BSN 266 Hesi updated
Study online at https://quizlet.com/_gyumyw
1. An older adult client with a long history of chronic obstructive pulmonary
disease (COPD) is admitted with progressive shortness of breath and a per-
sistent cough. She is anxious and is complaining of a dry mouth. Which
intervention should the nurse implement?
A. Administer a prescribed sedative
B. Assist client to an upright position
C. Encourage client to drink water
D. Apply a high flow venturi mask: B. Assist client to an upright position
2. A client with multiple sclerosis (MS) is admitted to the medical unit, The
client reports fatigue, muscle weakness, and diplopia. Which action should
the nurse implement to reduce the clients risk for falls? SATA
A. Provide assistance to bedside commode
B. Provide frequent rest periods.
C. Offer to assist with warm baths in the morning
D. Monitor pulse ox during activities
E. Teach to patch one eye while walking: A. Provide assistance to bedside commode\
C. Schedule frequent rest periods.
E. Teach to patch one eye while walking
3. A client arrives to the ED following a motor vehicle collision, The nurse
observes the client experiencing increasing dyspnea and notes absent breath
sounds on the left side, which procedure should the nurse prepare for the
client?
A. Bronchoscopy
B. Chest tube insertion
C. Endotracheal intubation
D. Pulmonary function test: B. Chest tube insertion
4. Following a transurethral resection of the prostate (TURP) a client is dis-
charged from the hospital with an indwelling urinary catheter, Which instruc-
tion is most important for the nurse to include in the discharge teaching plan?
A. Eliminate all spicy foods from your diet
B. Drink 3 liters of water each day
, BSN 266 Hesi updated
Study online at https://quizlet.com/_gyumyw
C. Clamp the catheter when taking a shower
D. Avoid driving a car for 2 weeks: B. Drink 3 liters of water each day
5. An adult woman with Graves disease is admitted with severe dehydration
and malnutrition, She is currently restless and refusing to eat. Which action is
most important for the nurse to implement?
A. Teach client relaxation techniques
B. Determine the clients food preferences
C. Maintain a patent Intravenous site
D. Keep room temperature cool: C. Maintain a paten intravenous site
6. A client tells the clinic nurse about experiencing burning on urination, and
assessment reveals that the client had sexual intercourse four days ago with
a person who was a casual acquaintance, Which action should the nurse
implement?
A. Obtain a specimen of urethral drainage for culture
B. Observe the perineal area for a chancre like lesion
C. Identify all sexual partners in the last four days.
D. Assess for perineal itching erythema and excoriation: A. Obtain a specimen of urethral
drainage for culture
7. The nurse is caring for a client admitted to the hospital with a tentative di-
agnosis of bacterial meningitis, which diagnostic procedure should the nurse
prepare the client for?
A. Lumbar puncture
B. Skull radiography
C. MRI
D. CT: A Lumbar puncture
8. An older adult client with long term type 2 DM is seen in the clinic for a
routine health assessment, which assessment would the nurse complete to
determine if a patient with type 2 DM is experiencing long term complica-
tions? SATA
A. Sensation in feet and legs
B. Skin condition of lower extremities
C. Visual acuity
, BSN 266 Hesi updated
Study online at https://quizlet.com/_gyumyw
D Serum creatinine and blood urea nitrogen (BUN)
E. Signs of respiratory tract infection: A. Sensation in feet and legs
B. Skin condition of lower extremities
C. Visual acuity
D. Serum Creatinine and blood urea nitrogen (BUN)
9. The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the
feet and legs, and massive ascites, Which mechanism contributes to edema
and ascites in a client with cirrhosis?
A. Decreased portacaval pressure with greater collateral circulation
B. Hypoalbuminemia that results in decreased colloidal oncotic pressure
C. Decreased renin angiotensin response related to an increase in renal blood
flow
D. Hyperaldosteronism causing an increased sodium absorption in renal
tubes: B. Hypoalbuminemia that results in decreased colloidal oncotic pressure
Hypoalbuminemia that results in a decreased colloidal oncotic pressure, this is correct, in cirrhosis liver damage leads
to decreased synthesis of albumin, Albumin plays a crucial role in maintaining colloidal oncotic pressure and when
it is decreased (hypoalbuminemia) fluid is more likely to leak out of blood vessels resulting n edema, the same
mechanism contributes to the development of ascites in the abdominal cavity.
D: Incorrect hyperaldosteronism is characterized by an excess of aldosterone a hormone that regulates sodium and
water balance in cirrhosis sodium retention is often related to other mechanisms such as portal hypertension and
hypoalbuminemia rather than hyperaldosteronism.
C. Cirrhosis is more commonly associated with an activated renin angiotensin aldosterone system, leading to
increased sodium and water retention, the increased renin angiotensin response is a compensatory mechanism to
maintain perfusion in the setting o cirrhosis and does not contribute to decreased renal blood flow
10. The nurse is planning care for an older adult client who experiences a
cerebrovascular accident several weeks ago. The client has expressive aphasia
(Broca's aphasia) and often becomes frustrated with the nursing staff. Which
intervention should the nurse implement?
A. Encourage clients use of picture charts
Study online at https://quizlet.com/_gyumyw
1. An older adult client with a long history of chronic obstructive pulmonary
disease (COPD) is admitted with progressive shortness of breath and a per-
sistent cough. She is anxious and is complaining of a dry mouth. Which
intervention should the nurse implement?
A. Administer a prescribed sedative
B. Assist client to an upright position
C. Encourage client to drink water
D. Apply a high flow venturi mask: B. Assist client to an upright position
2. A client with multiple sclerosis (MS) is admitted to the medical unit, The
client reports fatigue, muscle weakness, and diplopia. Which action should
the nurse implement to reduce the clients risk for falls? SATA
A. Provide assistance to bedside commode
B. Provide frequent rest periods.
C. Offer to assist with warm baths in the morning
D. Monitor pulse ox during activities
E. Teach to patch one eye while walking: A. Provide assistance to bedside commode\
C. Schedule frequent rest periods.
E. Teach to patch one eye while walking
3. A client arrives to the ED following a motor vehicle collision, The nurse
observes the client experiencing increasing dyspnea and notes absent breath
sounds on the left side, which procedure should the nurse prepare for the
client?
A. Bronchoscopy
B. Chest tube insertion
C. Endotracheal intubation
D. Pulmonary function test: B. Chest tube insertion
4. Following a transurethral resection of the prostate (TURP) a client is dis-
charged from the hospital with an indwelling urinary catheter, Which instruc-
tion is most important for the nurse to include in the discharge teaching plan?
A. Eliminate all spicy foods from your diet
B. Drink 3 liters of water each day
, BSN 266 Hesi updated
Study online at https://quizlet.com/_gyumyw
C. Clamp the catheter when taking a shower
D. Avoid driving a car for 2 weeks: B. Drink 3 liters of water each day
5. An adult woman with Graves disease is admitted with severe dehydration
and malnutrition, She is currently restless and refusing to eat. Which action is
most important for the nurse to implement?
A. Teach client relaxation techniques
B. Determine the clients food preferences
C. Maintain a patent Intravenous site
D. Keep room temperature cool: C. Maintain a paten intravenous site
6. A client tells the clinic nurse about experiencing burning on urination, and
assessment reveals that the client had sexual intercourse four days ago with
a person who was a casual acquaintance, Which action should the nurse
implement?
A. Obtain a specimen of urethral drainage for culture
B. Observe the perineal area for a chancre like lesion
C. Identify all sexual partners in the last four days.
D. Assess for perineal itching erythema and excoriation: A. Obtain a specimen of urethral
drainage for culture
7. The nurse is caring for a client admitted to the hospital with a tentative di-
agnosis of bacterial meningitis, which diagnostic procedure should the nurse
prepare the client for?
A. Lumbar puncture
B. Skull radiography
C. MRI
D. CT: A Lumbar puncture
8. An older adult client with long term type 2 DM is seen in the clinic for a
routine health assessment, which assessment would the nurse complete to
determine if a patient with type 2 DM is experiencing long term complica-
tions? SATA
A. Sensation in feet and legs
B. Skin condition of lower extremities
C. Visual acuity
, BSN 266 Hesi updated
Study online at https://quizlet.com/_gyumyw
D Serum creatinine and blood urea nitrogen (BUN)
E. Signs of respiratory tract infection: A. Sensation in feet and legs
B. Skin condition of lower extremities
C. Visual acuity
D. Serum Creatinine and blood urea nitrogen (BUN)
9. The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the
feet and legs, and massive ascites, Which mechanism contributes to edema
and ascites in a client with cirrhosis?
A. Decreased portacaval pressure with greater collateral circulation
B. Hypoalbuminemia that results in decreased colloidal oncotic pressure
C. Decreased renin angiotensin response related to an increase in renal blood
flow
D. Hyperaldosteronism causing an increased sodium absorption in renal
tubes: B. Hypoalbuminemia that results in decreased colloidal oncotic pressure
Hypoalbuminemia that results in a decreased colloidal oncotic pressure, this is correct, in cirrhosis liver damage leads
to decreased synthesis of albumin, Albumin plays a crucial role in maintaining colloidal oncotic pressure and when
it is decreased (hypoalbuminemia) fluid is more likely to leak out of blood vessels resulting n edema, the same
mechanism contributes to the development of ascites in the abdominal cavity.
D: Incorrect hyperaldosteronism is characterized by an excess of aldosterone a hormone that regulates sodium and
water balance in cirrhosis sodium retention is often related to other mechanisms such as portal hypertension and
hypoalbuminemia rather than hyperaldosteronism.
C. Cirrhosis is more commonly associated with an activated renin angiotensin aldosterone system, leading to
increased sodium and water retention, the increased renin angiotensin response is a compensatory mechanism to
maintain perfusion in the setting o cirrhosis and does not contribute to decreased renal blood flow
10. The nurse is planning care for an older adult client who experiences a
cerebrovascular accident several weeks ago. The client has expressive aphasia
(Broca's aphasia) and often becomes frustrated with the nursing staff. Which
intervention should the nurse implement?
A. Encourage clients use of picture charts
