BSN 366 Exit HESI Study Notes Nursing Interventions, Priority Scenarios & Rationales 2026 Nightingale College

A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? A. Hypokalemia B. Ketonuria. C. Peripheral edema D. Elevated blood pressure. (Pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes insipidus, which causes massive polyuria and serum electrolyte imbalances, including hypokalemia, which can lead to lethal arrhythmias.) After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply.) a. Take out dentures and place in a labeled cup b. Apply a body shroud c. Place a small pillow under the head d. Remove resuscitation equipment from the room e. Gently close the eyes When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat? (Select all that apply.) a. Lentils b. Potato soup c. Tea d. Cheese The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT computerized tomography scan of the head. After obtaining vital signs, the nurse should implement which intervention? A. Use Glasgow Coma Scale to assess level of consciousness prior to transport for imaging. B. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment. C. Verity prescribed laboratory tests include prothrombin time and platelet count. D. Initiate bilateral intermittent sequential pneumatic compression devices. The nurse is caring for four clients, Client A, who has emphysema and who's oxygen saturation is 94%. Client B, with the postoperative hemoglobin of 8.2 mg/dL (82 g/L). Client C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L) and Client D, scheduled for an appendectomy who has a white blood cell (WBC) count of 14,000 mm3 (14 x 103/L). What intervention should the nurse implement? A. Move Client D into an isolation room 24 hours before surgery(WBC 4,500-11,000 normal) B. Increase Client A's oxygen to 4 L a minute per nasal cannula C. Ask the dietitian to add a banana to Client C's breakfast tray(K=3.5-5 normal) D. Verify that Client B has two units of packed cells available(hemoglobin less than 11-13 =low)