B&A HESI Mid Curricular V2
with 100% correct answers
A patient with a urinary catheter in place is experiencing bladder
spasms and discomfort. Which of the following interventions should
the nurse implement first?
a) Administer an anticholinergic medication to relax the bladder
b) Encourage increased fluid intake to flush out the catheter
c) Obtain an order to change the catheter and drainage system
d) Assess for possible signs of a urinary tract infection
Answer: d) Assess for possible signs of a urinary tract infection
Rationale: Bladder spasms and discomfort in a patient with an
indwelling urinary catheter can be a sign of a urinary tract infection
(UTI). Before attempting other interventions, the nurse should first
assess for signs of a UTI, such as fever, cloudy or foul-smelling
urine, or suprapubic tenderness. If a UTI is suspected, appropriate
treatment should be initiated promptly to prevent further
complications.
A client in a group therapy session begins shouting and disrupting
the session. Which of the following is the most appropriate initial
nursing intervention?
a) Ask the client to leave the group session immediately
b) Ignore the client's behavior and continue with the session
c) Speak to the client in a calm, low voice and attempt to
understand the cause of anger
d) Raise your voice to match the client's volume and regain control
of the group
Answer: c) Speak to the client in a calm, low voice and attempt to
understand the cause of anger
Rationale: When a client becomes angry and disruptive in a group
setting, it is important for the nurse to remain calm and attempt to
understand the underlying cause of the anger. Speaking to the
client in a calm, low voice can help de-escalate the situation and
make the client feel heard and understood. This approach is more
,therapeutic than ignoring the behavior, asking the client to leave, or
raising one's voice, which could further escalate the situation.
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A patient with hypertension is prescribed an angiotensin-converting
enzyme (ACE) inhibitor. The nurse should monitor the patient for
which of the following adverse effects?
a) Bradycardia and hypotension
b) Dry mouth and constipation
c) Cough and hyperkalemia
d) Nausea and diarrhea
Answer: c) Cough and hyperkalemia
Rationale: ACE inhibitors can cause a dry, persistent cough as a side
effect due to increased levels of bradykinin. They can also lead to
hyperkalemia (elevated potassium levels) by decreasing
aldosterone secretion, which normally promotes potassium
excretion. Therefore, the nurse should monitor for cough and
hyperkalemia in patients taking ACE inhibitors.
During a general assessment, a patient reports difficulty swallowing
solid foods. Which of the following actions should the nurse take
next?
a) Recommend a liquid diet until further evaluation
,b) Obtain an order for a video swallow study
c) Encourage the patient to eat slowly and chew thoroughly
d) Document the finding and continue with the assessment
Answer: b) Obtain an order for a video swallow study
Rationale: Difficulty swallowing solid foods can be a sign of
dysphagia, which may indicate an underlying condition or risk for
aspiration. The appropriate next step is to obtain an order for a
video swallow study, which can help evaluate the patient's
swallowing function and identify the cause of the difficulty.
Recommending a liquid diet or providing general instructions may
not address the underlying issue, and simply documenting the
finding without further action could put the patient at risk.
A nurse is preparing to perform a sterile dressing change. Which of
the following is the correct technique for applying sterile gloves?
a) Open the glove package and slide hands into the gloves
b) Perform hand hygiene, open the glove package, and grasp the
glove cuff
c) Grasp the glove at the palm area and pull the glove onto the hand
d) Perform hand hygiene, open the glove package away from the
body, and slip hands into the gloves
Answer: d) Perform hand hygiene, open the glove package away
from the body, and slip hands into the gloves
Rationale: To maintain sterility, the nurse should perform hand
hygiene, open the glove package away from the body to prevent
contamination, and carefully slip hands into the gloves without
touching the outer surface. Grasping the glove cuff or palm area can
contaminate the gloves.
A nurse is providing education to a patient with a venous leg ulcer.
Which of the following instructions should the nurse include? (Select
all that apply)
a) Elevate the affected leg when possible
b) Massage the area around the ulcer
c) Wear compression stockings as directed
d) Avoid prolonged periods of sitting or standing
e) Perform range-of-motion exercises regularly
, Answer: a, c, d, e
Rationale: For patients with venous leg ulcers, the nurse should
instruct them to elevate the affected leg to promote venous return,
wear compression stockings as directed to reduce edema, avoid
prolonged sitting or standing to prevent venous stasis, and perform
range-of-motion exercises to improve circulation. Massaging the
area around the ulcer should be avoided as it can dislodge a
thrombus and cause complications.
A nurse is auscultating a patient's lung sounds and notes bronchial
breath sounds in the right lower lobe. Which of the following
conditions could cause this finding? (Select all that apply)
a) Atelectasis
b) Pneumonia
c) Pleural effusion
d) Lung tumor
Answer: a, b, d
Rationale: Bronchial breath sounds heard in peripheral lung fields
indicate an area of increased density or consolidation, such as in
atelectasis, pneumonia, or the presence of a lung tumor. Pleural
effusion would typically cause diminished or absent breath sounds.
A patient is admitted with signs and symptoms of a small bowel
obstruction. Which of the following would the nurse expect to
assess?
a) Diarrhea and lower abdominal pain
b) Midabdominal pain and vomiting
c) Constipation and upper abdominal pain
d) Melena and right lower quadrant pain
Answer: b) Midabdominal pain and vomiting
Rationale: In a small bowel obstruction, the patient often
experiences midabdominal pain or cramping, along with vomiting
that may contain bile or be foul-smelling. Diarrhea and lower
abdominal pain are more indicative of a colonic obstruction, while
constipation and upper abdominal pain could suggest a gastric
outlet obstruction. Melena (black, tarry stools) and right lower
quadrant pain are not typical findings in a small bowel obstruction.
