Download HESI BSN 246 Health Care & Treatment Assessment Exam Questions with Answers Graded A+. and more Exams Nursing in PDF only on Docsity!
HESI BSN 246 Health Care & Treatment Assessment
Exam Questions with Answers Graded A+.
Which action can be assigned to the unlicensed assistive personnel (UAP)? - Answers- Measure the client's urinary output. What is the best initial response by the nurse? - Answers-Describe the location and type of pain you are having Based on the nurse's assessment, which assessment data supports the decision to administer pain medication as the first intervention? (Select all that apply. One, some, or all options may be correct.) - Answers-Pain rating of 6/10 - Heart rate of 102 beats/minute - Blood pressure of 132/76 mmHg Which action should the nurse implement first? - Answers-Administer an analgesic. Which interventions are important to include in the client's plan of care while receiving multiple immunosuppressants? (Select all that apply. One, some, or all options may be correct.) - Answers-Instruct client to wear a mask when walking in the halls. - Instruct visitors that fresh flowers should not be taken into the room. - Monitor immunosuppression drug levels regularly. Which intervention should the nurse ensure is included in the plan of care during the immediate postoperative period? a. Monitor Judy's urinary output hourly using an urimeter. b. Assess Judy's surgical incision every shift. c. Monitor Judy's nasogastric tube every 4 hours. d. Encourage Judy to use the incentive spirometer daily. - Answers-a Which is the priority nursing assessment during the first 24-hour postoperative period? - Answers-Vital signs The nurse is teaching the patient about fluid management between dialysis treatments. Which instruction by the nurse is the most accurate? - Answers-Limit fluids in between treatments to minimize the amount of fluid that needs to be removed during dialysis. Which expected outcome should be included in the nurse's teaching plan? - Answers- Client will avoid canned and processed foods. The nurse assesses the dialysis graft. Which assessment should be reported to the healthcare provider (HCP) immediately? (Select all that apply. One, some, or all options may be correct.) - Answers-Yellow, purulent drainage from graft incision site. - Absence of a thrill over the graft site. - Capillary refill >10 seconds in the hand where the graft is placed.
Which intervention should the nurse ensure has been include in the client's plan of care? (Select all that apply. One, some, or all options may be correct.) A. Instruct lab personnel to obtain blood specimens from the dual-lumen catheter. B. Perform sterile dressing changes at the dual-lumen catheter site. C. Empty and record the drainage from the graft tubing regularly. D. Regularly rotate IV insertion sites above and below the graft site. E. Assess Judy's distal pulses and circulation in the arm with the access - Answers-B. Perform sterile dressing changes at the dual lumen catheter site - E. Assess the client's distal pulses and circulation in the arm with the access. The nurse documents the assessment of the arteriovenous (AV) graft. Which documentation best describes a properly functioning AV graft? - Answers-Thrill present and palpated The client asks the nurse to clarify what palliative care involves. Which explanation provides the client the best education regarding palliative care? (Select all that apply. One, some, or all options may be correct.) - Answers-Palliative care provides relief from symptoms including pain. - Palliative care supports holistic care and improves quality of life. - What complication would the client be most concerned about if choosing peritoneal dialysis? - Answers-Abdominal infection/Peritonitis The nurse prepares and instructs the client for hemodialysis. Which statements by the client indicate the need for further education? (Select all that apply. One, some, or all options may be correct.) - Answers-Hemodialysis will help restore kidney function back to a normal level. - Bowel or bladder perforation may occur with hemodialysis catheter placement. What action should the nurse take based on the response from the healthcare provider (HCP) phone call? (Select all that apply. One, some, or all options may be correct.) - Answers-Document both phone calls and the HCP's prescriptions. - Notify the charge nurse and activate the chain of command - Hold the potassium chloride Which intervention should the nurse implement? - Answers-Call and speak directly with the healthcare provider (HCP). Which intervention is most important for the nurse to implement? - Answers-Hold the dose of potassium chloride and contact the HCP to report the serum potassium level. Based on these problems, which nursing intervention should be included in the client's plan of care? - Answers-Encourage the client to ask questions and discuss fears about diagnosis Which assessment data indicates to the nurse that the desired outcome of the epoetin alfa has been achieved? - Answers-Conjunctival sac returns to a reddish pink color
some, or all options may be correct.) - Answers-- Hypertension - Polycystic kidney disease - Diabetes Mellitus- 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 Skin cool to touch Capillary refill less than 3 seconds Darkened skin on extremities - Answers-Diminished hair on legs Skin cool to touch 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? A. Recall of information. B. Orientation to surroundings. C. Attention to details. D. Ability to follow complex commands. - Answers-C 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.) A. Diminished hair on legs. B. Bruising on extremities. C. Skin cool to touch. D. Capillary refill less than 3 seconds. E. Darkened skin on extremities. - Answers-A, C Which action should the registered nurse (RN) implement to complete an assessment for a client while using an interpreter? A. Ask closed-ended questions with the assistance of the interpreter. B. Maintain eye contact with the client while listening to the translation. C. Instruct interpreter to answer questions from interpreter's point of view. D. Protect the client's privacy by asking a limited number of questions. - Answers-B A client with progressive hearing loss appears distressed when the registered nurse (RN) asks open-ended questions about the client's health history. Which forms of communication should the RN use? (Select all that apply.) A. Face the client so the client can see the RN's mouth.
B. Increase one's speech volume when interacting with the client. C. Repeat information to the client if misunderstood. D. Check if the client's hearing aides are working properly. E. Reduce environmental noise surrounding the client. - Answers-A, D, E Registered nurse (RN) is performing a mini-mental state examination (MMSE) for a client who is being admitted to an assisted living community. Which communication techniques should the RN implement to decrease anxiety in the client? (Select all that apply.) A. Use simple sentences during the examination. B. Move to another question if the client seems confused. C. Reduce environmental detractors during the examination. D. Allow family to answer for the client to decrease frustration. E. Ask questions one at a time to decrease confusion. - Answers-A, C, E 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? A. Explain how the nursing skill will be performed before proceeding. B. Examine client with an additional healthcare provider for support. C. Request a male nurse or healthcare provider to perform the exam. D. Avoid any skills that involve touching the client during the exam. - Answers-C A client who is uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after using the inhaler. Which action should the registered nurse (RN) implement first? A. Withhold medication and report symptoms and vital signs to healthcare provider. B. Give PRN medication for nausea and vomiting and evaluate client in 30 minutes. C. Reassure client that the ipratropium given will alleviate the symptoms. D. Delay administration of ipratropium until next maintenance medication is scheduled. - Answers-A While reviewing the client's electronic medical record (EMR), the registered nurse (RN) assesses a client who is at risk for a possible interaction with an over-the-counter (OTC) decongestant. Which client health history should the RN report to the healthcare provider concerning the OTC medication? (Select all that apply). A. Type I diabetes mellitus (DM). B. Closed angle glaucoma. C. Chronic hypertension. D. Rheumatoid arthritis. E. Crohn's disease. - Answers-B, C 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? A. Exercise bicycle. B. Sphygmomanometer.
A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys the client's understanding of the etiology of diverticula? A. Over use of laxatives for bowel regularity result in loss of peristaltic tone. B. Inflammation of the colon mucosa cause growths that protrude into the colon lumen. C. Diverticulosis is the result of high fiber diet and sedentary life style. D. Chronic constipation causes weakening of colon wall which result in out-pouching sacs. - Answers-D 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.) A. Native language. B. Education level. C. Type of lifestyle. D. Previous medical history. E. Financial resources. - Answers-A, B, C, D 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? A. African American women. B. Caucasian women. C. Asian women. D. Hispanic women. - Answers-A The registered nurse (RN) is making early morning rounds on a group of clients when a client begins exhibiting symptoms of an acute asthma attack. The RN administers a PRN prescription for a Beta 2 receptor agonist agent. Which client response should the RN expect? (Select all that apply.) A. Tachycardia. B. Increased blood pressure. C. Rapid resolution of wheezing. D. Improved pulse oximetry values. E. Reduce fever airway inflammation. - Answers-C, D The registered nurse (RN) is interviewing a female client who states she has a persistent productive cough during the winter caused by bronchitis. Which additional finding should the RN assess for bronchitis? A. Phlegm production and wheezing. B. Smoking history. C. Hemoptysis. D. Night sweats. - Answers-A
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? A. Creatine Kinase (CK-MB). B. Serum troponin. C. Myoglobin. D. Ischemia modified albumin. - Answers-B 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? A. Bradykinesia. B. Dystonia. C. Somatization. D. Akathisia. - Answers-B The registered nurse (RN) reviews the new prescription, phenelzine, a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess? A. Consumptiion of any alcohol or tyramine-rich foods. B. Complaints of nausea or vomiting. C. Therapeutic serum drug levels. D. Blood pressure and pulse prior to taking each dose. - Answers-A 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? A. Prepare the client for chest x-ray at the bedside. B. Review arterial blood gases after removal. C. Elevate the head of bed to 45 degrees. D. Assist with disassembling the drainage system. - Answers-A 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)? A. High fever. B. Low blood pressure. C. Muscle rigidity. D. Polydipsia. - Answers-D 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? A. Straignt fracture line that is also a simple, closed fracture. B. Nondisplaced fracture line that wraps around the bone. C. A complete fracture that also punctures the skin.
C. Creatinine. D. Uric acid. - Answers-B The registered nurse (RN) is caring for a client who has taken atenolol for 2 years. The healthcare provider recently changed the medication to enalapril to manage the client's blood pressure. Which instruction should the RN provide the client regarding the new medication? A. Take the medication at bedtime. B. Report presence of increased bruising. C. Check pulse before taking medication. D. Rise slowly when getting out of bed or chair. - Answers-D 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? A. Decreases respiratory rate. B. Increases O2 saturation throughout the body. C. Conserves energy while ambulating. D. Promotes CO2 elimination. - Answers-D 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? A. The development of resistant strains of TB are decreased with a combination of drugs. B. Compliance to the medication regimen is challenging but should be maintained. C. Side effects are minimized with the use of a single medication but is less effective. D. The treatment time is decreased from 6 months to 3 months with this standard regimen. - Answers-A The registered nurse (RN) is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the RN to report the healthcare provider? A. Lower back pain. B. Headache of 7 on scale 1 to 10. C. Blood pressure of 140/98. D. Dyspnea. - Answers-D 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? A. 140 mg/dl. B. 160 mg/dl. C. 180 mg/dl. D. 200 mg/dl. - Answers-A
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? A. Assist with frequent ambulation. B. Encourage visitors to visit. C. Maintain strict protective precautions. D. Avoid peripheral injections. - Answers-C After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the client. Which nursing intervention is most important for the RN to implement? A. Position client on left side with pillow placed under the costal margin. B. Assist the client with voiding immediately after the procedure. C. Evaluate vital signs q10 to 20 minutes for 2 hours after procedure. D. Ambulate client 3 times in first hour with pillow held at abdomen. - Answers-C 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? A. Decreased pedal pulses. B. Edema in upper extremities. C. Loss of appetite for food. D. Stiffness in right ankle joint. - Answers-D 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? A. Lower extremity edema. B. Orthostatic hypotension. C. Elevated blood pressure. D. Cheyne-Stokes respirations. - Answers-B The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. Which condition should the RN ask the client about his medical history? A. Irritable bowel syndrome. B. Diverticulitis. C. Crohn's disease. D. Ulcerative colitis. - Answers-D The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? A. The client cannot understand the nurse.
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? A. The incident will be reported to the state's Board of Nursing (BON). B. A medication error report will be completed and risk management will be notified. C. The RN will be suspended from medication administration until the error is investigated. D. The incident will be documented in the RN's personnel file. - Answers-B 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? A. Reduced pain and minimized brusing. B. Lowering of body core temperature. C. Increased circulation around injury. D. Reabsorption of edema at injury. - Answers-A 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. -School-age female. -Older males. -Adolescent males. - Answers-1. Older females.
- School-age female.
- Older males.
- Adolescent males. 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 Skin cool to touch Capillary refill less than 3 seconds Darkened skin on extremities - Answers-Diminished hair on legs Skin cool to touch
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. - Answers-Polydipsia 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. - Answers-Native language. Education level. Type of lifestyle. 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. - Answers-Stiffness in right ankle joint 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 brusing. Lowering of body core temperature.
The registered nurse (RN) is developing the plan of care for a client who is admitted for alcohol detoxification. Which goal should be most important for the RN to primarily focus the client's care? The client maintains optimal nutritional status. The client will remain alert and oriented. The client will remain free from injury. The client will remain alcohol free during hospitalization. - Answers-Client will remain free from injury A registered nurse (RN) is performing a mini-mental state examination (MMSE) for a client who is being admitted to an assisted living community. Which communication techniques should the RN implement to decrease anxiety in the client? (Select all that apply.) Select all that apply
- Use simple sentences during the examination.
- 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. - Answers-1, 3, 5 The registered nurse (RN) is interviewing a female client who states she has a persistent productive cough during the winter caused by bronchitis. Which additional finding should the RN assess for bronchitis? Phlegm production and wheezing. Smoking history. Hemoptysis. Night sweats. - Answers-Phlegm production and wheezing 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). 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. - Answers-Hematemesis Gastric Pain on Empty Stomach Intolerance to Spicy Foods 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. - Answers-Dystonia 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. - Answers-Request a male nurse or healthcare provider to perform the exam. The registered nurse (RN) is evaluating a client who presents with symptoms of viral gastroenteritis. Which assessment finding should the RN report to the healthcare provider? Dry mucous membranes and lips. Rebound abdominal tenderness over right lower quadrant. Dizziness when client ambulates from a sitting position. Poor skin turgor over client's wrist. - Answers-Rebound abdominal tenderness over right lower quadrant. While reviewing the client's electronic medical record (EMR), the registered nurse (RN) assesses a client who is at risk for a possible interaction with an over-the-counter (OTC) decongestant. Which client health history should the RN report to the healthcare provider concerning the OTC medication? (Select all that apply). Select all that apply Type I diabetes mellitus (DM).
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. - Answers-Urine output of 40ml/hour 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. - Answers-Amylase 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. - Answers-African American women 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. - Answers- 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. 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? A. The enlarged liver presses on the lower half of the esophagus which weakens blood vessel walls. B. Abnormal vessels form as a result of liver damage that causes chronic low serum protein levels. C. Esophageal swelling and tissue damage causes blood to circulate blood back through the stomach. D. Increased portal pressure causes blood flow through liver to be shunted to the esophageal vessels. - Answers-D. Increased portal pressure causes blood flow through liver to be shunted to the esophageal vessels. The registered nurse (RN) reviews the new prescription, phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess? Consumptiion of any alcohol or tyramine-rich foods. Complaints of nausea or vomiting. Therapeutic serum drug levels. Blood pressure and pulse prior to taking each dose.Consumptiion of any alcohol or tyramine-rich foods. - Answers-Consumptiion of any alcohol or tyramine-rich foods. A client with progressive hearing loss appears distressed when the registered nurse (RN) asks open-ended questions about the client's health history. Which forms of communication should the RN use? Select all that apply Face the client so the client can see the RN's mouth. Increase one's speech volume when interacting with the client. Repeat information to the client if misunderstood.
