100/50 mmHg. Which intervention is most important for the nurse to include in the client's plan of care? a. Encourage regular turning. b. Monitor skin for breakdown. c. Strict IV fluid replacement d. Assess wound drainage daily c. Strict IV fluid replacement A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instructions should the nurse provide? a. Painful areas should be rubbed gently until the pain subsides. b. Return appointments will be needed for IV pain medications. c. Enrolling in a pain clinic can provide relief alternatives. d. Wearing gloves when handling cold items guards against painful spasms. d. Wea ring gloves when handling cold items guards against painful spasms.
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