BSN 266 Practice HESI 115 Questions with Correct

BSN 266 Practice HESI 115 Questions with Correct Answer 100% Verified A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement?

• Position the head of the bed (HOB) flat.
• Withhold intravenous fluids.
• Administer a bolus of IV fluids.
• Give an antihypertensive medication. - Correct Answers 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.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?

• "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant."
• "Alopecia is a common side effect you will experience during long-term steroid therapy."
• "Your hair will grow back completely after your course of chemotherapy is completed."
• "The chemotherapy causes permanent alterations in your hair follicles that lead to hair loss." -

Correct Answers A. "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant." Rationale The common adverse effects of chemotherapy (nausea, vomiting, alopecia, bone marrow depression) are due to chemotherapy's effect on the rapidly reproducing cells, both normal and malignant.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?

• Report the findings to the surgeon.
• Irrigate the indwelling urinary catheter.
• Apply manual pressure to the bladder.
• Increase the IV flow rate for 15 minutes. - Correct Answers A. Report the findings to the surgeon.

Rationale 1 / 4

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.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 contributing to their difficulty. What information is best for the nurse to provide? (Select all that apply.) Select all that apply

• Marijuana cigarettes do not affect sperm count.
• Alcohol consumption can cause erectile dysfunction.
• Low testosterone levels affect sperm production.
• Cessation of smoking improves general health and fertility.
• Obesity has no effect on sperm production. - Correct Answers B, C and D

Rationale Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively affected by low testerone levels and obesity.A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client?

• Losing weight.
• Decreasing caffeine intake.
• Avoiding large meals.
• Raising the head of the bed on blocks. - Correct Answers 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 effective recommendation for a client experiencing severe gastroesophageal reflux during sleep.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?

• Information about smoking cessation.
• Diet instructions for a low-residue diet. 2 / 4

• Instructions on a weight-loss program.
• The importance of increasing milk in the diet. - Correct Answers 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.What types of medications should the nurse expect to administer to a client during an acute respiratory distress episode?

• Vasodilators and hormones.
• Analgesics and sedatives.
• Anticoagulants and expectorants.
• Bronchodilators and steroids. - Correct Answers 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.A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. What action should the nurse implement?

• Notify social services immediately of suspected elderly abuse.
• Discuss the need for mental health counseling with the daughter.
• Explain to the client that she needs to take better care of herself.
• Collect further data to determine whether self-neglect is occurring. - Correct Answers D. Collect

further data to determine whether self-neglect is occurring.Rationale Changes in weight and hygiene may be indicators of self-neglect or neglect by family members.Further assessment is needed before notifying social services or discussing a need for counseling.The nurse is assisting a client out of bed for the first time after surgery. What action should the nurse do first?

• Place a chair at a right angle to the bedside.
• Encourage deep breathing prior to standing. 3 / 4

• Help the client to sit and dangle legs on the side of the bed.
• Allow the client to sit with the bed in a high Fowler's position. - Correct Answers D. Allow the

client to sit with the bed in a high Fowler's position.Rationale The first step is to raise the head of the bed to a high Fowler's position, which allow venous return to compensate from lying flat and the vasodilation effects of perioperative drugs. This helps prevent the client from becoming light-headed and decreases the chance of a client fall.A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints?

• Frequent urinary tract infections.
• Inability to get pregnant.
• Premenstrual syndrome.
• Chronic use of laxatives. - Correct Answers B. Inability to get pregnant.

Rationale Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common symptoms of endometriosis, which is the abnormal displacement of endometrial tissue in the dependent areas of the pelvic peritoneum. A history of infertility is another common finding associated with endometriosis.The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the healthcare provider if the client's

• serum digoxin level is 1.5.
• blood pressure is 104/68.
• serum potassium level is 3.
• apical pulse is 68/min. - Correct Answers C. serum potassium level is 3.

Rationale Hypokalemia can precipitate digitalis toxicity in persons receiving digoxin which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L).In assessing cancer risk, the nurse identifies which woman as being at greatest risk of developing breast cancer?

• A 35-year-old multipara who never breastfed.
• A 50-year-old whose mother had unilateral breast cancer.
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