Exam (elaborations)
HESI BSN 266 PRACTICE QUESTIONS AND ANSWERS
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HESI BSN 266 PRACTICE QUESTIONS AND ANSWERS
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HESI BSN 266 PRACTICE QUESTIONS AND ANSWERSA client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg.
Which action should the nurse implement?
A. Position the head of the bed (HOB) flat.
B. Withhold intravenous fluids.
C. Administer a bolus of IV fluids.
D. Give an antihypertensive medication. - Answers- D. Give an antihypertensive
medication.
Rationale
Most ischemic strokes occur during sleep when baseline blood pressure declines or
blood viscosity increases due to minimal fluid intake. Completed strokes usually
produce neurologic deficits within an hour, and the client's current elevated blood
pressure requires antihypertensive medication.
A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair
falling out each day?" Which response by the nurse best explains the reason for
alopecia?
A. "Chemotherapy affects the cells of the body that grow rapidly, both normal and
malignant."
B. "Alopecia is a common side effect you will experience during long-term steroid
therapy."
C. "Your hair will grow back completely after your course of chemotherapy is
completed."
D. "The chemotherapy causes permanent alterations in your hair follicles that lead to
hair loss." - Answers- A. "Chemotherapy affects the cells of the body that grow rapidly,
both normal and malignant."
Rationale
The common adverse effects of chemotherapy (nausea, vomiting, alopecia, bone
marrow depression) are due to chemotherapy's effect on the rapidly reproducing cells,
both normal and malignant.
After checking the urinary drainage system for kinks in the tubing, the nurse determines
that a client who has returned from the post-anesthesia care has a dark, concentrated
urinary output of 54 ml for the last 2 hours. What priority nursing action should be
implemented?
A. Report the findings to the surgeon.
B. Irrigate the indwelling urinary catheter.
C. Apply manual pressure to the bladder.
D. Increase the IV flow rate for 15 minutes. - Answers- A. Report the findings to the
surgeon.
Rationale
An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly (1
ml/kg/hour). Dark, concentrated, and low volume of urine output should be reported to
the surgeon.
,A male client who smokes two packs of cigarettes a day states he understands that
smoking cigarettes is contributing to the difficulty that he and his wife are having in
getting pregnant and wants to know if other factors could be contributing to their
difficulty. What information is best for the nurse to provide? (Select all that apply.)
Select all that apply
A. Marijuana cigarettes do not affect sperm count.
B. Alcohol consumption can cause erectile dysfunction.
C. Low testosterone levels affect sperm production.
D. Cessation of smoking improves general health and fertility.
E. Obesity has no effect on sperm production. - Answers- B, C and D
Rationale
Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also
negatively affected by low testerone levels and obesity.
A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30 pounds
overweight is diagnosed with having a gastric ulcer. What content is most important for
the nurse to include in the discharge teaching for this client?
A. Information about smoking cessation.
B. Diet instructions for a low-residue diet.
C. Instructions on a weight-loss program.
D. The importance of increasing milk in the diet. - Answers- A. Information about
smoking cessation.
Rationale
Smoking has been associated with ulcer formation, and stopping or decreasing the
number of cigarettes smoked per day is an important aspect of ulcer management.
What types of medications should the nurse expect to administer to a client during an
acute respiratory distress episode?
A. Vasodilators and hormones.
B. Analgesics and sedatives.
C. Anticoagulants and expectorants.
D. Bronchodilators and steroids. - Answers- D. Bronchodilators and steroids.
Rationale
Besides supplemental oxygen, this client with ARDS needs medications to widen air
passages, increase air space, and reduce alveolar membrane inflammation, such as
bronchodilators and steroids.
A female client is brought to the clinic by her daughter for a flu shot. She has lost
significant weight since the last visit. She has poor personal hygiene and inadequate
clothing for the weather. The client states that she lives alone and denies problems or
concerns. What action should the nurse implement?
A. Notify social services immediately of suspected elderly abuse.
B. Discuss the need for mental health counseling with the daughter.
C. Explain to the client that she needs to take better care of herself.
,D. Collect further data to determine whether self-neglect is occurring. - Answers- D.
Collect further data to determine whether self-neglect is occurring.
Rationale
Changes in weight and hygiene may be indicators of self-neglect or neglect by family
members. Further assessment is needed before notifying social services or discussing
a need for counseling.
A client with gastroesophageal reflux disease (GERD) has been experiencing severe
reflux during sleep. Which recommendation by the nurse is most effective to assist the
client?
A. Losing weight.
B. Decreasing caffeine intake.
C. Avoiding large meals.
D. Raising the head of the bed on blocks. - Answers- D. Raising the head of the bed on
blocks.
Rationale
Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce reflux
and subsequent aspiration is the most non-pharmacological effective recommendation
for a client experiencing severe gastroesophageal reflux during sleep.
The nurse is assisting a client out of bed for the first time after surgery. What action
should the nurse do first?
A. Place a chair at a right angle to the bedside.
B. Encourage deep breathing prior to standing.
C. Help the client to sit and dangle legs on the side of the bed.
D. Allow the client to sit with the bed in a high Fowler's position. - Answers- D. Allow the
client to sit with the bed in a high Fowler's position.
Rationale
The first step is to raise the head of the bed to a high Fowler's position, which allow
venous return to compensate from lying flat and the vasodilation effects of perioperative
drugs. This helps prevent the client from becoming light-headed and decreases the
chance of a client fall.
A 32-year-old female client complains of severe abdominal pain each month before her
menstrual period, painful intercourse, and painful defecation. Which additional history
should the nurse obtain that is consistent with the client's complaints?
A. Frequent urinary tract infections.
B. Inability to get pregnant.
C. Premenstrual syndrome.
D. Chronic use of laxatives. - Answers- B. Inability to get pregnant.
Rationale
Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common symptoms
of endometriosis, which is the abnormal displacement of endometrial tissue in the
dependent areas of the pelvic peritoneum. A history of infertility is another common
finding associated with endometriosis.
, The nurse would be correct in withholding a dose of digoxin in a client with congestive
heart failure without specific instruction from the healthcare provider if the client's
A. serum digoxin level is 1.5.
B. blood pressure is 104/68.
C. serum potassium level is 3.
D. apical pulse is 68/min. - Answers- C. serum potassium level is 3.
Rationale
Hypokalemia can precipitate digitalis toxicity in persons receiving digoxin which will
increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5
mEq/L).
In assessing cancer risk, the nurse identifies which woman as being at greatest risk of
developing breast cancer?
A. A 35-year-old multipara who never breastfed.
B. A 50-year-old whose mother had unilateral breast cancer.
C. A 55-year-old whose mother-in-law had bilateral breast cancer.
D. A 20-year-old whose menarche occurred at age 9. - Answers- B. A 50-year-old
whose mother had unilateral breast cancer.
Rationale
The most predictive risk factors for development of breast cancer are over 40 years of
age and a positive family history (occurrence in the immediate family, i.e., mother or
sister). Other risk factors include nulliparity, no history of breastfeeding, early menarche
and late menopause, but are not considered as predictive as a positive history of an
immediate family member and over 40 years old.
A client taking a thiazide diuretic for the past six months has a serum potassium level of
3. The nurse anticipates which change in prescription for the client?
A. The dosage of the diuretic will be decreased.
B. The diuretic will be discontinued.
C. A potassium supplement will be prescribed.
D. The dosage of the diuretic will be increased. - Answers- C. A potassium supplement
will be prescribed.
Rationale
This client's potassium level is too low (normal is 3.5 to 5). Taking a thiazide diuretic
often results in a loss of potassium, so a potassium supplement needs to be prescribed
to restore a normal serum potassium level.
Which milestone indicates to the nurse successful achievement of young adulthood?
A. Demonstrates a conceptualization of death and dying.
B. Completes education and becomes self-supporting.
C. Creates a new definition of self and roles with others.
D. Develops a strong need for parental support and approval. - Answers- B. Completes
education and becomes self-supporting.
Rationale
Transitioning through young adulthood is characterized by establishing independence
as an adult, and includes developmental tasks such as completing education, beginning
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