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BSN 266 HESI
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BSN HESI 266 BSN266 Hesi Chapter 17 PrepU
79 terms 55 terms 34 terms
EEEYAHHHH Preview kianaschorr1 Preview sgmuer157
A client who underwent cardiac D
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 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.
,A client with type 2 diabetes B
mellitus arrives to the clinic
reporting episodes of
weakness and palpitations.
Which finding should the nurse
recognize as a
possible complication?
a. anxiety and sighing
b. myalgia in wrists and hands
c. hyperactive bowel sounds
d. dark yellow urine
4While completing a health C
assessment for a client with Explanation: The nurse should gather additional assessment data
migraine headaches, about the pain and
the nurse assesses bilateral weakness to better understand the client's condition and to
weakness in the clients hand determine if there is an
grips. The client underlying issue or if the symptoms are related to the migraine
reports joint pain and trouble headaches.
twisting a door knob due to
weaknesses. 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
5. A client who has developed B
acute kidney injury (AKI) due to Explanation: During the diuretic phase of AKI, the client may
aminoglycoside experience increased urine
antibiotics has moved from the output, which can lead to hypovolemia and electrolyte
oliguric phase to the diuretic imbalances. Monitoring for
phase of AKI. Which hypovolemia and ECG changes can help detect any
parameters are most important complications or worsening of the
for the nurse to plan to carefully client's condition.
monitor?
a. Uremic irritation of mucous
membranes and skin surfaces.
b. Hypovolemia and
electrocardiographic (ECG)
changes.
c. Side effects of total parental
nutrition (TPN) and Intralipids.
d. Elevated creatinine and blood
urea nitrogen (BUN).
, 6. The nurse is caring for a client B
diagnosed with psoriasis Explanation: Overexposure to PUVA treatment can cause skin
vulgaris who is irritation, tenderness,
receiving psoralen and and erythema. If the client exhibits these symptoms, the nurse
ultraviolet A light (PUVA) should notify the
treatment. Which assessment healthcare provider for possible treatment modifications.
finding indicates that the client
has been overexposed to the
treatment?
a. Thick skin plaques topped by
silvery white scales
b. Tenderness upon palpation
and generalized erythema
c. Brown, rough, greasy, wart-
like papules on the face
d. Requires sunglasses because
sunlight hurts eyes
7. An adult client who had a C
gastric bypass surgery 2 weeks Explanation: The client's vital signs indicate possible sepsis
ago, is admitted with or systemic infection. Strict
possible anastomosis leakage. IV fluid replacement is important to maintain adequate
The client's abdomen is circulation, support blood
tender to touch, and the pressure, and treat potential sepsis. The other interventions are
vital signs are temperature 101 F also essential but not
(38 3 C). heart rate 130 as critical as fluid replacement in this situation.
beats/minute,
respiratory rate 26
breaths/minute, and blood
pressure 100/50 mmHg. Which
intervention is most important
for the nurse to include in the
client's plan of care?
a. Encourage regular turning.
b. Monitor skin for breakdown.
c. Strict IV fluid replacement.
d. Assess wound drainage daily.
8. A client who was recently D
diagnosed with Raynaud's Explanation: For clients with Raynaud's disease, cold
disease is concerned temperatures can trigger painful
about pain management. Which episodes. Instructing the client to wear gloves when handling
nursing instructions should the cold items can help
nurse provide? protect against these episodes and manage pain.
a. Painful areas should be
rubbed gently until the pain
subsides.
b. Return appointments will be
needed for IV pain medications.
c. Enrolling in a pain clinic can
provide relief alternatives.
d. Wearing gloves when
handling cold items guards
against painful
spasms.
BSN 266 HESI
Save
Students also studied
Flashcard sets Study guides
BSN HESI 266 BSN266 Hesi Chapter 17 PrepU
79 terms 55 terms 34 terms
EEEYAHHHH Preview kianaschorr1 Preview sgmuer157
A client who underwent cardiac D
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 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.
,A client with type 2 diabetes B
mellitus arrives to the clinic
reporting episodes of
weakness and palpitations.
Which finding should the nurse
recognize as a
possible complication?
a. anxiety and sighing
b. myalgia in wrists and hands
c. hyperactive bowel sounds
d. dark yellow urine
4While completing a health C
assessment for a client with Explanation: The nurse should gather additional assessment data
migraine headaches, about the pain and
the nurse assesses bilateral weakness to better understand the client's condition and to
weakness in the clients hand determine if there is an
grips. The client underlying issue or if the symptoms are related to the migraine
reports joint pain and trouble headaches.
twisting a door knob due to
weaknesses. 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
5. A client who has developed B
acute kidney injury (AKI) due to Explanation: During the diuretic phase of AKI, the client may
aminoglycoside experience increased urine
antibiotics has moved from the output, which can lead to hypovolemia and electrolyte
oliguric phase to the diuretic imbalances. Monitoring for
phase of AKI. Which hypovolemia and ECG changes can help detect any
parameters are most important complications or worsening of the
for the nurse to plan to carefully client's condition.
monitor?
a. Uremic irritation of mucous
membranes and skin surfaces.
b. Hypovolemia and
electrocardiographic (ECG)
changes.
c. Side effects of total parental
nutrition (TPN) and Intralipids.
d. Elevated creatinine and blood
urea nitrogen (BUN).
, 6. The nurse is caring for a client B
diagnosed with psoriasis Explanation: Overexposure to PUVA treatment can cause skin
vulgaris who is irritation, tenderness,
receiving psoralen and and erythema. If the client exhibits these symptoms, the nurse
ultraviolet A light (PUVA) should notify the
treatment. Which assessment healthcare provider for possible treatment modifications.
finding indicates that the client
has been overexposed to the
treatment?
a. Thick skin plaques topped by
silvery white scales
b. Tenderness upon palpation
and generalized erythema
c. Brown, rough, greasy, wart-
like papules on the face
d. Requires sunglasses because
sunlight hurts eyes
7. An adult client who had a C
gastric bypass surgery 2 weeks Explanation: The client's vital signs indicate possible sepsis
ago, is admitted with or systemic infection. Strict
possible anastomosis leakage. IV fluid replacement is important to maintain adequate
The client's abdomen is circulation, support blood
tender to touch, and the pressure, and treat potential sepsis. The other interventions are
vital signs are temperature 101 F also essential but not
(38 3 C). heart rate 130 as critical as fluid replacement in this situation.
beats/minute,
respiratory rate 26
breaths/minute, and blood
pressure 100/50 mmHg. Which
intervention is most important
for the nurse to include in the
client's plan of care?
a. Encourage regular turning.
b. Monitor skin for breakdown.
c. Strict IV fluid replacement.
d. Assess wound drainage daily.
8. A client who was recently D
diagnosed with Raynaud's Explanation: For clients with Raynaud's disease, cold
disease is concerned temperatures can trigger painful
about pain management. Which episodes. Instructing the client to wear gloves when handling
nursing instructions should the cold items can help
nurse provide? protect against these episodes and manage pain.
a. Painful areas should be
rubbed gently until the pain
subsides.
b. Return appointments will be
needed for IV pain medications.
c. Enrolling in a pain clinic can
provide relief alternatives.
d. Wearing gloves when
handling cold items guards
against painful
spasms.
