HESI BSN 266 PRACTICE EXAM
Questions and Answers
1. A client with a completed ischemic stroke has a blood pressure of
180/90 mm Hg. Which action should the nurse implement?
A. Position the head of the bed (HOB) flat.
B. Withhold intravenous fluids.
C. Administer a bolus of IV fluids.
D. Give an antihypertensive medication.: D. Give an antihypertensive
medication. Rationale
Most ischemic strokes occur during sleep when baseline blood pressure declines or blood viscosity
increases due to minimal fluid intake. Completed strokes usually produce neurologic deficits within an
hour, and the client's current elevated blood pressure requires antihypertensive medication.
2. A client who is receiving chemotherapy asks the nurse, "Why is
so much of my hair falling out each day?" Which response by the
nurse best explains the reason for alopecia?
A. "Chemotherapy affects the cells of the body that grow rapidly,
both normal and malignant."
B. "Alopecia is a common side effect you will experience during
long-term steroid therapy."
C. "Your hair will grow back completely after your course of
chemotherapy is completed."
,D. "The chemotherapy causes permanent alterations in your hair
follicles that lead to hair loss.": A. "Chemotherapy attects the cells of the body that grow
rapidly, both normal and malignant."
Rationale
The common adverse ettects of chemotherapy (nausea, vomiting, alopecia, bone marrow depression) are
due to chemotherapy's ettect on the rapidly reproducing cells, both normal and malignant.
3. After checking the urinary drainage system for kinks in the tubing,
the nurse determines that a client who has returned from the post-
anesthesia care has a dark, concentrated urinary output of 54 ml
for the last 2 hours. What priority nursing action should be
implemented?
A. Report the findings to the surgeon.
B. Irrigate the indwelling urinary catheter.
C. Apply manual pressure to the bladder.
D. Increase the IV flow rate for 15 minutes.: A. Report the findings to
the surgeon. Rationale
An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly (1 ml/kg/hour).
Dark, concentrated, and low volume of urine output should be reported to the surgeon.
4. A male client who smokes two packs of cigarettes a day states he
understands that smoking cigarettes is contributing to the difficulty
that he and his wife are having in getting pregnant and wants to
know if other factors could be con- tributing to their difficulty.
,What information is best for the nurse to provide? (Select all that
apply.)
Select all that apply
A. Marijuana cigarettes do not affect sperm count.
B. Alcohol consumption can cause erectile dysfunction.
C. Low testosterone levels affect sperm production.
D. Cessation of smoking improves general health and fertility.
E. Obesity has no effect on sperm production.: B,
C and D Rationale
Use of tobacco, alcohol, and marijuana may attect sperm counts. Sperm count is also negatively
attected by low testerone levels and obesity.
5. A client with gastroesophageal reflux disease (GERD) has been
experiencing severe reflux during sleep. Which recommendation by
the nurse is most effec- tive to assist the client?
A. Losing weight.
B. Decreasing caffeine intake.
C. Avoiding large meals.
D. Raising the head of the bed on blocks.: D. Raising the head of the bed
on blocks. Rationale
Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce reflux and subsequent
aspiration is the most non-pharmacological ettective recommendation for a client experiencing severe
gastroesophageal reflux during sleep.
, 6. A 51-year-old truck driver who smokes two packs of cigarettes a
day and is 30 pounds overweight is diagnosed with having a gastric
ulcer. What content
is most important for the nurse to include in the discharge
teaching for this client?
A. Information about smoking cessation.
B. Diet instructions for a low-residue diet.
C. Instructions on a weight-loss program.
D. The importance of increasing milk in the diet.: A. Information about
smoking cessation. Rationale
Smoking has been associated with ulcer formation, and stopping or decreasing the number of cigarettes
smoked per day is an important aspect of ulcer management.
7. What types of medications should the nurse expect to administer
to a client during an acute respiratory distress episode?
A. Vasodilators and hormones.
B. Analgesics and sedatives.
C. Anticoagulants and expectorants.
D. Bronchodilators and steroids.: D. Bronchodilators and
steroids. Rationale
Besides supplemental oxygen, this client with ARDS needs medications to widen air passages, increase air
space, and reduce alveolar membrane inflammation, such as bronchodilators and steroids.
8. A female client is brought to the clinic by her daughter for a flu
Questions and Answers
1. A client with a completed ischemic stroke has a blood pressure of
180/90 mm Hg. Which action should the nurse implement?
A. Position the head of the bed (HOB) flat.
B. Withhold intravenous fluids.
C. Administer a bolus of IV fluids.
D. Give an antihypertensive medication.: D. Give an antihypertensive
medication. Rationale
Most ischemic strokes occur during sleep when baseline blood pressure declines or blood viscosity
increases due to minimal fluid intake. Completed strokes usually produce neurologic deficits within an
hour, and the client's current elevated blood pressure requires antihypertensive medication.
2. A client who is receiving chemotherapy asks the nurse, "Why is
so much of my hair falling out each day?" Which response by the
nurse best explains the reason for alopecia?
A. "Chemotherapy affects the cells of the body that grow rapidly,
both normal and malignant."
B. "Alopecia is a common side effect you will experience during
long-term steroid therapy."
C. "Your hair will grow back completely after your course of
chemotherapy is completed."
,D. "The chemotherapy causes permanent alterations in your hair
follicles that lead to hair loss.": A. "Chemotherapy attects the cells of the body that grow
rapidly, both normal and malignant."
Rationale
The common adverse ettects of chemotherapy (nausea, vomiting, alopecia, bone marrow depression) are
due to chemotherapy's ettect on the rapidly reproducing cells, both normal and malignant.
3. After checking the urinary drainage system for kinks in the tubing,
the nurse determines that a client who has returned from the post-
anesthesia care has a dark, concentrated urinary output of 54 ml
for the last 2 hours. What priority nursing action should be
implemented?
A. Report the findings to the surgeon.
B. Irrigate the indwelling urinary catheter.
C. Apply manual pressure to the bladder.
D. Increase the IV flow rate for 15 minutes.: A. Report the findings to
the surgeon. Rationale
An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly (1 ml/kg/hour).
Dark, concentrated, and low volume of urine output should be reported to the surgeon.
4. A male client who smokes two packs of cigarettes a day states he
understands that smoking cigarettes is contributing to the difficulty
that he and his wife are having in getting pregnant and wants to
know if other factors could be con- tributing to their difficulty.
,What information is best for the nurse to provide? (Select all that
apply.)
Select all that apply
A. Marijuana cigarettes do not affect sperm count.
B. Alcohol consumption can cause erectile dysfunction.
C. Low testosterone levels affect sperm production.
D. Cessation of smoking improves general health and fertility.
E. Obesity has no effect on sperm production.: B,
C and D Rationale
Use of tobacco, alcohol, and marijuana may attect sperm counts. Sperm count is also negatively
attected by low testerone levels and obesity.
5. A client with gastroesophageal reflux disease (GERD) has been
experiencing severe reflux during sleep. Which recommendation by
the nurse is most effec- tive to assist the client?
A. Losing weight.
B. Decreasing caffeine intake.
C. Avoiding large meals.
D. Raising the head of the bed on blocks.: D. Raising the head of the bed
on blocks. Rationale
Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce reflux and subsequent
aspiration is the most non-pharmacological ettective recommendation for a client experiencing severe
gastroesophageal reflux during sleep.
, 6. A 51-year-old truck driver who smokes two packs of cigarettes a
day and is 30 pounds overweight is diagnosed with having a gastric
ulcer. What content
is most important for the nurse to include in the discharge
teaching for this client?
A. Information about smoking cessation.
B. Diet instructions for a low-residue diet.
C. Instructions on a weight-loss program.
D. The importance of increasing milk in the diet.: A. Information about
smoking cessation. Rationale
Smoking has been associated with ulcer formation, and stopping or decreasing the number of cigarettes
smoked per day is an important aspect of ulcer management.
7. What types of medications should the nurse expect to administer
to a client during an acute respiratory distress episode?
A. Vasodilators and hormones.
B. Analgesics and sedatives.
C. Anticoagulants and expectorants.
D. Bronchodilators and steroids.: D. Bronchodilators and
steroids. Rationale
Besides supplemental oxygen, this client with ARDS needs medications to widen air passages, increase air
space, and reduce alveolar membrane inflammation, such as bronchodilators and steroids.
8. A female client is brought to the clinic by her daughter for a flu
