,BSN 366 HESI RN Exit V1, Nightingale
1. A client experiencing an acute dystonic reaction presents with a laryngeal spasm.
Which treatment should the nurse prepare?
A 24-year-old client receiving an antipsychotic medication suddenly develops severe
muscle contractions, neck stiffness, and difficulty breathing due to a suspected acute
dystonic reaction. The nurse recognizes that the client is experiencing a potentially
life-threatening complication involving involuntary muscle spasms of the airway. The
healthcare provider orders emergency treatment to reverse the medication-induced
reaction and prevent airway obstruction.
Which treatment should the nurse prepare to administer?
A. Intravenous administration of benztropine.
B. Oral administration of divalproex.
C. Intravenous administration of isotonic crystalloid fluid.
D. Oral administration of lorazepam.
Correct Answer: A. Intravenous administration of benztropine.
Rationale:
Benztropine is an anticholinergic medication used to rapidly treat acute dystonic
reactions caused by dopamine-blocking medications, including severe muscle spasms
involving the neck and airway. Intravenous administration provides rapid relief when
the client develops a laryngeal spasm because airway compromise requires
immediate intervention.
2. Assessment findings for a client following a colectomy for familial polyposis include
an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of
dextrose 5% in lactated Ringer’s infusing at 100 mL/hour. Which assessment is most
important for the nurse to monitor?
A client is recovering after a colectomy with creation of an ileostomy due to familial
polyposis. During the postoperative assessment, the nurse observes a large amount
,of liquid stool collecting in the ileostomy pouch while the client continues receiving
IV fluids. The nurse understands that ileostomies can result in significant fluid and
electrolyte losses because stool bypasses the colon.
Which assessment finding is the priority for the nurse to monitor?
A. Urinary output.
B. Serum electrolytes.
C. Peristomal skin integrity.
D. Skin turgor.
Correct Answer: B. Serum electrolytes.
Rationale:
Clients with ileostomies are at increased risk for electrolyte imbalances because large
amounts of liquid stool can cause losses of sodium, potassium, and other
electrolytes. Monitoring serum electrolyte levels allows early identification and
treatment of potentially dangerous imbalances.
3. The charge nurse is making assignments for one practical nurse (PN) and three
registered nurses (RN) who are caring for neurologically compromised clients. Which
client with which change in status is best to assign to the PN?
The charge nurse is assigning care responsibilities for four clients experiencing
neurological conditions. One client has a stable condition with a minor expected
change, while the other clients demonstrate signs of possible neurological
deterioration requiring RN assessment and intervention. The nurse must determine
which client can be safely assigned to the practical nurse based on scope of practice
and client stability.
Which client should the charge nurse assign to the practical nurse (PN)?
A. Viral meningitis whose temperature changed from 101°F (38.3°C) to 102°F
(38.9°C).
B. Myxedema coma whose blood pressure changed from 80/50 mm Hg to 70/40 mm
Hg.
C. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7.
,D. Subdural hematoma whose blood pressure changed from 150/80 mm Hg to
170/60 mm Hg.
Correct Answer: A. Viral meningitis whose temperature changed from 101°F (38.3°C)
to 102°F (38.9°C).
Rationale:
The client with viral meningitis has an expected finding of fever and does not
demonstrate signs of acute neurological deterioration requiring RN-level assessment.
A practical nurse can provide care for stable clients and report changes in condition
to the RN.
4. Following an acute myocardial infarction that occurred two weeks ago, an adult
male presents for his follow-up appointment accompanied by his spouse. He tells the
nurse that he has lost his appetite, cannot seem to make decisions, and cannot sleep
at night. Which intervention is most important for the nurse to implement?
A 58-year-old client returns for a follow-up appointment two weeks after
experiencing an acute myocardial infarction. During the visit, the client reports loss of
appetite, difficulty making decisions, and inability to sleep, which are possible
indicators of emotional distress following a life-threatening event. The nurse
recognizes the need to assess the client’s mental health status and provide
appropriate support.
Which intervention should the nurse implement first?
A. Ask the spouse if the client seems to be depressed.
B. Tell the spouse to wait outside so the client can be assessed for depression.
C. Explain that depression often occurs after life-threatening experiences.
D. Encourage the client to further describe his feelings.
Correct Answer: D. Encourage the client to further describe his feelings.
Rationale:
Encouraging the client to discuss feelings allows the nurse to perform a direct
assessment of emotional status while promoting therapeutic communication. The
,client’s statements suggest possible depression, and further exploration is necessary
before determining appropriate interventions.
5. The nurse is caring for a client with the sexually transmitted infection (STI) syphilis.
The client reports having had prior sexually transmitted infections. Which response
should the nurse provide?
A client diagnosed with syphilis tells the nurse that they have previously been treated
for sexually transmitted infections and expresses uncertainty about STI prevention
and transmission. The client asks questions based on information they have heard
from previous partners. The nurse recognizes the need to provide accurate education
while maintaining a nonjudgmental approach.
Which response by the nurse is most appropriate?
A. Discuss that partners without similar symptoms may not be infected.
B. Answer the question directly and correct any misinformation.
C. Provide counseling that most contraceptives protect against infections.
D. Notify that persons with STIs are reported to local health departments.
Correct Answer: B. Answer the question directly and correct any misinformation.
Rationale:
The nurse should provide factual, clear, and nonjudgmental education to correct
misunderstandings about STI transmission and prevention. Syphilis can be
transmitted even when symptoms are not present, so accurate information helps
reduce further transmission and promotes appropriate treatment and follow-up.
6. Four hours after surgery, a client reports nausea and begins to vomit. The nurse
notes that the client has a scopolamine transdermal patch applied behind the ear.
What action should the nurse take?
A client is recovering four hours after surgery and suddenly develops nausea with
episodes of vomiting. The nurse observes that a scopolamine transdermal patch is in
place behind the client’s ear for postoperative nausea prevention. Because the
, client’s symptoms may indicate a medication-related complication or inadequate
response to therapy, the nurse evaluates the next appropriate action.
What action should the nurse take?
A. Reposition the transdermal patch to the client's trunk.
B. Remove the transdermal patch until the vomiting subsides.
C. Notify the healthcare provider of the vomiting.
D. Explain that this is a side effect of the medication in the patch.
Correct Answer: C. Notify the healthcare provider of the vomiting.
Rationale:
Vomiting despite the use of scopolamine requires further evaluation because the
medication should help prevent postoperative nausea and vomiting. The nurse
should notify the healthcare provider to determine whether additional antiemetic
therapy or evaluation for another cause is needed.
7. A client is receiving “Heparin Sodium 25,000 Units in 250 mL 5% Dextrose” IV at 7
mL/hour. The healthcare provider changes the prescription to 900 units/hour. The
nurse should program the infusion pump to deliver how many mL/hour?
A client receiving a continuous heparin infusion requires a dosage adjustment based
on the healthcare provider’s new prescription. The medication concentration
available is 25,000 units of heparin mixed in 250 mL of 5% dextrose. The nurse must
calculate the correct infusion rate in milliliters per hour to safely administer the
prescribed dose.
How many mL/hour should the nurse program into the infusion pump?
Correct Answer: 9 mL/hour
Rationale:
The concentration of the solution is calculated as 25,000 units ÷ 250 mL = 100
units/mL. To deliver 900 units/hour, the nurse divides 900 units by 100 units/mL,
resulting in 9 mL/hour. Correct dosage calculations are essential because excessive
heparin administration can increase the risk of bleeding.
1. A client experiencing an acute dystonic reaction presents with a laryngeal spasm.
Which treatment should the nurse prepare?
A 24-year-old client receiving an antipsychotic medication suddenly develops severe
muscle contractions, neck stiffness, and difficulty breathing due to a suspected acute
dystonic reaction. The nurse recognizes that the client is experiencing a potentially
life-threatening complication involving involuntary muscle spasms of the airway. The
healthcare provider orders emergency treatment to reverse the medication-induced
reaction and prevent airway obstruction.
Which treatment should the nurse prepare to administer?
A. Intravenous administration of benztropine.
B. Oral administration of divalproex.
C. Intravenous administration of isotonic crystalloid fluid.
D. Oral administration of lorazepam.
Correct Answer: A. Intravenous administration of benztropine.
Rationale:
Benztropine is an anticholinergic medication used to rapidly treat acute dystonic
reactions caused by dopamine-blocking medications, including severe muscle spasms
involving the neck and airway. Intravenous administration provides rapid relief when
the client develops a laryngeal spasm because airway compromise requires
immediate intervention.
2. Assessment findings for a client following a colectomy for familial polyposis include
an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of
dextrose 5% in lactated Ringer’s infusing at 100 mL/hour. Which assessment is most
important for the nurse to monitor?
A client is recovering after a colectomy with creation of an ileostomy due to familial
polyposis. During the postoperative assessment, the nurse observes a large amount
,of liquid stool collecting in the ileostomy pouch while the client continues receiving
IV fluids. The nurse understands that ileostomies can result in significant fluid and
electrolyte losses because stool bypasses the colon.
Which assessment finding is the priority for the nurse to monitor?
A. Urinary output.
B. Serum electrolytes.
C. Peristomal skin integrity.
D. Skin turgor.
Correct Answer: B. Serum electrolytes.
Rationale:
Clients with ileostomies are at increased risk for electrolyte imbalances because large
amounts of liquid stool can cause losses of sodium, potassium, and other
electrolytes. Monitoring serum electrolyte levels allows early identification and
treatment of potentially dangerous imbalances.
3. The charge nurse is making assignments for one practical nurse (PN) and three
registered nurses (RN) who are caring for neurologically compromised clients. Which
client with which change in status is best to assign to the PN?
The charge nurse is assigning care responsibilities for four clients experiencing
neurological conditions. One client has a stable condition with a minor expected
change, while the other clients demonstrate signs of possible neurological
deterioration requiring RN assessment and intervention. The nurse must determine
which client can be safely assigned to the practical nurse based on scope of practice
and client stability.
Which client should the charge nurse assign to the practical nurse (PN)?
A. Viral meningitis whose temperature changed from 101°F (38.3°C) to 102°F
(38.9°C).
B. Myxedema coma whose blood pressure changed from 80/50 mm Hg to 70/40 mm
Hg.
C. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7.
,D. Subdural hematoma whose blood pressure changed from 150/80 mm Hg to
170/60 mm Hg.
Correct Answer: A. Viral meningitis whose temperature changed from 101°F (38.3°C)
to 102°F (38.9°C).
Rationale:
The client with viral meningitis has an expected finding of fever and does not
demonstrate signs of acute neurological deterioration requiring RN-level assessment.
A practical nurse can provide care for stable clients and report changes in condition
to the RN.
4. Following an acute myocardial infarction that occurred two weeks ago, an adult
male presents for his follow-up appointment accompanied by his spouse. He tells the
nurse that he has lost his appetite, cannot seem to make decisions, and cannot sleep
at night. Which intervention is most important for the nurse to implement?
A 58-year-old client returns for a follow-up appointment two weeks after
experiencing an acute myocardial infarction. During the visit, the client reports loss of
appetite, difficulty making decisions, and inability to sleep, which are possible
indicators of emotional distress following a life-threatening event. The nurse
recognizes the need to assess the client’s mental health status and provide
appropriate support.
Which intervention should the nurse implement first?
A. Ask the spouse if the client seems to be depressed.
B. Tell the spouse to wait outside so the client can be assessed for depression.
C. Explain that depression often occurs after life-threatening experiences.
D. Encourage the client to further describe his feelings.
Correct Answer: D. Encourage the client to further describe his feelings.
Rationale:
Encouraging the client to discuss feelings allows the nurse to perform a direct
assessment of emotional status while promoting therapeutic communication. The
,client’s statements suggest possible depression, and further exploration is necessary
before determining appropriate interventions.
5. The nurse is caring for a client with the sexually transmitted infection (STI) syphilis.
The client reports having had prior sexually transmitted infections. Which response
should the nurse provide?
A client diagnosed with syphilis tells the nurse that they have previously been treated
for sexually transmitted infections and expresses uncertainty about STI prevention
and transmission. The client asks questions based on information they have heard
from previous partners. The nurse recognizes the need to provide accurate education
while maintaining a nonjudgmental approach.
Which response by the nurse is most appropriate?
A. Discuss that partners without similar symptoms may not be infected.
B. Answer the question directly and correct any misinformation.
C. Provide counseling that most contraceptives protect against infections.
D. Notify that persons with STIs are reported to local health departments.
Correct Answer: B. Answer the question directly and correct any misinformation.
Rationale:
The nurse should provide factual, clear, and nonjudgmental education to correct
misunderstandings about STI transmission and prevention. Syphilis can be
transmitted even when symptoms are not present, so accurate information helps
reduce further transmission and promotes appropriate treatment and follow-up.
6. Four hours after surgery, a client reports nausea and begins to vomit. The nurse
notes that the client has a scopolamine transdermal patch applied behind the ear.
What action should the nurse take?
A client is recovering four hours after surgery and suddenly develops nausea with
episodes of vomiting. The nurse observes that a scopolamine transdermal patch is in
place behind the client’s ear for postoperative nausea prevention. Because the
, client’s symptoms may indicate a medication-related complication or inadequate
response to therapy, the nurse evaluates the next appropriate action.
What action should the nurse take?
A. Reposition the transdermal patch to the client's trunk.
B. Remove the transdermal patch until the vomiting subsides.
C. Notify the healthcare provider of the vomiting.
D. Explain that this is a side effect of the medication in the patch.
Correct Answer: C. Notify the healthcare provider of the vomiting.
Rationale:
Vomiting despite the use of scopolamine requires further evaluation because the
medication should help prevent postoperative nausea and vomiting. The nurse
should notify the healthcare provider to determine whether additional antiemetic
therapy or evaluation for another cause is needed.
7. A client is receiving “Heparin Sodium 25,000 Units in 250 mL 5% Dextrose” IV at 7
mL/hour. The healthcare provider changes the prescription to 900 units/hour. The
nurse should program the infusion pump to deliver how many mL/hour?
A client receiving a continuous heparin infusion requires a dosage adjustment based
on the healthcare provider’s new prescription. The medication concentration
available is 25,000 units of heparin mixed in 250 mL of 5% dextrose. The nurse must
calculate the correct infusion rate in milliliters per hour to safely administer the
prescribed dose.
How many mL/hour should the nurse program into the infusion pump?
Correct Answer: 9 mL/hour
Rationale:
The concentration of the solution is calculated as 25,000 units ÷ 250 mL = 100
units/mL. To deliver 900 units/hour, the nurse divides 900 units by 100 units/mL,
resulting in 9 mL/hour. Correct dosage calculations are essential because excessive
heparin administration can increase the risk of bleeding.
