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BSN 246 HESI HEALTH ASSESSMENT EXAM LATEST UPDATED 2024/
QUESTIONS AND VERIFIED ANSWERS |100% CORRECT WITH RATIONALE
"The registered nurse (RN) is assessing a client who was discharged home after management of chronic hypertension. Which equipment should the RN instruct the client to use at home? Exercise bicycle. Sphygmomanometer. Blood glucose monitor.
Weekly medication box. - CORRECT ANSWER Sphygmomanometer.
Rationale Self-awareness is the best way for a client to manage chronic hypertension, so the client should obtain a sphygmomanometer and learn how to monitor blood pressure daily and maintain a record." "The registered nurse (RN) is teaching a client who is newly diagnosed with emphysema how to perform pursed lip breathing. What is the primary reason for teaching the client this method of breathing? Decreases respiratory rate. Increases O2 saturation throughout the body. Conserves energy while ambulating.
Promotes CO2 elimination. - CORRECT ANSWER Promotes CO2 elimination.
Rationale Pursed lip breathing helps eliminate CO2 by increasing positive pressure within the alveoli increasing the surface area of the alveoli making it easier for the O2 and CO2 gas exchange to occur ." "A Muslim male client refuses to let the female registered nurse (RN) listen to his breath sounds during the examination. How should the RN respond? Explain how the nursing skill will be performed before proceeding. Examine client with an additional healthcare provider for support. Request a male nurse or healthcare provider to perform the exam.
Avoid any skills that involve touching the client during the exam. - CORRECT ANSWER
Request a male nurse or healthcare provider to perform the exam. Rationale Modesty is an important value in the Muslim community, and Muslims are reluctant to expose any part of their body to healthcare members. Muslim clients are accustomed to examination by "same sex" healthcare providers, so is the best solution for the client."
"The registered nurse (RN) recognizes which client group is at the greatest risk for developing a urinary tract infection (UTI)? (Rank from highest risk to lowest risk.) Older females. Adolescent males. Older males.
School-age female. - CORRECT ANSWER 1.Older females.
2.School-age female. 3.Older males. 4.Adolescent males. Rationale Hypoestrogenism and alkalotic urine are other age-related factors put older women at the highest risk for UTIs. School age girls (6 to 12 years) are at risk for UTIs due to a higher prevalence to taking baths instead of showers, but these risks can be controlled in this population as well as hypoestrogenism and alkalotic urine. Older men are at risk due to possible obstruction of the bladder due to benign prostatic hypertrophy (BPH). Adolescent males (12 to 19 years) are the lowest at risk for a UTI.All individuals regardless of gender and/or age are at risk if the following conditions exist: vesicoureteral reflux, neuromuscular conditions, like Parkinson's disease, previous brain attacks, or the use of anticholinergic medications can all cause incomplete bladder emptying which can create bacterial overgrowth. Fecal and urinary incontinence contributes to poor perineal hygiene and bacterial growth." "The registered nurse (RN) is caring for a client with tuberculosis (TB) who is taking a combination drug regimen. The client complains about taking "so many pills." What information should the RN provide to the client about the prescribed treatement? The development of resistant strains of TB are decreased with a combination of drugs. Compliance to the medication regimen is challenging but should be maintained. Side effects are minimized with the use of a single medication but is less effective. The treatment time is decreased from 6 months to 3 months with this standard regimen. Rationale Combination therapy is necessary to decrease the development of resistant strains of TB and
ensure treatment efficacy. - CORRECT ANSWER The development of resistant strains of TB
are decreased with a combination of drugs. Rationale Combination therapy is necessary to decrease the development of resistant strains of TB and ensure treatment efficacy." "The registered nurse (RN) palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.)Select all that apply Some correct answers were not selected
Chronic bronchitis. Gastroesophageal reflux disease (GERD). Heart failure (HF).
Chronic pancreatitis. - CORRECT ANSWER Heart failure (HF)
Rationale Paroxysmal nocturnal dyspnea is classic sign of heart failure and is secondary to fluid overload associated with heart failure which causes pulmonary edema." "A female client is recently diagnosed with Sarcoidosis. The client tells the registered nurse (RN) that she does not understand why she has this. When teaching about the occurrence of sarcoidosis, the RN should include that sarcoidosis most commonly occurs with which ethnic group of women? African American women. Caucasian women. Asian women.
Hispanic women. - CORRECT ANSWER African American women.
Rationale Sarcoidosis, an autoimmune inflammatory disease affecting multiple organs and has shown familial tendency due to multiple genes that together increase the susceptibility of developing the disease. In research studies it occurs more commonly in African American women (10-80 out of 100,000); compare to Caucasian women of the United States (8 out of 100,000)." "The registered nurse (RN) did not note that a prescription dose was recently changed and did not note the updated medication administration record (MAR). After giving the client the original dose, the RN reports the medication error to the nurse manager. What consequences will the RN experience due to this error in medication administration? The incident will be reported to the state's Board of Nursing (BON). A medication error report will be completed and risk management will be notified. The RN will be suspended from medication administration until the error is investigated.
The incident will be documented in the RN's personnel file. - CORRECT ANSWER A
medication error report will be completed and risk management will be notified. Rationale By reviewing quality of care internally, steps of care can be evaluated and staff can be educated where gaps are identified. The medication report and notification of management is the responsibility of the RN who made the mistake, so an internal review of the steps of the occurrence can be completed to determine further risk potentials."
"The registered nurse (RN) assesses a client's results for arterial blood gases who has emphysema. Which finding is consistent with respiratory acidosis? pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L. pH 7.45 , pCO2 37 mmHg, HCO3 24 mEq/L. pH 7.34, pCO2 36 mmHg, HCO3 21 mEq/L.
pH 7.46, pCO2 35 mmHg, HCO3 28 mEq/L. - CORRECT ANSWER pH 7.32, pCO2 46 mmHg,
HCO3 24 MEq/L Rationale Normal ABG ranges are pH 7.35 to 7.45; pCO2 35 to 45 mmHg; HCO3 21 to 28 mEq/L, and pO2 80 to 100 mmHg. An ABG of pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L represents a client with respiratory acidosis which is characterized by: low pH, pCO2higher than normal, and HCO within normal limits." "An older client is admitted to the hospital with severe diarrhea. The registered nurse (RN) is completing an assessment and notes the client has dry mucous membranes and poor skin turgor. Which assessment data should the RN gather to determine if the client has a fluid volume deficit? Lower extremity edema. Orthostatic hypotension. Elevated blood pressure.
Cheyne-Stokes respirations. - CORRECT ANSWER Orthostatic hypotension.
Rationale Orthostatic hypotension can be a sign of fluid volume deficit in an older client who has experienced severe diarrhea." "A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be elevated if the client experienced myocardial damage? Creatine Kinase (CK-MB). Serum troponin. Myoglobin.
Ischemia modified albumin. - CORRECT ANSWER Serum troponin.
Rationale Troponin is the most sensitive and specific test for myocardial damage. Troponin elevation is more specific than CK-MB."
"The registered nurse (RN) notifies the spouse of a client who was admitted to hospice with shallow respirations, of a change in the client's condition. Over the past hour, the client's respiratory pattern has changed to a Cheyne Stokes pattern. After receiving this information, the client's spouse begins vacuuming around the bed. Which stage of grief is the spouse displaying during the visit? Acceptance. Denial. Bargaining.
Depression. - CORRECT ANSWER Denial.
Rationale The spouse is exhibiting the first stage of denial of Kubler-Ross's grief model by ignoring that the client's death is imminent." "The registered nurse (RN) is caring for a client with aplastic anemia who is hospitalized for weight loss and generalized weakness. Laboratory values show a white blood count (WBC) of 2,500/mm3 and a platelet countof 160,000/mm3. Which intervention is the primary focus in the client's plan of care for the RN to implement? Assist with frequent ambulation. Encourage visitors to visit. Maintain strict protective precautions.
Avoid peripheral injections. - CORRECT ANSWER Maintain strict protective precautions
Rationale The client should be under strict protective transmission precautions because the WBC values are low and normal WBC levels are 4,000-10,000/mm3, so the client is an increased high risk for infection." "Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock? Faint pedal pulses. Decrease in blood pressure. Lethargy.
Slow breathing. - CORRECT ANSWER Lethargy.
Rationale
One of the early signs of hypovolemic shock is changes in the client's level of consciousness due to the decrease perfusion to the brain which can manifests as lethargy or confusion." "The registered nurse (RN) is administering haloperidol 0.5 mg IM PRN to a client for the first time. What side effects should the RN assess the client for during the initial dose? Bradykinesia. Dystonia. Somatization.
Akathisia. - CORRECT ANSWER Dystonia.
Rationale Dystonia can be a sudden adverse reaction to this psychotropic medication which should be discontinued to resolve dystonia, and the healthcare provider notified immediately." "A male client is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the humerus. The family ask the RN what this means. Which type of fracture should the RN explain from these findings? Straignt fracture line that is also a simple, closed fracture. Nondisplaced fracture line that wraps around the bone. A complete fracture that also punctures the skin.
A fracture that bends or splinters part of the bone. - CORRECT ANSWER A fracture that
bends or splinters part of the bone Rationale An incomplete fracture occurs when part of the bone is splintered (broken) and it has not gone completely through the thickness of the bone." "While caring for a client who has esophageal varices, which nursing intervention is most important for the registered nurse (RN) to implement? Monitor infusing IV fluids and any replacement blood products. Prepare for esophagogastroduodenoscopy (EGD). Maintain the client on strict bedrest.
Insert a nasogastric tube (NGT) for intermittent suction. - CORRECT ANSWER Monitor
infusing IV fluids and any replacement blood products. Rationale Maintaining hemodynamic stability in a client with esophageal varicescan precipitatea life- threatening crisis if esophageal varies leak or rupture and can result in hemorrhage. The priority is assessing and monitoring infusions of IV fluids and any replacement blood products."
Rationale The RN should ask the client if he has a history of ulcerative colitis, which is characterized by severe abdominal cramping, pain, tenesmus, and dehydration" "The registered nurse (RN) is caring for a client with peptic ulcer disease (PUD). What assessment should the RN identify and document that is consistent with PUD? (Select all that apply). Hematemesis. Gastric pain on an empty stomach. Colic-like pain with fatty food ingestion. Intolerance of spicy foods.
Diarrhea and stearrhea. - CORRECT ANSWER Hematemesis.
Gastric pain on an empty stomach. Intolerance of spicy foods. Rationale Manifestations of PUD include hematemesis, gastric pain, and spicy food intolerance." "The registered nurse (RN) places an ice pack on a middle school student who comes to the school clinic complaining of a sprained ankle. Which therapeutic response should the RN anticipate? Reduced pain and minimized bruising. Lowering of body core temperature. Increased circulation around injury.
Reabsorption of edema at injury. - CORRECT ANSWER Reduced pain and minimized
bruising Rationale Cold applications produce a topical anesthetic effect to reduce pain as well as constricts blood vessels to minimize bruising." "The registered nurse (RN) is caring for a client with acute pancreatitis and assesses the admission laboratory results. What laboratory value should the RN anticipate being elevated with this diagnosis? Triglycerides. Amylase. Creatinine.
Uric acid. - CORRECT ANSWER Amylase.
Rationale An elevated amylase level is associated with acute pancreatitis." “The registered nurse (RN) is caring for a young adult who is having an oral glucose tolerance tests (OGTT). Which laboratory result should the RN assess as a normal value for the two hour postprandial result? 140 mg/dl. 160 mg/dl. 180 mg/dl.
200 mg/dl. - CORRECT ANSWER 140 mg/dl.
Rationale The two-hour postprandial level should be less 140 mg/dl for a young adult client." "The registered nurse (RN) is caring for a client who has a closed head injury from a motor vehicle collision. Which finding should the RN assess the client for the risk of diabetes insipidus (DI)? High fever. Low blood pressure. Muscle rigidity.
Polydipsia. - CORRECT ANSWER Polydipsia.
Rationale A characteristic finding of DI is excretion of large quantities of urine (5 to 20L/day), and most clients compensate for fluid loss by drinking large amounts of water (polydipsia). DI can occur when there has been damage or injury to the pituitary gland or hypothalamus as a result of head trauma, tumor or an illness such as meningitis. This damage interrupts the ADH production, storage and release causing the excessive urination and thirst." "The registered nurse (RN) is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the RN that the client is stabilizing? Urine output of 40 mL/hour. Apical pulse 100 and blood pressure 76/42. Urine specific gravity 1.001.
Tented skin on dorsal surface of hands. - CORRECT ANSWER Urine output of 40 mL/hour.
Rationale
Move to another question if the client seems confused. Reduce environmental detractors during the examination. Allow family to answer for the client to decrease frustration.
Ask questions one at a time to decrease confusion. - CORRECT ANSWER Use simple
sentences during the examination. Reduce environmental detractors during the examination. Ask questions one at a time to decrease confusion. Rationale Communication techniques for clients with cognitive impairments should be simple, without environmental distractions, and direct." "The registered nurse (RN) is assessing common complications related to a client's recent diagnosis, systemic lupus erythematosus (SLE). Which symptom should the RN instruct the client to report immediately? Fever related to infection. Weight loss and anorexia. Depressed mood.
Break in tissue integrity. - CORRECT ANSWER Fever related to infection
Rationale Secondary infections are a major concern with SLE clients due to the use of corticosteroids and chemotherapeutic agents, which suppresses the immune system, so reporting fever and infections should be reported immediately." "A client with cirrhosis of the liver asks the registered nurse (RN) to explain how varicose veins can occur in the esophagus. Which statement should the RN provide to teach the client about the physiological etiology? The enlarged liver presses on the lower half of the esophagus which weakens blood vessel walls. Abnormal vessels form as a result of liver damage that causes chronic low serum protein levels. Esophageal swelling and tissue damage causes blood to circulate blood back through the stomach. Increased portal pressure causes blood flow through liver to be shunted to the esophageal vessels.
- CORRECT ANSWER Increased portal pressure causes blood flow through liver to be
shunted to the esophageal vessels. Rationale
Cirrhotic and fibrosed liver damage causes obstructed blood flow through portal vessels to the liver which increases the portal pressure causing the blood flow through the liver to be shunted to the esophageal vessels. The result of this shunting of blood causes the esophageal vessels (veins) to balloon out and weaken. As the portal hypertension increases, these esophageal varices can rupture and cause bleeding resulting in bloody emesis and black tarry stools" "The registered nurse (RN) is caring for a client who has taken atenolol for 2 years. The healthcare provider recently changed the medication to enalaprilto manage the client's blood pressure. Which instruction should the RN provide the client regarding the new medication? Take the medication at bedtime. Report presence of increased bruising. Check pulse before taking medication.
Rise slowly when getting out of bed or chair. - CORRECT ANSWER Rise slowly when getting
out of bed or chair. Rationale The client's new medication is an angiotensin-converting enzyme (ACE) inhibitor, which has the side effect oforthostatic hypotension. Instructing the client to rise slowly from a sitting or lying down position is important to teach the client to avoid dizziness and potentially falling" "The registered nurse (RN) is teaching a client who is being discharged after treatment of tuberculosis (TB). Which cultural issues should the RN assess when preparing the client for discharge? (Select all that apply.) Native language. Education level. Type of lifestyle. Financial resources.
Previous medical history. - CORRECT ANSWER Native language.
Education level. Type of lifestyle. Financial resources. Rationale To ensure compliance the client's native language, education level, lifestyle, and financial resources should be considered when preparing the client's discharge instructions about the continuation of treatment for TB." "The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.) Diminished hair on legs Bruising on extremities
Rationale RLQ rebound abdominal tenderness may be related to acute appendicitis and should be reported to the healthcare provider." "The registered nurse (RN) is caring for an older client who has been bedridden for two weeks. Which assessment findings indicate to the RN that the client is developing a complication related to immobility? Decreased pedal pulses. Edema in upper extremities. Loss of appetite for food.
Stiffness in right ankle joint. - CORRECT ANSWER Stiffness in right ankle joint.
Rationale Stiffness in joints is an early sign of contractures and muscle atrophy related to inactivity and immobility" "The registered nurse (RN) uses the mini-mental state examination (MMSE) when assessing a client for admission to an assisted living facility. Which finding is the RN assessing when requesting the client to count by 7s? Recall of information. Orientation to surroundings. Attention to details.
Ability to follow complex commands. - CORRECT ANSWER Attention to details.
Rationale When conducting the MMSE and having the client count backwards by 7s; this evaluates their ability to do simple calculations and is specific to the client's attention to detail and staying focus and not getting distracted by external stimuli." "The registered nurse (RN) is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the RN after the removal of the chest tube? Prepare the client for chest x-ray at the bedside. Review arterial blood gases after removal. Elevate the head of bed to 45 degrees.
Assist with disassembling the drainage system. - CORRECT ANSWER Prepare the client for
chest x-ray at the bedside Rationale
A chest x-ray should be performed immediately after the removal of a chest tube to ensure lung expansion has been maintained after its removal." "An infant with heart failure receives a prescription, digoxin 35 mcg PO. The registered nurse (RN) calcuate the desired dose for administration using the available concentration of digoxin labeled, 0.05 mg/mL. How many milliliters should the registered nurse (RN) prepare for administration?(Enter the numerical value only. If rounding is required round to the nearest
tenth.) - CORRECT ANSWER 0.
Rationale Desired dose, 35 mcg converts to 0.035 mg because the equivalent is 1 mg = 1,000 mcgUsing the formula, D/H x A = 0.035 mg / 0.05 mg x 1 mL = 0.7 mLor use the ratio proportion method of: 35mcg/X ml :: 1000mcg/1mL = 0.035mg; 0.035mg/XmL :: 0.05mg/mL =0.035mg/0.7mL" "A female client calls the clinic and talks with the registered nurse (RN) to inquire about a possible reaction after taking amoxicillin for 5 days. She reports having vaginal discomfort, itching, and a white discharge. The RN should discuss which action with the client? Discontinue the antibiotic because original symptoms have subsided. Continue taking medication until finished until the symptoms subside. Consult with healthcare provider about another treatment for this effect.
Use an over-the-counter (OTC) vaginal wash to flush out the secretions. - CORRECT ANSWER
Consult with healthcare provider about another treatment for this effect Rationale A superinfection with normal flora yeast may occur during antibiotic therapy. If suspected, the new onset of findings should be reported to the healthcare provider for another prescribed treatment to treat the superinfection." "A client is admitted for dehydration, weight loss, and a flat affect. After reviewing the client's history, the registered nurse (RN) discovers that the client's spouse died 2 weeks ago. Which nursing interventions should the RN implement to help the client begin the process of dealing with loss? Select all that apply Establish trust by creating an safe atmosphere for sharing. Share personal stories about how other clients dealt with grief. Help the client identify ways to adapt lifestyle to accommodate loss. Assure the client that their grief will last a short period of time.
Explore ways to assist the client to make new emotional investments. - CORRECT ANSWER
Establish trust by creating an safe atmosphere for sharing. Help the client identify ways to adapt lifestyle to accommodate loss. Explore ways to assist the client to make new emotional investments. Rationale
Chronic hypertension. Rationale OTC decongestants can increase intraocular pressure and should be avoided in clients with closed angle glaucoma. Decongestants also can increase the heart rate and elevate blood pressure which can impact the client's management of chronic hypertension."
