BSN 266 HESI V2 WITH ALL CORRECT & VERIFIED
ANSWERS (UPDATED TO PASS)
1. Neutrophil count- The patient is experi- While caring for a client with full
thickness burns
encing infection, so a nurse should re- covering 40% of the body, the nurse observes
view the neutrophil count purulent drainage from the wounds. Before
before con- tacting the HCP. re- porting the finding, what is the best lab
value to evaluate?
2. Demonstrate the use of visual older woman who experienced a
scan- ning during meals to the cerebrovas- cular accident (CVA) has
client and family. diflculty with visual per- ception and she
only eats half of the food on her meal tray.
Her family expresses concern about her
nutritional status. How should the nurse
3. High Fowler's Position- High respond to the family's concern?
fowlers helps to decrease venous
Best position for respiratory distress?
return, which decreases fluid
volume in the heart that results
in decreased cardiac work- load.
4. High risk for injury A patient with peripheral artery disease
has marked peripheral neuropath. An
appropriate nursing diagnosis for the
patient is
5. Check feet every day for cuts Type 2 diabetes patient discharge teaching
or in- juries.
pa- tient and family
6. Institute Contact precautions for
Plan of care for patient with skin lesions of
staff and visitors
lower extremities with possible MRSA. SATA
Send wound drainage for culture
and sensitivity
Monitor the clients WBC count
1/
17
, BSN 266 HESI V2 WITH ALL CORRECT & VERIFIED
ANSWERS (UPDATED TO PASS)
7.
2/
17
, BSN 266 HESI V2 WITH ALL CORRECT & VERIFIED
ANSWERS (UPDATED TO PASS)
Hematemesis- - Contact HCP if A patient with acute anterior wall MI 1 week ago
blood is visible in body fluids is given low-dose aspirin. The medication is
such as he- matemesis. related to which problem and HCP should
be notified?
8. Elevated blood urea nitrogen (BUN) For a patient with SLE exacerbation
what is the
most important to report which assessment
find- ing?
9. Rate of pain on a scale from 0-10. 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?
10. Keep patient NPO- Patient should be Patient had bariatric surgery 2 months
ago who
kept NPO until procedure is successful- developed post-op strictures who is
experiencing
ly completed. The patient should nausea and vomiting and anorexia who is
not take anything by mouth. ad- mitted for fluid resuscitation. Which
intervention should the nurse implement?
11. Vital sign changes and ECGs- Acute Kidney Injury due to aminoglycoside
Priority parameters are vital sign an- tibiotic moved from oliguric phase to the
changes re- diuretic
lated to hypovolemia and ECG changes phase. Which parameters are most
important to
due to serum electrolyte loss, and spinach.
which can be life threatening.
13. Pancreatitis-
12. Nuts, chocolate, dark greens, complications include
3/
17
ANSWERS (UPDATED TO PASS)
1. Neutrophil count- The patient is experi- While caring for a client with full
thickness burns
encing infection, so a nurse should re- covering 40% of the body, the nurse observes
view the neutrophil count purulent drainage from the wounds. Before
before con- tacting the HCP. re- porting the finding, what is the best lab
value to evaluate?
2. Demonstrate the use of visual older woman who experienced a
scan- ning during meals to the cerebrovas- cular accident (CVA) has
client and family. diflculty with visual per- ception and she
only eats half of the food on her meal tray.
Her family expresses concern about her
nutritional status. How should the nurse
3. High Fowler's Position- High respond to the family's concern?
fowlers helps to decrease venous
Best position for respiratory distress?
return, which decreases fluid
volume in the heart that results
in decreased cardiac work- load.
4. High risk for injury A patient with peripheral artery disease
has marked peripheral neuropath. An
appropriate nursing diagnosis for the
patient is
5. Check feet every day for cuts Type 2 diabetes patient discharge teaching
or in- juries.
pa- tient and family
6. Institute Contact precautions for
Plan of care for patient with skin lesions of
staff and visitors
lower extremities with possible MRSA. SATA
Send wound drainage for culture
and sensitivity
Monitor the clients WBC count
1/
17
, BSN 266 HESI V2 WITH ALL CORRECT & VERIFIED
ANSWERS (UPDATED TO PASS)
7.
2/
17
, BSN 266 HESI V2 WITH ALL CORRECT & VERIFIED
ANSWERS (UPDATED TO PASS)
Hematemesis- - Contact HCP if A patient with acute anterior wall MI 1 week ago
blood is visible in body fluids is given low-dose aspirin. The medication is
such as he- matemesis. related to which problem and HCP should
be notified?
8. Elevated blood urea nitrogen (BUN) For a patient with SLE exacerbation
what is the
most important to report which assessment
find- ing?
9. Rate of pain on a scale from 0-10. 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?
10. Keep patient NPO- Patient should be Patient had bariatric surgery 2 months
ago who
kept NPO until procedure is successful- developed post-op strictures who is
experiencing
ly completed. The patient should nausea and vomiting and anorexia who is
not take anything by mouth. ad- mitted for fluid resuscitation. Which
intervention should the nurse implement?
11. Vital sign changes and ECGs- Acute Kidney Injury due to aminoglycoside
Priority parameters are vital sign an- tibiotic moved from oliguric phase to the
changes re- diuretic
lated to hypovolemia and ECG changes phase. Which parameters are most
important to
due to serum electrolyte loss, and spinach.
which can be life threatening.
13. Pancreatitis-
12. Nuts, chocolate, dark greens, complications include
3/
17
