BSN HESI 266
Study online at https://quizlet.com/_d2o3fc
1. Client is recovering from a transurethral prostatectomy. Which activity
should be limited until after the first postoperative visit with the healthcare
provider?: Drink 3L
2. A client with stage IV bone cancer is admitted to the hospital for a 1-10
scale. Which intervention should the nurse implement?: Administer opioid and
non-opioid medications simultaneously
3. 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: a. low back pain and hypotension
ANSWER: (A) LOW BACK PAIN AND HYPOTENSTION
4. When conducting discharge teaching for a client
diagnosed with diverticulosis, which diet instruction should the nurse in-
clude?
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: c. Eat a high
fiber diet and increase fluid intake.
ANSWER (C) EAT A HIGH-FIBER DIET AND INCREASE FLUID INTAKE
5. 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
, BSN HESI 266
Study online at https://quizlet.com/_d2o3fc
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: c. Increase the flow of the
bladder
irrigation
ANSWER (C) Increase the flow of the bladder irrigation
6. 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: Remove
all morphine patches
7. 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?: Right foot pale with sluggish capillary refill
8. 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: a. Check finger stick
glucose
b. Assess skin temperature
and moisture
, BSN HESI 266
Study online at https://quizlet.com/_d2o3fc
c. Measure pulse and blood
pressure
ANSWER: (CAM)
9. 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
hythm 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 monitor-
ing
.: d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring
10. While completing a health assessment for a client with migraine
headaches, the nurse assesses bilateral weakness in the clients hand grips.
The client reports joint pain and trouble twisting a door knob due to weak-
nesses. 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: c.
Gather additional assessment data about the pain and weakness.
11. The nurse is caring for a client diagnosed with psoriasis vulgaris who is
receiving psoralen and ultraviolet A light (PUVA) treatment.
Which assessment finding indicates that the client has been overexposed to
the treatment?
Study online at https://quizlet.com/_d2o3fc
1. Client is recovering from a transurethral prostatectomy. Which activity
should be limited until after the first postoperative visit with the healthcare
provider?: Drink 3L
2. A client with stage IV bone cancer is admitted to the hospital for a 1-10
scale. Which intervention should the nurse implement?: Administer opioid and
non-opioid medications simultaneously
3. 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: a. low back pain and hypotension
ANSWER: (A) LOW BACK PAIN AND HYPOTENSTION
4. When conducting discharge teaching for a client
diagnosed with diverticulosis, which diet instruction should the nurse in-
clude?
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: c. Eat a high
fiber diet and increase fluid intake.
ANSWER (C) EAT A HIGH-FIBER DIET AND INCREASE FLUID INTAKE
5. 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
, BSN HESI 266
Study online at https://quizlet.com/_d2o3fc
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: c. Increase the flow of the
bladder
irrigation
ANSWER (C) Increase the flow of the bladder irrigation
6. 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: Remove
all morphine patches
7. 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?: Right foot pale with sluggish capillary refill
8. 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: a. Check finger stick
glucose
b. Assess skin temperature
and moisture
, BSN HESI 266
Study online at https://quizlet.com/_d2o3fc
c. Measure pulse and blood
pressure
ANSWER: (CAM)
9. 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
hythm 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 monitor-
ing
.: d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring
10. While completing a health assessment for a client with migraine
headaches, the nurse assesses bilateral weakness in the clients hand grips.
The client reports joint pain and trouble twisting a door knob due to weak-
nesses. 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: c.
Gather additional assessment data about the pain and weakness.
11. The nurse is caring for a client diagnosed with psoriasis vulgaris who is
receiving psoralen and ultraviolet A light (PUVA) treatment.
Which assessment finding indicates that the client has been overexposed to
the treatment?
