BSN HESI 266
1. Client is recovering from a transurethral prostatectomy. Which activity should be limited until after the
first postoperative visit with the healthcare provider?: Drink 3L
2. A client with stage IV bone cancer is admitted to the hospital for a 1-10 scale. Which intervention should the
nurse implement?: Administer opioid and non-opioid medications simultaneously
3. 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: a. low back pain and hypotension
ANSWER: (A) LOW BACK PAIN AND HYPOTENSTION
4. When conducting discharge teaching for a client
diagnosed with diverticulosis, which diet instruction should the nurse in- clude?
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: c. Eat a high fiber diet and increase fluid intake.
ANSWER (C) EAT A HIGH-FIBER DIET AND INCREASE FLUID INTAKE
5. 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
, BSN HESI 266
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: c. Increase the flow of the bladder
irrigation
ANSWER (C) Increase the flow of the bladder irrigation
6. 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
-to-toe assessment, the nurse discovers four analgesic patches on: Remove all morphine patches
7. Coming down the basement steps, a client is brought to the emergency room X-ray ... cast, which
assessment finding warrants immediate Intervention by the nurse?: Right foot pale with sluggish capillary
refill
8. An overweight, young adult who was
recently Check finger stick glucose diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He
tells the nurse that he is feeling very weak and jittery.
Which actions should the nurse implement? (Select all that apply.)
a. Check finger stick glucose
b. Assess skin temperature and
moisture
c. Measure pulse and blood pressure: a.
Check finger stick glucose
b. Assess skin temperature and moisture
, BSN HESI 266
c. Measure pulse and blood pressure
ANSWER: (CAM)
9. 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 monitor- ing
.: d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring
10.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 weak-
nesses. 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: c. Gather additional assessment data
about the pain and weakness.
11.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?
1. Client is recovering from a transurethral prostatectomy. Which activity should be limited until after the
first postoperative visit with the healthcare provider?: Drink 3L
2. A client with stage IV bone cancer is admitted to the hospital for a 1-10 scale. Which intervention should the
nurse implement?: Administer opioid and non-opioid medications simultaneously
3. 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: a. low back pain and hypotension
ANSWER: (A) LOW BACK PAIN AND HYPOTENSTION
4. When conducting discharge teaching for a client
diagnosed with diverticulosis, which diet instruction should the nurse in- clude?
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: c. Eat a high fiber diet and increase fluid intake.
ANSWER (C) EAT A HIGH-FIBER DIET AND INCREASE FLUID INTAKE
5. 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
, BSN HESI 266
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: c. Increase the flow of the bladder
irrigation
ANSWER (C) Increase the flow of the bladder irrigation
6. 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
-to-toe assessment, the nurse discovers four analgesic patches on: Remove all morphine patches
7. Coming down the basement steps, a client is brought to the emergency room X-ray ... cast, which
assessment finding warrants immediate Intervention by the nurse?: Right foot pale with sluggish capillary
refill
8. An overweight, young adult who was
recently Check finger stick glucose diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He
tells the nurse that he is feeling very weak and jittery.
Which actions should the nurse implement? (Select all that apply.)
a. Check finger stick glucose
b. Assess skin temperature and
moisture
c. Measure pulse and blood pressure: a.
Check finger stick glucose
b. Assess skin temperature and moisture
, BSN HESI 266
c. Measure pulse and blood pressure
ANSWER: (CAM)
9. 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 monitor- ing
.: d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring
10.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 weak-
nesses. 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: c. Gather additional assessment data
about the pain and weakness.
11.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?
