BSN HESI 266 QUESTIONS AND VERIFIED
CORRECT ANSWERS
Client is recovering from a transurethral prostatectomy. Which activity should be limited until
after the first postoperative visit with the healthcare provider? answer - Drink 3L
A client with stage IV bone cancer is admitted to the hospital for a 1-10 scale. Which
intervention should the nurse implement? answer - Administer opioid and non-opioid
medications simultaneously
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 answer - a. low back pain and hypotension
ANSWER: (A) LOW BACK PAIN AND HYPOTENSTION
When conducting discharge teaching for a client
diagnosed with diverticulosis, which diet instruction should the nurse include?
,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 answer - c. Eat a high fiber diet
and increase fluid intake.
ANSWER (C) EAT A HIGH-FIBER DIET AND INCREASE FLUID INTAKE
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
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 answer - c. Increase the flow of the
bladder
irrigation
,ANSWER (C) Increase the flow of the bladder irrigation
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 answer - Remove all
morphine patches
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? answer - Right foot pale with sluggish capillary refill
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 answer - a. Check finger stick
glucose
, b. Assess skin temperature
and moisture
c. Measure pulse and blood
pressure
ANSWER: (CAM)
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
rhythm 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 monitoring
. answer - d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring
CORRECT ANSWERS
Client is recovering from a transurethral prostatectomy. Which activity should be limited until
after the first postoperative visit with the healthcare provider? answer - Drink 3L
A client with stage IV bone cancer is admitted to the hospital for a 1-10 scale. Which
intervention should the nurse implement? answer - Administer opioid and non-opioid
medications simultaneously
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 answer - a. low back pain and hypotension
ANSWER: (A) LOW BACK PAIN AND HYPOTENSTION
When conducting discharge teaching for a client
diagnosed with diverticulosis, which diet instruction should the nurse include?
,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 answer - c. Eat a high fiber diet
and increase fluid intake.
ANSWER (C) EAT A HIGH-FIBER DIET AND INCREASE FLUID INTAKE
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
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 answer - c. Increase the flow of the
bladder
irrigation
,ANSWER (C) Increase the flow of the bladder irrigation
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 answer - Remove all
morphine patches
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? answer - Right foot pale with sluggish capillary refill
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 answer - a. Check finger stick
glucose
, b. Assess skin temperature
and moisture
c. Measure pulse and blood
pressure
ANSWER: (CAM)
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
rhythm 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 monitoring
. answer - d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring
