BSN 246 HESI EXAM | STUDY
QUESTIONS WITH CORRECT
ANSWERS AND RATIONALE | RATED
A+ | NIGHTINGALE
The registered nurse (RN) places an ice pack on a middle school
student who comes to the school clinic complaining of a sprained ankle.
Which therapeutic response should the RN anticipate?
A. Reduced pain and minimized bruising.
B. Lowering of body core temperature.
C. Increased circulation around injury.
D. Reabsorption of oedema at injury.
- Correct Answer - A. Reduced pain and minimized bruising.
Rationale
Cold applications produce a topical anaesthetic effect to reduce pain as
well as constricts blood vessels to minimize bruising.
A client who is uses ipratropium reports having nausea, blurred vision,
headaches, and insomnia after using the inhaler. Which action should
the registered nurse (RN) implement first?
A. Withhold medication and report symptoms and vital signs to
healthcare provider.
,B. Give PRN medication for nausea and vomiting and evaluate client in
30 minutes.
C. Reassure client that the ipratropium given will alleviate the symptoms.
D. Delay administration of ipratropium until next maintenance medication
is scheduled.
- Correct Answer - A. Withhold medication and report symptoms and
vital signs to healthcare provider.
Rationale
Headache, nausea, blurred vision and insomnia are symptoms of
excessive use of ipratropium, so withholding the medication until the
healthcare provider is notified should be initiated to maintain client
safety.
A Muslim male client refuses to let the female registered nurse (RN)
listen to his breath sounds during the examination. How should the RN
respond?
A. Explain how the nursing skill will be performed before proceeding.
B. Examine client with an additional healthcare provider for support.
C. Request a male nurse or healthcare provider to perform the exam.
D. Avoid any skills that involve touching the client during the exam. -
Correct Answer - C. Request a male nurse or healthcare provider to
perform the exam.
Rationale
,Modesty is an important value in the Muslim community, and Muslims
are reluctant to expose any part of their body to healthcare members.
Muslim clients are accustomed to examination by "same sex" healthcare
providers, so is the best solution for the client.
A client with cirrhosis of the liver asks the registered nurse (RN) to
explain how varicose veins can occur in the esophagus. Which
statement should the RN provide to teach the client about the
physiological etiology?
A. The enlarged liver presses on the lower half of the esophagus which
weakens blood vessel walls.
B. Abnormal vessels form as a result of liver damage that causes chronic
low serum protein levels.
C. Esophageal swelling and tissue damage causes blood to circulate
blood back through the stomach.
D. Increased portal pressure causes blood flow through liver to be
shunted to the esophageal vessels.
- Correct Answer - D. Increased portal pressure causes blood flow
through liver to be shunted to the esophageal vessels.
Rationale
Cirrhotic and fibrosed liver damage causes obstructed blood flow
through portal vessels to the liver which increases the portal pressure
causing the blood flow through the liver to be shunted to the esophageal
vessels. The result of this shunting of blood causes the esophageal
vessels (veins) to balloon out and weaken. As the portal hypertension
, increases, these esophageal varices can rupture and cause bleeding
resulting in bloody emesis and black tarry stools.
The registered nurse (RN) is assessing common complications related to
a client's recent diagnosis, systemic lupus erythematosus (SLE). Which
symptom should the RN instruct the client to report immediately?
A. Fever related to infection.
B. Weight loss and anorexia.
C. Depressed mood.
D. Break in tissue integrity.
- Correct Answer - A. Fever related to infection.
Rationale
Secondary infections are a major concern with SLE clients due to the
use of corticosteroids and chemotherapeutic agents, which suppresses
the immune system, so reporting fever and infections should be reported
immediately.
A client with chest pain, dizziness, and vomiting for the last 2 hours is
admitted for evaluation for Acute Coronary Syndrome (ACS). Which
cardiac biomarker should the registered nurse (RN) anticipate to be
elevated if the client experienced myocardial damage?
A. Creatine Kinase (CK-MB).
B. Serum troponin.
C. Myoglobin.
QUESTIONS WITH CORRECT
ANSWERS AND RATIONALE | RATED
A+ | NIGHTINGALE
The registered nurse (RN) places an ice pack on a middle school
student who comes to the school clinic complaining of a sprained ankle.
Which therapeutic response should the RN anticipate?
A. Reduced pain and minimized bruising.
B. Lowering of body core temperature.
C. Increased circulation around injury.
D. Reabsorption of oedema at injury.
- Correct Answer - A. Reduced pain and minimized bruising.
Rationale
Cold applications produce a topical anaesthetic effect to reduce pain as
well as constricts blood vessels to minimize bruising.
A client who is uses ipratropium reports having nausea, blurred vision,
headaches, and insomnia after using the inhaler. Which action should
the registered nurse (RN) implement first?
A. Withhold medication and report symptoms and vital signs to
healthcare provider.
,B. Give PRN medication for nausea and vomiting and evaluate client in
30 minutes.
C. Reassure client that the ipratropium given will alleviate the symptoms.
D. Delay administration of ipratropium until next maintenance medication
is scheduled.
- Correct Answer - A. Withhold medication and report symptoms and
vital signs to healthcare provider.
Rationale
Headache, nausea, blurred vision and insomnia are symptoms of
excessive use of ipratropium, so withholding the medication until the
healthcare provider is notified should be initiated to maintain client
safety.
A Muslim male client refuses to let the female registered nurse (RN)
listen to his breath sounds during the examination. How should the RN
respond?
A. Explain how the nursing skill will be performed before proceeding.
B. Examine client with an additional healthcare provider for support.
C. Request a male nurse or healthcare provider to perform the exam.
D. Avoid any skills that involve touching the client during the exam. -
Correct Answer - C. Request a male nurse or healthcare provider to
perform the exam.
Rationale
,Modesty is an important value in the Muslim community, and Muslims
are reluctant to expose any part of their body to healthcare members.
Muslim clients are accustomed to examination by "same sex" healthcare
providers, so is the best solution for the client.
A client with cirrhosis of the liver asks the registered nurse (RN) to
explain how varicose veins can occur in the esophagus. Which
statement should the RN provide to teach the client about the
physiological etiology?
A. The enlarged liver presses on the lower half of the esophagus which
weakens blood vessel walls.
B. Abnormal vessels form as a result of liver damage that causes chronic
low serum protein levels.
C. Esophageal swelling and tissue damage causes blood to circulate
blood back through the stomach.
D. Increased portal pressure causes blood flow through liver to be
shunted to the esophageal vessels.
- Correct Answer - D. Increased portal pressure causes blood flow
through liver to be shunted to the esophageal vessels.
Rationale
Cirrhotic and fibrosed liver damage causes obstructed blood flow
through portal vessels to the liver which increases the portal pressure
causing the blood flow through the liver to be shunted to the esophageal
vessels. The result of this shunting of blood causes the esophageal
vessels (veins) to balloon out and weaken. As the portal hypertension
, increases, these esophageal varices can rupture and cause bleeding
resulting in bloody emesis and black tarry stools.
The registered nurse (RN) is assessing common complications related to
a client's recent diagnosis, systemic lupus erythematosus (SLE). Which
symptom should the RN instruct the client to report immediately?
A. Fever related to infection.
B. Weight loss and anorexia.
C. Depressed mood.
D. Break in tissue integrity.
- Correct Answer - A. Fever related to infection.
Rationale
Secondary infections are a major concern with SLE clients due to the
use of corticosteroids and chemotherapeutic agents, which suppresses
the immune system, so reporting fever and infections should be reported
immediately.
A client with chest pain, dizziness, and vomiting for the last 2 hours is
admitted for evaluation for Acute Coronary Syndrome (ACS). Which
cardiac biomarker should the registered nurse (RN) anticipate to be
elevated if the client experienced myocardial damage?
A. Creatine Kinase (CK-MB).
B. Serum troponin.
C. Myoglobin.
