BSN HESI 266 EXAM
BSN HESI 266 Med Surg PREDICTOR Actual
Exam (Latest ) Verified
Questions & Correct Answers With
Detailed Rationales, 100% Guaranteed Pass
|| Complete A+ Guide - Nightingale
The nurse is interviewing a client who is taking interferon-alfa-2a and ribavirin combination
therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression.
Which action should the nurse take first?
A.
Recommend mental health counseling.
A+ TEST BANK 1
, BSN HESI 266 EXAM
B.
Review the medication actions and interactions.
C.
Assess for the client's daily activity level.
D.
Provide information regarding a support group. –
Correct Answer :B
Rationale:
Interferon-alfa-2a and ribavirin combination therapy can cause severe depression; therefore, it
is most important for the nurse to review the medication effects and report these to the
health care provider. Options A, C, and D might be implemented after the physiologic aspects
of the situation have been assessed.
The nurse in the emergency room assesses a client with a head trauma and notes a Glasgow
Coma Scale (GCS) score of 5. What actions will the nurse take to ensure the client's safety?
(Select all that apply.)
A.
Place the client in the supine position.
B.
Assess airway and suction secretions as needed.
C.
Change the client's position every 2 hours.
D.
Avoid mouth care, to avoid stimulating a seizure.
E.
A+ TEST BANK 2
, BSN HESI 266 EXAM
Monitor for drainage from the ears. –
Correct Answer :B, C, E
Rationale:
The client should be at least sitting at a 45 degree angle to avoid aspiration and increased
intracranial pressure. Provide frequent mouth care as the client is unable to do so at this time.
The remaining actions are appropriate for the client with a GCS score of 5.
A client is placed on a mechanical ventilator following a cerebral hemorrhage. What are the
priority nursing actions for this client? (Select all that apply.)
A.
Assess lung sounds.
B.
Look for equal and bilateral expansion of the chest.
C.
Monitor skin color.
D.
Evaluate the need for suctioning.
E.
Tell the family the client is expected to fully recover.
F.
Make sure the ventilator alarms are set. –
Correct Answer :A, B, C, D, F
Rationale:
The outcome of the client is too early to relay to the family. The nurse must not offer false
reassurance. The remaining actions are correct for a client on a ventilator.
A+ TEST BANK 3
, BSN HESI 266 EXAM
The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after
chest tube insertion for hemothorax. What is the best initial action for the nurse to take?
A.
Document this expected decrease in drainage.
B.
Clamp the chest tube while assessing for air leaks.
C.
Milk the tube to remove any excessive blood clot buildup.
D.
Assess for kinks or dependent loops in the tubing. –
Correct Answer :D
Rationale:
The least invasive nursing action should be performed first to determine why the drainage has
diminished. Option A is completed after assessing for any problems causing the decrease in
drainage. Option B is no longer considered standard protocol because the increase in
pressure may be harmful to the client. Option C is an appropriate nursing action after the tube
has been assessed for kinks or dependent loops.
A client who received a nephrotoxic drug is admitted with acute renal failure and asks the
nurse if dialysis will always be needed. Which pathophysiologic consequence should the nurse
explain that supports the need for temporary dialysis until acute tubular necrosis subsides?
A.
Azotemia
B.
Oliguria
A+ TEST BANK 4
BSN HESI 266 Med Surg PREDICTOR Actual
Exam (Latest ) Verified
Questions & Correct Answers With
Detailed Rationales, 100% Guaranteed Pass
|| Complete A+ Guide - Nightingale
The nurse is interviewing a client who is taking interferon-alfa-2a and ribavirin combination
therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression.
Which action should the nurse take first?
A.
Recommend mental health counseling.
A+ TEST BANK 1
, BSN HESI 266 EXAM
B.
Review the medication actions and interactions.
C.
Assess for the client's daily activity level.
D.
Provide information regarding a support group. –
Correct Answer :B
Rationale:
Interferon-alfa-2a and ribavirin combination therapy can cause severe depression; therefore, it
is most important for the nurse to review the medication effects and report these to the
health care provider. Options A, C, and D might be implemented after the physiologic aspects
of the situation have been assessed.
The nurse in the emergency room assesses a client with a head trauma and notes a Glasgow
Coma Scale (GCS) score of 5. What actions will the nurse take to ensure the client's safety?
(Select all that apply.)
A.
Place the client in the supine position.
B.
Assess airway and suction secretions as needed.
C.
Change the client's position every 2 hours.
D.
Avoid mouth care, to avoid stimulating a seizure.
E.
A+ TEST BANK 2
, BSN HESI 266 EXAM
Monitor for drainage from the ears. –
Correct Answer :B, C, E
Rationale:
The client should be at least sitting at a 45 degree angle to avoid aspiration and increased
intracranial pressure. Provide frequent mouth care as the client is unable to do so at this time.
The remaining actions are appropriate for the client with a GCS score of 5.
A client is placed on a mechanical ventilator following a cerebral hemorrhage. What are the
priority nursing actions for this client? (Select all that apply.)
A.
Assess lung sounds.
B.
Look for equal and bilateral expansion of the chest.
C.
Monitor skin color.
D.
Evaluate the need for suctioning.
E.
Tell the family the client is expected to fully recover.
F.
Make sure the ventilator alarms are set. –
Correct Answer :A, B, C, D, F
Rationale:
The outcome of the client is too early to relay to the family. The nurse must not offer false
reassurance. The remaining actions are correct for a client on a ventilator.
A+ TEST BANK 3
, BSN HESI 266 EXAM
The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after
chest tube insertion for hemothorax. What is the best initial action for the nurse to take?
A.
Document this expected decrease in drainage.
B.
Clamp the chest tube while assessing for air leaks.
C.
Milk the tube to remove any excessive blood clot buildup.
D.
Assess for kinks or dependent loops in the tubing. –
Correct Answer :D
Rationale:
The least invasive nursing action should be performed first to determine why the drainage has
diminished. Option A is completed after assessing for any problems causing the decrease in
drainage. Option B is no longer considered standard protocol because the increase in
pressure may be harmful to the client. Option C is an appropriate nursing action after the tube
has been assessed for kinks or dependent loops.
A client who received a nephrotoxic drug is admitted with acute renal failure and asks the
nurse if dialysis will always be needed. Which pathophysiologic consequence should the nurse
explain that supports the need for temporary dialysis until acute tubular necrosis subsides?
A.
Azotemia
B.
Oliguria
A+ TEST BANK 4
