Science Medicine Nursing
BSN HESI 266-- consolidated
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BSN HESI 266 BSN 266 Hesi updated C: Removing an Indw
79 terms 55 terms 5 terms
EEEYAHHHH Preview theknowingnone Preview mechamb
A client experiences an AOB a. low back pain and hypotension
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
See an expert-written answer!
When conducting discharge c. Eat a high-fiber diet and increase fluid intake.
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
,The nurse observes an c. Increase the flow of the bladder irrigation
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
See an expert-written answer!
A client with lung cancer who B. Administer a narcotic antagonist
wears subcutaneous morphine
sulfate patch for pain is short of
breath and is difficult to arouse.
When performing a head to toe
assessment, the nurse discovers
four analgesic patches on the
client's body. Which intervention
should the nurse implement
first?
A. Remove all of the morphine
patches
B. Administer a narcotic
antagonist
C. Apply oxygen per face mask
D. Measure the client's blood
pressure
c. Right foot pale with sluggish capillary refill
After falling down the basement
steps, a client is brought to the The answer indicates a potential problem with the blood
emergency room. X-ray confirms circulation in the client's right foot. When a leg cast is applied, it
that the client's right leg is should not interfere with the blood flow to the foot. However, if
fractured. Following application the foot becomes pale and the capillary refill is sluggish, it
of a leg cast, which assessment suggests that the blood flow might be compromised. Capillary
finding warrants immediate refill is the time taken for color to return to an external capillary
intervention by the nurse? bed after pressure is applied to cause blanching. Normal
a. Circumferential edema of capillary refill time is usually less than 2 seconds. Sluggish or
right foot. delayed capillary refill can be a sign of peripheral vascular
b. Complaint of throbbing right disease, shock, or hypothermia. In this case, it could be due to
leg pain. the cast being too tight, causing a reduction in blood flow to the
c. Right foot pale with sluggish foot. This is a serious condition that requires immediate
capillary refill. intervention by the nurse to prevent further complications such
d. Increased temperature to as tissue necrosis due to lack of oxygen and nutrients. The nurse
lower extremity may need to adjust or remove the cast to restore proper blood
flow.
, An overweight, young adult who A. Check finger stick glucose
was recently diagnosed with B. Assess skin temperature and moisture
type 2 diabetes mellitus is C. Measure pulse and blood pressure
admitted for a hernia repair. He
tells the nurse that he is feeling ANSWER: (CAM)
very weak and jittery. Which
actions should the nurse
implement?
(Select all that apply.)
A. Check his fingerstick glucose
level
B. Assess his skin temperature
and moisture
C. Measure his pulse and blood
pressure
D. Document anxiety on the
surgical checklist
E. Administer a PRN dose of
regular insulin
A client who underwent cardiac d. Obtain a 12-lead electrocardiogram and begin continuous
stent placement four days ago cardiac monitoring
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.
BSN HESI 266-- consolidated
Save
Students also studied
Flashcard sets Study guides
BSN HESI 266 BSN 266 Hesi updated C: Removing an Indw
79 terms 55 terms 5 terms
EEEYAHHHH Preview theknowingnone Preview mechamb
A client experiences an AOB a. low back pain and hypotension
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
See an expert-written answer!
When conducting discharge c. Eat a high-fiber diet and increase fluid intake.
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
,The nurse observes an c. Increase the flow of the bladder irrigation
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
See an expert-written answer!
A client with lung cancer who B. Administer a narcotic antagonist
wears subcutaneous morphine
sulfate patch for pain is short of
breath and is difficult to arouse.
When performing a head to toe
assessment, the nurse discovers
four analgesic patches on the
client's body. Which intervention
should the nurse implement
first?
A. Remove all of the morphine
patches
B. Administer a narcotic
antagonist
C. Apply oxygen per face mask
D. Measure the client's blood
pressure
c. Right foot pale with sluggish capillary refill
After falling down the basement
steps, a client is brought to the The answer indicates a potential problem with the blood
emergency room. X-ray confirms circulation in the client's right foot. When a leg cast is applied, it
that the client's right leg is should not interfere with the blood flow to the foot. However, if
fractured. Following application the foot becomes pale and the capillary refill is sluggish, it
of a leg cast, which assessment suggests that the blood flow might be compromised. Capillary
finding warrants immediate refill is the time taken for color to return to an external capillary
intervention by the nurse? bed after pressure is applied to cause blanching. Normal
a. Circumferential edema of capillary refill time is usually less than 2 seconds. Sluggish or
right foot. delayed capillary refill can be a sign of peripheral vascular
b. Complaint of throbbing right disease, shock, or hypothermia. In this case, it could be due to
leg pain. the cast being too tight, causing a reduction in blood flow to the
c. Right foot pale with sluggish foot. This is a serious condition that requires immediate
capillary refill. intervention by the nurse to prevent further complications such
d. Increased temperature to as tissue necrosis due to lack of oxygen and nutrients. The nurse
lower extremity may need to adjust or remove the cast to restore proper blood
flow.
, An overweight, young adult who A. Check finger stick glucose
was recently diagnosed with B. Assess skin temperature and moisture
type 2 diabetes mellitus is C. Measure pulse and blood pressure
admitted for a hernia repair. He
tells the nurse that he is feeling ANSWER: (CAM)
very weak and jittery. Which
actions should the nurse
implement?
(Select all that apply.)
A. Check his fingerstick glucose
level
B. Assess his skin temperature
and moisture
C. Measure his pulse and blood
pressure
D. Document anxiety on the
surgical checklist
E. Administer a PRN dose of
regular insulin
A client who underwent cardiac d. Obtain a 12-lead electrocardiogram and begin continuous
stent placement four days ago cardiac monitoring
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.
