BSN 246 Hesi Review

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. -Check if the client's hearing aides are working properly. -Reduce environmental noise surrounding the client.

-Face the client so the client can see the RN's mouth. -Check if the client's hearing aides are working properly. -Reduce environmental noise surrounding the client. Rationale A client with hearing loss can develop the ability to read "lips," so facing the client during conversation allows visualization of the lips and directs the sound towards the client. Inspection of the hearing aide device's functionality is a vital step in communication. Hearing aides magnify all surrounding noise, so it is imperative to reduce outside environmental noise during the interview process. Speaking clearly with enunciation and in a regular tone is easier for a client to understand than increasing the volume of speech. If a client shows signs of confusion, rephrasing the question, instead of repeating, should be done to decrease client anxiety and facilitate understanding.

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.

140 mg/dl. Rationale The two hour postprandial level should be less 140 mg/dl for a young adult client.

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.

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.

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.

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) 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.

Amylase. Rationale An elevated amylase level is associated with acute pancreatitis.

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? -Over use of laxatives for bowel regularity result in loss of peristaltic tone. -Inflammation of the colon mucosa cause growths that protrude into the colon lumen. -Diverticulosis is the result of high fiber diet and sedentary life style. -Chronic constipation causes weakening of colon wall which result in out-pouching sacs.

Chronic constipation causes weakening of colon wall which result in out-pouching sacs. Rationale A client who has chronic constipation often strains to pass constipated stool which increases intestinal pressure that weakens the intestinal walls and causes out-pouching sacs, called diverticula which commonly occur in the sigmoid.

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.

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.

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. Rationale The consumption of any type of tyramine containing foods such as aged cheeses, fermented fruits and vegetables, smoked or cured meats, dark wines and other alcoholic products should be avoided when a client is prescribed a MAOIs due to the a food-drug interaction causing a hypertensive crisis which can lead to a hemorrhagic stroke.

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? -Lower back pain. -Headache of 7 on scale 1 to 10. -Blood pressure of 140/98. -Dyspnea.

Dyspnea. Rationale A client with a large bone fracture is at risk for intramedullary fat leaking into the blood stream and becoming embolic. Dyspnea is an indication of fat embolism to the lungs and should be reported to the healthcare provider immediately.

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.

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.

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 pressurecausing 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.

Which action should the registered nurse (RN) implement to complete an assessment for a client while using an interpreter? -Ask closed-ended questions with the assistance of the interpreter. -Maintain eye contact with the client while listening to the translation. -Instruct interpreter to answer questions from interpreter's point of view. -Protect the client's privacy by asking a limited number of questions.

Maintain eye contact with the client while listening to the translation. Rationale When completing an assessment, the RN should maintain eye contact with the client to gather additional information from the client's nonverbal cues.

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.

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.

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.

Orthostatic hypotension. Rationale Orthostatic hypotension can be a sign of fluid volume deficit in an older client who has experienced severe diarrhea.

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.

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 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.

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.

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 -Tachycardia. -Increased blood pressure. -Rapid resolution of wheezing. -Improved pulse oximetry values. -Reduce fever airway inflammation.

Rapid resolution of wheezing. Improved pulse oximetry values. Rationale Beta 2 receptor agonist agents should provide immediate return of airflow and resolve wheezing and improve oxygenation.

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.

Rebound abdominal tenderness over right lower quadrant. 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 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.

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 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.

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 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.

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) 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? -Irritable bowel syndrome. -.Diverticulitis. -Crohn's disease. -Ulcerative colitis.

Ulcerative colitis. 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 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.

Urine output of 40 mL/hour. Rationale A decrease in urinary output is a sign of dehydration. When the urine output returns to a normal range, 40 mL/hour, the client's kidneys are perfusing adequately and indicates the client's status is stablizing.

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.) 1.Older males. 2.School-age female. 3.Older females. 4.Adolescent males.

orrect 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) 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.

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 HCO3 within normal limits.