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BSN HESI 225 Fundamentals of Nursing Exam (Latest 2024/ 2025 Update) Questions and Verified Answers|100% Correct| Grade A- Nightingale $10.99   Add to cart
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BSN HESI 225 Fundamentals of Nursing Exam (Latest 2024/ 2025 Update) Questions and Verified Answers|100% Correct| Grade A- Nightingale
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BSN HESI 225 Fundamentals of Nursing Exam (Latest 2024/ 2025 Update) Questions and Verified Answers|100% Correct| Grade A- Nightingale Q: 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...

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  • November 19, 2024
  • 28
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

Subjects

  • bsn225bsn 225hesi fundame
  • the nurse is assisting a client who has been on be
  • the nurse notes that a client who is receiving oxy
  • bsn225bsn 225bsn hesi 225 fundamentals
  • bsn225bsn 225bsn 225 fundamentals

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BSNlHESIl225lFundamentalsloflNursingl
Examl(LatestlUpdate)lQuestionslandl
VerifiedlAnswers|100%lCorrect|lGradelA-
lNightingale

Q:lThelnurselnoteslthatlalclientlwholislreceivingloxygenlbylnasallcannulalcontinuesltolremove
ltheloxygenlprongslfromlthelnares.lWhatlactionlshouldlthelnurseltake?

a.ltapeltheloxygenltubingltolthelclient'slnares
b.lassesslwhylthelclientlremoveslthelnasallcannula
c.lincreaseltheloxygenlflowlrate
d.lchangelthelnasallcannulaltolalmask


Answer:
b.lassesslwhylthelclientlremoveslthelnasallcannula

Rationale:
Usinglthelnursinglprocess,lthelnurselwouldlfirstlassesslwhylthelclientlislremovinglthelnasallcan
nulalfromlthelnares.lNasallprongslcanlcauseldiscomfortlinlthelnoselorlaroundlthelears.lIflthelcli
entlreportsldiscomfort,lthelnurselcanltroubleshootlbasedlonltheirlsymptomsltolensurelproperloxy
genldeliveryl(e.g.,liflnasallirritationlislpresent,lthelairlcanlbelhumidified,letc.)




Q:lThelnurselislconcernedlthatlalbloodlpressurelreadinglisldangerouslylelevatedlforlanlobeselc
lient.lWhatlshouldlthelnurseldolfirstlbeforelcontactinglthelhealthlcarelproviderlwithlthelreading?

a.lreassesslthelbloodlpressurelusinglallargerlcuff
b.lreassesslthelbloodlpressurelusinglalsmallerlcuff
c.lreassesslthelbloodlpressurelwhilelthelclientlislstanding
d.lreassesslthelbloodlpressurelwhilelthelclientlisllyingldown


Answer:
a.lreassesslthelbloodlpressurelusinglallargerlcuff

,Rationale:
Bloodlpressurelcuffslarelsensitivelandlwilllprovideleitherlfalselylhighlorlfalselyllowlreadingslifl
anlincorrectlsizelislused.lsincelthelclientlislobeselandlthelreadinglwasldangerouslylelevated,lthel
nurselshouldlfirstlassurelthatlthelcorrectlsizeloflcufflwaslusedlforlthelreadinglandlthenlreassesslt
helclient'slbloodlpressure.lThelnurselshouldluselallargerlcuffltolaccuratelylassesslthislclient'slblo
odlpressure.




Q:lBPl-l136/80lmmHg
HRl-l88lbeats/min
RespRl-l20lbreaths/min
O2%lsatl-l92l%lonl2LlO2
Templ-l37lCl(99.6lF)loral

Alclientlwithltracheostomylisladmittedlwithlpneumonia.lThelclientlhaslalproductivelcoughlwithl
thicklyellowlsputum,lbilaterallcrackleslonllunglauscultation,landlvitallsignlasllistedlabove.lWhe
nlcreatinglthislclient'slcarelplan,lwhichlclientloutcomelshouldlbelthelnurselidentifylaslalpriority?

a.lclientlwilllbelableltoleffectivelylcoughlsecretionslvialtracheostomy
b.lclientlwilllhavelclearllungslsounds
c.lclientlwilllbelafebrile
d.lclientlwilllhaveloxygenlsaturationlgreaterlthanl90%lduringlhospitalization


Answer:
a.lclientlwilllbelableltoleffectivelylcoughlsecretionslvialtracheostomy

Rationale:
Altracheostomylislanlopeninglinltheltrachealthatlbypasseslanlobstructedlupperlairway.lTherelare
lmultiplelindicationslforlandltypeslofltracheostomieslbutlregardlesslofltheselvariations,lthelnurse
lshouldlfocuslcarelplanninglusinglthelABCl(airway,lbreathing,lcirculation)lframework,lcombine
dlwithlthelnursinglprocess.lThelfirstlsteplislassessment,lduringlwhichlthelnurselhaslgatheredldat
alrelatedltolcough,llunglsounds,landlvitallsigns.lNext,lthelnurselshouldlanalyzedlthisldata,lnotin
glabnormallfindingslandllookinglforlpatterns.lInlthislscenario,lthelnurselshouldlnoticelthatlthelcl
ientlhaslmanylabnormalldatalpointslrelatedltolpatentlairwaylandlcompromisedlrespiratorylsyste
mlandlwilllbuildlthelcarelplanlfromltheselabnormalldatalpoints.

, Q:lAnladultlclientlislprescribedltolreceivel2.5lmLloflmedicationlthroughlanlIMlinjection.lThel
nurselshouldlselectlwhichlsiteltolprovidelthislmedication?

a.ldorsogluteallsite
b.lventrogluteallsite
c.ldeltoidlsite
d.labdomen


Answer:
b.lventrogluteallsite

Rationale:
ThelventrogluteallsitelislthelpreferredlsitelforlIMlinjectionslbecauselthelinjectionlarealislfreelofl
majorlnerveslandlbloodlvesselslandlhaslonlylalnarrowllayerloflfatloflconsistentlthinnessl(whichl
guaranteeslthatlthelneedlelinjectsltheldruglintolthelmusclelinsteadloflthelsubQlfatllayer).lThelve
ntrogluteallsitelcanlholdllargelvolumeslandlislconsideredltolbelthelsagestlsitelforlIMlinjectionslo
verall.




Q:lThelnurselislassistinglalclientlwholhaslbeenlonlbedrestlforlseveralldaysltolmovelfromlsittin
glonlthelsideloflthelbedltolalstandinglposition.lAslthelclientlbeginsltolstand,lthelclientlcomplain
sloflbeingldizzylandlthenlloseslconsciousness.lWhatlshouldlthelnurseldo?

a.lcalllforlhelplwhilelmaintaininglthelclientlinlalstandinglposition.
b.lassistlthelclientltolthelfloor
c.lguidelthelclient'slbodylbacklintolthelbed
d.lliftlthelclientltolthelchair


Answer:
c.lguidelthelclient'slbodylbacklintolthelbed

Rationale:
Orthostaticlhypotensionlislalcommonlproblemlaffectinglthelelderlylpopulation,lesp.lafterlseveral
ldaysloflbedrest.lThelresultingldecreaselinlbloodlflowltolthelbrainlcanlcausellightheadednesslorl
evenllossloflconsciousness.lSincelthelclientlhasllostlconsciousness,lthelsafestlactionlwouldlbelfo
rlthelnurseltolguidelthelclient'slbodylbacklintolthelbed.

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