BSN 266 HESI V2 EXAM QUESTIONS AND
ANSWERS
1. While caring for a client with full thickness burns covering 40% of
the body, the nurse observes purulent drainage from the wounds.
Before reporting the finding, what is the best lab value to evaluate?: Neutrophil
count- The patient is experiencing infection, so a nurse should review the neutrophil count
before contacting the HCP.
2. An older woman who experienced a cerebrovascular accident (CVA)
has dif- ficulty with visual perception and she only eats half of the
food on her meal tray. Her family expresses concern about her
nutritional status. How should the nurse respond to the family's concern?:
Demonstrate the use of visual scanning during meals to the client and family.
3. Best position for respiratory distress?: High Fowler's Position- High fowlers helps
to decrease venous return, which decreases fluid volume in the heart that results in decreased
cardiac workload.
4. A patient with peripheral artery disease has marked peripheral
neuropath. An appropriate nursing diagnosis for the patient is: High
risk for injury
5. Type 2 diabetes patient discharge teaching patient and family: Check
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, feet every day for cuts or injuries.
6. Plan of care for patient with skin lesions of lower extremities
with possible MRSA. SATA: Institute Contact precautions for statt and visitors
Send wound drainage for culture and
sensitivity Monitor the clients WBC count
7. A patient with acute anterior wall MI 1 week ago is given low-dose
aspirin. The
medication is related to which problem and HCP should be notified?:
Hematemesis-
- Contact HCP if blood is visible in body fluids such as hematemesis.
8. For a patient with SLE exacerbation what is the most important to
report which assessment finding?: Elevated blood urea nitrogen (BUN)
9. Before selecting a medication to administer, which action should
the nurse implement in the post-op patient who reports incisional pain
and has 2 PRN analgesia available in MAR?: Rate of pain on a scale from 0-
10.
10. Patient had bariatric surgery 2 months ago who developed
post-op strictures who is experiencing nausea and vomiting and
anorexia who is admitted for fluid resuscitation. Which intervention
should the nurse implement?: Keep patient NPO- Patient should be kept NPO until
2/
11
ANSWERS
1. While caring for a client with full thickness burns covering 40% of
the body, the nurse observes purulent drainage from the wounds.
Before reporting the finding, what is the best lab value to evaluate?: Neutrophil
count- The patient is experiencing infection, so a nurse should review the neutrophil count
before contacting the HCP.
2. An older woman who experienced a cerebrovascular accident (CVA)
has dif- ficulty with visual perception and she only eats half of the
food on her meal tray. Her family expresses concern about her
nutritional status. How should the nurse respond to the family's concern?:
Demonstrate the use of visual scanning during meals to the client and family.
3. Best position for respiratory distress?: High Fowler's Position- High fowlers helps
to decrease venous return, which decreases fluid volume in the heart that results in decreased
cardiac workload.
4. A patient with peripheral artery disease has marked peripheral
neuropath. An appropriate nursing diagnosis for the patient is: High
risk for injury
5. Type 2 diabetes patient discharge teaching patient and family: Check
1/
11
, feet every day for cuts or injuries.
6. Plan of care for patient with skin lesions of lower extremities
with possible MRSA. SATA: Institute Contact precautions for statt and visitors
Send wound drainage for culture and
sensitivity Monitor the clients WBC count
7. A patient with acute anterior wall MI 1 week ago is given low-dose
aspirin. The
medication is related to which problem and HCP should be notified?:
Hematemesis-
- Contact HCP if blood is visible in body fluids such as hematemesis.
8. For a patient with SLE exacerbation what is the most important to
report which assessment finding?: Elevated blood urea nitrogen (BUN)
9. Before selecting a medication to administer, which action should
the nurse implement in the post-op patient who reports incisional pain
and has 2 PRN analgesia available in MAR?: Rate of pain on a scale from 0-
10.
10. Patient had bariatric surgery 2 months ago who developed
post-op strictures who is experiencing nausea and vomiting and
anorexia who is admitted for fluid resuscitation. Which intervention
should the nurse implement?: Keep patient NPO- Patient should be kept NPO until
2/
11
