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HESI BSN 225 FUNDAMENTALS
LATEST EXAM WITH DETAILED
QUESTIONS AND COMPLETE
ANSWERS
Question-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 - answer-a. Low back pain and hypotension Answer: (a) low back pain and hypotenstion Client is recovering from a transurethral prostatectomy. Which activity should be limited until after the first postoperative visit with the healthcare provider? - answer-Drink 3L Question-A client with stage IV bone cancer is admitted to the hospital for a 1-10 scale. Which intervention should the nurse implement? - answer-Administer opioid and non-opioid medications simultaneously Question-When conducting discharge teaching for a client Diagnosed with diverticulosis, 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 increased intake of milk and milk products - answer-c. Eat a high fiber diet and increase fluid intake. ANSWER (C) EAT A HIGH-FIBER DIET AND INCREASE FLUID INTAKE Question-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 - answer-c. Increase the flow of the bladder Irrigation ANSWER (C) Increase the flow of the bladder irrigation Question-A client wit lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and difficult to arouse. When performing a head
ANSWER: (CAM)
Question-A client who underwent cardiac stent 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 r Hythm with the bell of The stethoscope. 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 monitoring
. - answer-d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring Question-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 and 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 symptoms. C. Gather additional assessment data about the pain and weakness.
D. Consult with the occupational therapist for a functional assessment - answer-c. Gather additional assessment data about the pain and weakness. Question-The nurse is caring for a client diagnosed with 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 palpation and generalized erythema C. Brown, rough, greasy, wart-like papules on the face D. Requires sunglasses because sunlight hurts eyes - answer-b. Tenderness upon palpation and generalized erythema Question-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
Question-The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi.? A. Jogs more frequently than usual daily routine. B. Eats a vegetarian diet with Cheese 2 to 3 times a day. C. Experiences additional stress since adopting a child. D. Drinks several bottles of carbonated water daily - answer-b. Eats a vegetarian diet with Cheese 2 to 3 times a day. Question-An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary system, and that he does not feel like his bladder is ever completely Empty. Which intervention should the nurse implement? A. Review the client's fluid intake prior to bedtime. B. Obtain a finger stick blood glucose level. C. Palpate the bladder above the symphysis pubis. D. Collect a urine specimen for culture analysis - answer-c. Palpate the bladder above the symphysis pubis. Question-A client is diagnosed with chronic kidney disease and needs to begin dialysis.
Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis? A. Nephrotic syndrome history. B. Latent hepatitis C. C. Crohn's disease with colectomy. D. Type 2 diabetes mellitus - answer-c. Crohn's disease with colectomy. Question-When providing care for an unconscious client who has seizures. Which nursing intervention is most essential? A. Maintain the client in a semi-Fowler's position. B. Keep the room at a comfortable Temperature. C. Ensure oral suction is available. D. Provide frequent mouth care - answer-c. Ensure oral suction is available. Question-A client presents to the emergency department reporting chest pain that is radiation to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider? A. Fentanyl.
C. Minimize symptoms by wearing loose, comfortable clothing. D. Avoid participation in any aerobic exercise programs - answer-c. Minimize symptoms by wearing loose, comfortable clothing. Question-A client arrives to the emergency department Reporting an intermittent fever And night sweats for the past 3 weeks and has developed a productive cough Containing small amounts of blood. Which intervention should the nurse Prioritize? A. Move into airborne isolation B. Collect specimens for Blood cultures. C. Arrange transport for radiographic imaging. D. Obtain a sputum sample - answer-a. Move into airborne isolation Question-A client receives a prescription for 1 liter of Ringer's intravenously to be infused over 6 hours. How many ml/hr should the nurse program the infusion pump to deliver? (Enter numerical value only. If rounding is required, round to the nearest whole number.) - answer- 167 ml 1000ml/6(hours) =166.6=167ml
Question-The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is Most important for the nurse to obtain? A. Activity level of bowel sounds. B. Eating patterns of dietary intake. C. Level and amount of physical activity D. Color and consistency of feces - answer-b. Eating patterns of dietary intake. Question-An older adult client with a long hist Ory of chronic obstructive pulmonary Disease (COPD) is admitted with progressive shortness of breath and a Persistent cough. The client is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? A. Apply a tight flow venturi mask. B. Encourage client to drink water. C. Assist client to an upright position. D. Administer a prescribed sedative - answer-c. Assist client to an upright position. Question-Which action should the nurse implement to reduce the risk of vesicant Extravasation in the client who is receiving intravenous chemotherapy?
Muscles to breathe is admitted for further treatment. Initial assessment includes a Heart rate 128 beats/minute and irregular, respirations 38 breathe/minute. Blood Pressure 168/100 mmhg, wheezes, and crackles in all lung fields. An hour after the administration of furosemide 60 mg IV. Which assessments should the nurse obtain to determine the client's response to treatment? Select at that apply. A. Oxygen saturation B. Pain scale C. Lung sounds D. Urinary output E. Skin elasticity - answer-a. Oxygen saturation C. Lung sounds D. Urinary output (LOU) Question-While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound Before Reporting this finding to the healthcare provider, the nurse should review which of the client's Laboratory values? A. White blood cell (WBC) count B. Hematocrit.
C. Platelet count. D. Blood ph level - answer-a. White blood cell (WBC) count Question-The nurse assesses a client with petechiae and ecchymosis scattered across The arms and legs. Which laboratory result should the nurse review? A. Red blood cell count. B. Platelet count. C. White blood cell count. D. Hemoglobin levels. - answer-b. Platelet count. Question-A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for the continuous bladder Irrigation with normal saline is infused and the nurse observes dark-pink tinged outflow with blood clots in the tubing collection bag. Which action should the nurse take? A. Monitoring catheter drainage (pic one says this) B. Irrigation the catheter manually. C. Decreasing the flow rate.
D. Strategies for smoking cessation - answer-b. Guidelines for oxygen use. Question-The healthcare provider prescribes penicillin 200,000 units intramuscularly for a client with pneumonia. The available vial is labeled, "Penicillin 500,000 units/ml". How many ml should the nurse administer to this client? (Enter numerical value only. If rounding is required, round the nearest tenth.) - answer-0. Question-The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs; heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmhg. Which intervention is most important for the nurse to implement? A. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter. B. Medicate for pain and monitor vital signs according to protocol. C. Administer intravenous fluid bolus as prescribed by the healthcare Provider. D. Encourage the Client to splint the incision with a pillow to cough and deep breathe - answer-b. Medicate for pain and monitor vital signs according to protocol. Question-While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take? A. Assesses the client's radical pulses and capillary refill time.
B. Discuss approaches to chronic pain control with the client. C. Notify the healthcare provider of the finding immediately. D. Review the client's dietary intake of high- Protein foods - answer-b. Discuss approaches to chronic pain control with the client. Question-A client with draining skin lesions of the lover extremity is admitted with Possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse i Include in the plan of care? (Select all that apply.) A. Explain the purpose of a low bacteria diet. B. Monitor the client's white blood cell count. C. Send wound drainage for culture and sensitivity D. Use standard precautions and wear a Mask E. Institute contact precautions for staff and visitors - answer-b. Monitor the client's white blood cell count. C. Send wound drainage for culture and sensitivity E. Institute contact precautions for staff and visitors (MIS) Question-The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a
Question-A client who has a history of hypothyroidism was initially with lethargy and confusion. Which additional finishing warrants finding warrants the most immediate action by the nurse? A. Facial puffiness and periorbital edema. B. Further decline in level consciousness. C. Hematocrit of 30% (0.30). D. Cold and dry skin. - answer-b. Further decline in level consciousness. Question-The nurse is caring for a client with human immunodeficiency virus (HIV) who has developed oral thrush and is experiencing burning and soreness in the south, Which intervention should the nurse implement first. A. Cleanse the mouth with swabs. B. Encourage frequent mouth care. C. Obtain a soft diet for the client. D. Administer a topical analgesic - answer-d. Administer a topical analgesic Question-The healthcare provider prescribes diagnostic tests for a client whose chest ray indicates pneumonia. Which diagnostic test should the nurse review for Implementation in the most therapeutic treatment of the pneumonia?
A. Sputum culture and sensitivity. B. Arterial blood gases (ABG). C. Computerized tomography (CT) of the chest. D. Blood cultures. - answer-a. Sputum culture and sensitivity. Question-The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding? A. Carotid bruit. B. Jugular vein distention. C. Palpable cervical lymph node. D. Nuchal rigidity - answer-a. Carotid bruit. Question-A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching? A. Eat high protein foods to achieve ideal body weight. B. Use electric heating pad when pain is at its worse.
