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BSN 366 EXIT HESI FULL ACTUAL EXAM | ALL VERIFIED QUESTIONS ACCURATELY
ANSWERED
A male client with heart failure become short of breath, anxious, and has audible wheezing with sputum pink and frothy. The nurse sits the client upright and provides oxygen per nasal cannula. The nurse receives a prescription to administer a one time dose of morphine sulfate IV. What action should the nurse take? A) Consult with the charge nurse regarding the morphine prescription. B) Administer the dose of morphine sulfate as prescribed. C) Withhold the morphine until the clients dyspnea resolves. D) Review the need for the prescription with the healthcare provider. D) Review the need for the prescription with the healthcare provider. A mother calls the nurse to report that aa 0900 she administered an oral dose of digoxin to her four-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother? A) Withhold this dose. B) Mix the next dose with food. C) Give another dose. D) Administer a half dose now. A) Withhold this dose.
Bryant is receiving continuous ambulatory peritoneal dialysis since the AV graft in the right arm is no longer available to use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5. Which intervention is a priority for the nurse to implement? A) Evaluate patency of the AV graft for resumption of hemodialysis. B) Ensure the client receives frequent small meals containing complete proteins. C) Instruct the client to continue to follow the prescribed rigid fluid regimen amounts. D) Recommend the use of support stockings to enhance venous return. B) Ensure the client receives frequent small meals containing complete proteins. The nurse is assigning care of the client with prostatitis to a practical nurse. Which instruction should the nurse provide the p.m. regarding care of this client? A) Restrict oral fluid intake. B) Strain all urine. C) Maintain contact isolation. D) Avoid urinary catheterization. D) Avoid urinary catheterization. The nurse observes an unlicensed assistive personnel who is preparing to provide personal care for a client who requires contact precautions. The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. Which action should the nurse take?
D) Anxiety. Adult male client reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his deceased parents have heart disease and his father had diabetes. He lives with his male partner, is a vegetarian, and takes atenolol which maintains his blood pressure at 130/74. Which risk factors should the nurse explore further with the client? SATA. A) History of hypertension. B) Homosexual lifestyle. C) Vegetarian diet. D) Excessive aerobic exercise. E) Family health history. A) History of hypertension. E) Family health history. Nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? SATA. A) Sodium intake can be regulated by limiting canned foods in the diet. B) Salt substitutes can help with maintaining a healthy diet. C) Alcohol consumption will not produce vascular changes. D) Uncontrolled hypertension can lead to renal damage. E) Blood pressure readings should be taken at noon time. F) Weight management is promoted by taking daily walks for 30 minutes.
A) Sodium intake can be regulated by limiting canned foods in the diet. B) Salt substitutes can help with maintaining a healthy diet. D) Uncontrolled hypertension can lead to renal damage. F) Weight management is promoted by taking daily walks for 30 minutes. A female client with fibromyalgia asked the nurse to arrange for hospice care to help her manage the severe, chronic pain. Which intervention should the nurse provide to address the clients problem? A) Contact a hospice nurse for an evaluation. B) Arrange an appointment with a pain specialist. C) Form an interdisciplinary team for evaluation. D) Ask for a consultation with a psychologist. B) Arrange an appointment with a pain specialist. Three hours after birth, a newborn becomes jittery and tacky piña. What should the nurse do first? A) Obtain a capillary glucose level. B) Feed 30 mL of 10% dextrose in water. C) Wrapped tightly in a warm blanket. D) Encourage the mother to breast-feed. A) Obtain a capillary glucose level.
To auscultation for a car droid Bruett, the nurse place is the stethoscope at what location? Place the stethoscope at base of neck in the front. The nurse on a pediatric unit observes a distraught mother in the hallway scolding her three year old son for wedding his pants. What initial action should the nurse take? A) Inform the mother that toilet training is slower for boys. B) Refer the mother to a community parent education program. C) Suggest that the mother consult a pediatric nephrologist. D) Provide disposable training pants while calming the mother. D) Provide disposable training pants while calming the mother. NGN: the client is an 81-year-old female who is in the hospital for treatment of a blood clot. She has a history of type two diabetes mellitus and takes Met Forman. She is active at home and performs activities of daily living independently but has required assistance from her son for the last couple of weeks due to weakness and fatigue. (Complete the diagram by dragging from the choices to specify which condition the client is most likely experiencing, to actions the nurse should take, and two parameters the nurse should monitor.) ???? When is it most important for the nurse to assess a pregnant clients deep tendon reflexes? A) When the client has ankle edema.
B) During admission to labor and delivery. C) If the client has an elevated blood pressure. D) Within the first trimester of pregnancy. C) If the client has an elevated blood pressure. Situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider? A) The client is walking the halls at night rubbing his hands together. B) A family member expresses concern about their relative picking at the NG tube. C) A 16 year old boy swung his fist at the nurse. D) A disoriented client removed the mesh wrapped IV for the second time. D) A disoriented client removed the mesh wrapped IV for the second time. Audio of lung sounds. The nurse is auscultating a client lung sounds which description should the nurse use to document this sound? A) High-pitched wheeze. B) Low-pitched or coarse crackles. C) Stridor. D) High-pitched or fine crackles. C) Stridor.
Client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? A) Serum calcium. B) Hemoglobin. C) Osmolality. D) Erythrocyte sedimentation rate. B) Hemoglobin. A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to know before administering the initial dose? A) Current diagnosis of hepatitis B. B) History of IV drug use. C) Length of time of the exposure to tuberculosis. D) Conversion of the clients PPD test from negative to positive. A) Current diagnosis of hepatitis B. A client with obstructive sleep apnea ambulates in the hallway with the nurse prior to bedtime. Which intervention is most important for the nurse to implement before leaving the client?
A) Apply the clients positive airway pressure device. B) Elevate the head of the bed to a 45° angle. C) Left and lock the side rails in place. D) Remove dentures or other oral appliance. A) Apply the clients positive airway pressure device. The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse and an unlicensed assistive personnel. Which tasks should the nurse assigned to the pen? A) Determine the need for urinary catheterizations. B) Titrate oxygen to prescribed parameters. C) Evaluate an update plans of care for clients. D) Receive a postoperative client and conduct the assessment. B) Titrate oxygen to prescribed parameters. The nurse is planning to assess a clients oxygen saturation to determine if additional oxygen is needed for via nasal cannula. The client has a bilateral below the knee amputation and pedal pulses that are weak and thready. What action should the nurse take? A) Document that an accurate oxygen saturation reading cannot be obtained. B) Elevate the clients hands for five minutes prior to obtaining a reading from the finger. C) Increase the oxygen based on a clients breathing patterns and lung sounds.
The nurse is providing educations to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to informations about prescribed medications and administration, which instruction should the nurse include in the teaching? A) Center attention on positive upbeat music B) Find outlets for more social interaction C) Practice using muscle relaxation techniques D) Think about reasons the episodes occur C) Practice using muscle relaxation techniques The charge nurse is planning for the shift and has a RN and a PN on the team. Which client should the charge nurse assign to the RN? A) A 75-year old client with renal calculi who requires urine straining B) A 64-year old client who had a total hip replacement the preious day C) A 30-year old depresses client who admits to suicide ideation D) An adolescent with multiple contusions due to a fall that occurred 2 days ago C) A 30-year old depresses client who admits to suicide ideation NGN: (Nurses Notes) 1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother, who was diagnosed with gestational diabetes. Following a spontaneous vaginal birth, she received Apgar scores of seven at one minute and eight at five minutes. The client weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30min of age. Axillary temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin seven, fontanelles soft, mongolian
spot noted on lower back, Ballard maturity rating 37 weeks. (For each assessment finding, click to indicate whether the findings are associated with an infant of a diabetic mother or normal presentation.) Soft Fontanelles Blood Glucose 35 Axillary temp. 96F Acrocyanosis Ballard score maturity rating 37 Diabetic Findings: BG 35 Axillary temp 96 Ballard score maturity rating 37 ??????? Normal Presentation: Soft Fontanelles Acrocyanosis (normal findings include acrocyanosis, soft fontanelles, mongolian spots, and Apgar scores 7 to 10) NGN: (Nurses Notes) 1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother, who was diagnosed with gestational diabetes. Following a spontaneous vaginal birth, she received Apgar scores of seven at one minute and eight at five minutes. The client weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30min of age. Axillary temperature
B) Monitor for Respiratory Distress D) Keep in warmer with bili lights E) Monitor temp q30min G) Contact RT for ABG and O2 therapy J) Blood glucose level NGN Laboratory Results (same case of patient who just gave birth) Which actions are appropriate for the nurse to take at this time? SATA A) Keep infant in warmer with bili lights to maintain temp of 97.6F B) Monitor Temp C) Continue to monitor glucose level D) Tell the mother that she will need to discuss this with the neonatologist E) Explain to the mother that the babys RR needs to be below 60 F) Inform the mother that the baby is stable enought to take out of the warmer G) Observe for signs of respiratory distress and monitor O2 with pulse ox A) Keep infant in warmer with bili lights to maintain temp of 97F E) Explain to the mother that the babys RR need to be below 60 F) Inform the mother that the baby is stable enough to take out of the warmer G) Observe for signs of respiratory distress and monitor oxygenation by pulse ox NGN: 1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother, who was diagnosed with gestational diabetes. Following a spontaneous vaginal birth, she received Apgar scores of seven at one minute and eight at five minutes. The client weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a moderate amount of
subcutaneous fat. She is noted to be slightly jittery at 30min of age. Axillary temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin seven, fontanelles soft, mongolian spot noted on lower back, Ballard maturity rating 37 weeks. (The day shift nurse reviews the nurses notes, labs, and flow sheet from the night before. The nurse plans on providing health teaching for the client and her family in preparation for discharge.) For each teaching point, click to indicate whether it is indicated or contraindicated. Only one right option per row. A) You will need to se A) B) C) D) Indicated E) ????????? NGN: 1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother, who was diagnosed with gestational diabetes. Following a spontaneous vaginal birth, she received Apgar scores of seven at one minute and eight at five minutes. The client weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30min of age. Axillary temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin seven, fontanelles soft, mongolian spot noted on lower back, Ballard maturity rating 37 weeks. (Click to highlight notes that demonstrate a positive outcome) Day 2, 0630: Vitals have remained stable throughout the night. Oxygen 98% on nasal canal. Mother to breastfeed in the nursery on demand. Able to tolerate breastmilk. Glucose after
D) Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy A male client with a brain tumor is scheduled for a biopsy in the morning. During the admission procedure, the client has a tonic colonic seizure that last 50 seconds. Following the seizure, the client is lethargic and confused, and his wife tells the nurse that her husband has never had a seizure before and has always been alert and communicative. Which action should the nurse take? A) ask the wife to wait outside the room until the nurse can talk with her. B) keep orienting the client the client to time in space until he is less confused C) notify the emergency response team of the client's seizure D) explain the postictal state that usually follows seizures D) explain the postical state that usually follows seizures A nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement made by the client should the nurse recognize as needing additional education? A) Keep a food diary. B) Eat more canned vegetables. C) Consume foods with saturated fat. D) Walk 30 minutes per day. E) Include oatmeal for breakfast. F) Use a salt substitute B) Eat more canned vegetables. C) Consume foods with saturated fats.
The nurse observes an unlicensed assistive personnel applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take? A) Instruct the UP to return to the clients room to perform handwashing. B) Advise the UP to wear gloves when obtaining vital signs for all clients. C) Supervise the UP in the next clients room to evaluate hand hygiene. D) Remind the UAP to continue rubbing their hands together until they are dry. D) Remind the UAP to continue rubbing their hands together until they are dry. Nurse is caring for a group of clients with the help of a practical nurse. Which nursing actions should the nurse assigned to the PN? SATA. A) Perform daily surgical dressing change for a client who had an abdominal hysterectomy. B) Administer a dose of insulin per sliding scale for a client with type two diabetes mellitus. C) Initiate patient-controlled analgesia (PCA) pumps for two clients immediately post operatively. D) Start the second blood transfusion for a client 12 hours following a below knee amputation. E) Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty. A) Perform daily surgical dressing change for a client who had an abdominal hysterectomy. B) Administer a dose of insulin per sliding scale for a client with type two diabetes mellitus. E) Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty.
