Exam (elaborations)
BSN 266 HESI V2 QUESTIONS AND ANSWERS
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BSN 266 HESI V2 QUESTIONS AND ANSWERS
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BSN 266 HESI V2 QUESTIONS AND ANSWERSNeutrophil count- The patient is experiencing infection, so a nurse should review the
neutrophil count before contacting the HCP. - Answers- 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?
Demonstrate the use of visual scanning during meals to the client and family. -
Answers- 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?
High Fowler's Position- High fowlers helps to decrease venous return, which decreases
fluid volume in the heart that results in decreased cardiac workload. - Answers- Best
position for respiratory distress?
High risk for injury - Answers- A patient with peripheral artery disease has marked
peripheral neuropath. An appropriate nursing diagnosis for the patient is
Check feet every day for cuts or injuries. - Answers- Type 2 diabetes patient discharge
teaching patient and family
Institute Contact precautions for staff and visitors
Send wound drainage for culture and sensitivity
Monitor the clients WBC count - Answers- Plan of care for patient with skin lesions of
lower extremities with possible MRSA. SATA
Hematemesis- - Contact HCP if blood is visible in body fluids such as hematemesis. -
Answers- 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?
Elevated blood urea nitrogen (BUN) - Answers- For a patient with SLE exacerbation
what is the most important to report which assessment finding?
Rate of pain on a scale from 0-10. - Answers- 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?
Keep patient NPO- Patient should be kept NPO until procedure is successfully
completed. The patient should not take anything by mouth. - Answers- 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?
, 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. - Answers- Acute Kidney Injury due to aminoglycoside antibiotic moved
from oliguric phase to the diuretic phase. Which parameters are most important to
monitor?
Nuts, chocolate, dark greens, and spinach. - Answers- Patient has a calcium oxalate
renal stone. Which food are you going to teach the patient to avoid?
Pancreatitis- complications include pancreatitis that may manifest with upper left
quadrant or mid-epigastric pain which radiates to the back and accompanied by nausea,
vomiting, and fever. - Answers- A patient had a cholecystectomy 2 days ago, the patient
is febrile, abdominal pain radiating to the back and has had 3 episodes of vomiting in
the last 8 hours. The patient is exhibiting symptoms for which condition?
Uncompensated Metabolic Alkalosis - Answers- Patient has a bowel obstruction and
ABGs read ph- 7.50 PaCO2-42 and HCO3-33. How would you define this acid base
balance?
Prescription strength Corticosteroids- decrease inflammation and help manage
psoriasis plaques. Psoriasis is a skin cell proliferation of the surface of the skin causing
thick silvery scales or itchy red patches. - Answers- Psoriasis with silvery, scaly areas
on elbows and palms that burn and bleed. Which prescription should the nurse teach
the client to use for skin condition?
Assess swallowing abilities is a high priority for patients. - Answers- Which additional
nursing assessments takes priority in response to a patient with Parkinson's disease
exhibiting a mask like facial appearance?
Take prescribed cortisone accurately - Answers- A patient is recently diagnosed with
Addison's disease. Which instructions is most important for the nurse to include in
discharge teaching?
Teach the client to elevate the head of the bed on blocks - Answers- Which instructions
is most important for the nurse to emphasize during discharge for a patient with GERD?
Breath deeply and cough to produce sputum. - Answers- Which steps should the nurse
instruct the client to follow when collecting sputum?
250/4 = 62.5 = 63 mL/hr - Answers- The nurse should regulate the infusion pump to
deliver how many mL/hr? IV normal saline 250 mL with 30 mEq to administer over 4
hours is prescribed for post-op patients.
Provide a soft bristled toothbrush- allows for gentle cleaning with less risk of trauma
than a hard bristled brush. Candidiasis often called oral thrush which is a fungal
infection of the mouth, it is common in babies, people with immune deficiency, and
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