BSNl 366l HESIl RNl Exitl Examl Prepl (Latestl 2025/l 2026l Update)l Questionsl &l Answers|l Gradel A|l 100%l Correctl (Verifiedl Solutions)-l Nightingale
Q:l Al clientl withl pancreatitisl complainsl ofl severel epigastricl pain,l sol thel nursel administersl al prescribedl narcoticl analgesic.l Tenl minutesl later,l thel clientl insistsl onl sittingl upl andl leaningl forward.l Whichl interventionl shouldl thel nursel implement?
A.l Encouragel restl untill thel analgesicl becomesl effective.
B.l Raisel headl ofl bedl untill atl al 90l degreel angle.
C.l Placel bedl inl al reversel Trendelenburgl position.
D.l Positionl bedsidel tablel sol thel clientl canl leanl acrossl it.
Answer:
D.l Positionl bedsidel tablel sol thel clientl canl leanl acrossl it.
-Choicel D:l Positionl bedsidel tablel sol thel clientl canl leanl acrossl it.l Thisl isl thel bestl intervention,l asl itl addressesl thel client'sl preferencel andl comfortl level.l Leaningl forwardl mayl helpl decreasel thel tensionl onl thel pancreasl andl relievel thel pain.l Thel bedsidel tablel canl providel supportl andl stabilityl forl thel clientl whilel sittingl up.
Choicel A:l Encouragel restl untill thel analgesicl becomesl effective.l Thisl isl notl thel bestl intervention,l asl itl doesl notl addressl thel client'sl preferencel orl comfortl level.l Thel analgesicl mayl takel somel timel tol relievel thel pain,l andl forcingl thel clientl tol liel downl mayl increasel thel pressurel onl thel pancreasl andl worsenl thel pain.
Choicel B:l Raisel headl ofl bedl untill atl al 90l degreel angle.l Thisl isl notl thel bestl intervention,l asl itl doesl notl addressl thel client'sl preferencel orl comfortl level.l Raisingl thel headl ofl bedl mayl helpl reducel abdominall distensionl andl improvel breathing,l butl itl mayl notl relievel thel painl asl muchl asl leaningl forward.
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Choicel C:l Placel bedl inl al reversel Trendelenburgl position.l Thisl isl notl thel bestl intervention,l asl itl doesl notl addressl thel client'sl preferencel orl comfortl level.l Placingl thel bedl inl al reversel Trendelenburgl positionl mayl helpl shiftl thel abdominall organsl awayl froml thel pancreasl andl reducel inflammation,l butl itl mayl notl relievel thel painl asl muchl asl leaningl forward.
Q:l Thel nursel isl caringl forl al clientl whol arrivesl tol thel EDl withl reportsl ofl experiencingl dizzinessl andl difficultyl walkingl tol thel bathroom.l Thel nursel observesl R- sidedl weaknessl andl sluggishl enunciationl ofl speech.l Thel nursel shouldl immediatelyl takel whichl action?
A)l Maintainl elevatedl positioningl ofl thel dependentl jointsl onl thel affectedl side.l
B)l Keepl thel bedl inl thel lowestl positionl andl initiatel seizurel andl falll precautions
C)l Placel anl indwellingl urinaryl catheterl andl measurel strictl I/Os
D)l Startl twol large-borel IVl cathetersl andl reviewl inclusionl criterial forl IVl fibrinolyticl therapy.
Answer:
D)l Startl twol large-borel IVl cathetersl andl reviewl inclusionl criterial forl IVl fibrinolyticl therapy.
Choicel Al reason:l Keepingl thel bedl inl thel lowestl positionl andl initiatingl seizurel andl falll precautionsl isl notl anl immediatel actionl forl thel nursel tol take.l Seizurel andl falll precautionsl arel measuresl thatl preventl injuryl orl harml tol thel clientl inl casel ofl al seizurel orl al fall.l Seizurel andl falll precautionsl includel loweringl thel bed,l paddingl thel sidel rails,l removingl anyl objectsl thatl mayl causel injury,l andl havingl suctionl andl oxygenl equipmentl ready.l However,l thesel precautionsl arel notl specificl tol thel client'sl conditionl andl dol notl addressl thel underlyingl cause.
Choicel Bl reason:l Placingl anl indwellingl urinaryl catheterl andl measuringl strictl intakel andl outputl isl notl anl urgentl actionl forl thel nursel tol take.l Anl indwellingl urinaryl catheterl isl al tubel thatl drainsl urinel froml thel bladderl intol al collectionl bag.l Measuringl intakel andl outputl isl al wayl ofl monitoringl fluidl balancel andl kidneyl function.l However,l thesel interventionsl arel notl essentiall forl thel client'sl conditionl andl mayl increasel thel riskl ofl infectionl orl trauma.
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Choicel Cl reason:l Maintainingl elevatedl positioningl ofl thel dependentl jointsl onl affectedl sidel isl notl al relevantl actionl forl thel nursel tol take.l Dependentl jointsl arel jointsl thatl arel belowl thel levell ofl thel heart,l suchl asl thel anklesl orl wrists.l Elevatingl dependentl jointsl canl helpl reducel swellingl orl painl byl improvingl bloodl flowl andl drainage.l However,l thisl interventionl isl notl relatedl tol thel client'sl conditionl andl doesl notl improvel neurologicall function.
Q:l Al malel clientl withl al brainl tumorl isl scheduledl forl al biopsyl inl thel morning.l Duringl thel admissionl procedure,l thel clientl hasl al tonicl colonicl seizurel thatl lastl 50l seconds.l Followingl thel seizure,l thel clientl isl lethargicl andl confused,l andl hisl wifel tellsl thel nursel thatl herl husbandl hasl neverl hadl al seizurel beforel andl hasl alwaysl beenl alertl andl communicative.l Whichl actionl shouldl thel nursel take?
A.l Notifyl thel emergencyl responsel teaml ofl thel client'sl seizure.
B.l Keepl orientingl thel clientl tol timel andl placel untill hel isl lessl confused.
C.l Explainl thel postictall statel thatl usuallyl followsl seizures.
D.l Askl thel wifel tol waitl outsidel thel rooml untill thel nursel canl talkl withl her.
Answer:
B.l Keepl orientingl thel clientl tol timel andl placel untill hel isl lessl confused.
-Choicel B:l Keepingl orientingl thel clientl tol timel andl placel untill hel isl lessl confusedl isl anl appropriatel actionl forl thel nurse,l asl thisl canl helpl restorel thel client'sl cognitivel functionl andl reducel hisl anxietyl afterl al seizure.l Therefore,l thisl isl thel correctl choice.
Choicel A:l Notifyingl thel emergencyl responsel teaml ofl thel client'sl seizurel isl notl al necessaryl actionl forl thel nurse,l asl thel seizurel hasl alreadyl stoppedl andl therel isl nol immediatel threatl tol thel client'sl life.l Thisl isl al distractorl choice.
Choicel C:l Explainingl thel postictall statel thatl usuallyl followsl seizuresl isl notl al priorityl actionl forl thel nurse,l asl thisl canl bel donel laterl whenl thel clientl isl morel alertl andl receptive.l Thisl isl anotherl distractorl choice.
Choicel D:l Askingl thel wifel tol waitl outsidel thel rooml untill thel nursel canl talkl withl herl isl notl al consideratel actionl forl thel nurse,l asl thisl canl increasel herl stressl andl worryl aboutl herl husband'sl condition.l Thisl isl al contraindicatedl choice. 3 / 4
Q:l Al nursel isl providingl lifestylel changel educationl forl al clientl tol slowl thel progressionl ofl coronaryl arteryl disease.l Whichl statementl madel byl thel clientl shouldl thel nursel recognizel asl needingl additionall education?l
Selectl Alll Thatl Apply.
A.l Consumel foodsl withl saturatedl fats.
B.l Walkl 30l minutesl perl day.
C.l Usel al saltl substitute.
D.l Keepl al foodl diary.
E.l Eatl morel cannedl vegetables.
F.l Includel oatmeall forl breakfast.
Answer:
Al -l E
A.l Consumel foodsl w/l saturatedl fats.-Consumingl foodsl w/l saturatedl fatsl isl notl al healthyl lifestylel changel forl al clientl w/l coronaryl arteryl disease,l asl thisl canl increasel levell ofl cholesteroll &l triglyceridesl inl blood,l whichl canl leadl tol plaquel formationl &l narrowingl ofl arteries.l Therefore,l thisl statementl indicatesl thel clientl needsl additionall education.
E.l Eatl morel cannedl vegetables.-Eatingl morel cannedl vegetablesl isl notl al goodl lifestylel changel forl clientl w/l coronaryl arteryl disease,l asl cannedl vegetablesl oftenl containl highl amountsl ofl sodium,l whichl canl raisel bloodl pressurel &l worsenl condition.l Therefore,l thisl statementl indicatesl thatl thel clientl needsl additionall education.
Q:l Whilel caringl forl al toddlerl receivingl oxygenl vial facemask,l thel nursel observesl thatl thel child'sl lipsl andl naresl arel dryl andl cracked.l Whichl interventionl shouldl thel nursel implement?l
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