BSN 366 EXIT HESI EXAMPREP PRIORITY
SCENARIOS AND NURSING INTERVENTIONS
◉ The family of an older adult client who received a lung transplant
asks if the 2-year-old grandchild can visit. Which response should
the nurse offer?
a. "Yes, grandchildren offer emotional support and positive
diversion."
b. "No, protective precautions are required after a lung transplant."
c. "No, small children are often carriers of infectious organisms."
d. "Yes, if the child is not ill or has not recently received a live
vaccine."
Answer: d. "Yes, if the child is not ill or has not recently received a
live vaccine."
◉ The nurse is using a straight urinary catheter kit to collect a
sterile urine specimen from a female client. After positioning and
prepping the client, rank the actions in the sequence they should be
implemented. (place the first action at the top, and last action at the
bottom)
a. Place the distal end of the catheter in a sterile specimen cup and
insert catheter into meatus Open
,b. Cleans the urinary meatus using the solution, swabs, and forceps
c. Don sterile gloves and prepare the sterile field
d. the sterile catheter kit close to the clients perineum
Answer: d. the sterile catheter kit close to the clients perineum
c. Don sterile gloves and prepare the sterile field
b. Cleans the urinary meatus using the solution, swabs, and forceps
a. Place the distal end of the catheter in a sterile specimen cup and
insert the catheter into the meatus Open
◉ An older adult client presents to the emergency department with
abdominal pain due to constipation. The nurse is providing a list of
high-fiber foods to the client that the healthcare provider has
recommended. Which action should the nurse implement when
reviewing the list of foods?
a. Provide handouts written at a 12th grade reading level.
b. Use background music to promote relaxation.
c. Turn on overhead lights while giving instructions.
d. Stand behind the client to avoid intimidation.
Answer: c. Turn on overhead lights while giving instructions.
◉ After receiving report on an inpatient acute care unit , which
client should the nurse assess first ?
,a. The client with an obstruction of the large intestine who is
experiencing abdominal distention.
b. The client who had surgery yesterday and is experiencing a
paralytic ileus with absent bowel sounds
c. The client with a small bowel obstruction who has a nasogastric
tube that is draining greenish fluid.
d. The client with a bowel obstruction due to a volvulus who is
experiencing abdominal rigidity.
Answer: d. The client with a bowel obstruction due to a volvulus
who is experiencing abdominal rigidity.
◉ A client who underwent an uncomplicated gastric bypass surgery
has difficulty with diet management. What dietary instruction is
most important for the nurse to explain to the client?
a. Chew food slowly and thoroughly before attempting to swallow
b. Plan volume-controlled evenly-spaced meals throughout the day
c. Sip fluid slowly with each meal and between meals
d. Eliminate or reduce intake of fatty and gas-forming food
Answer: b. Plan volume-controlled evenly-spaced meals throughout
the day
, ◉ The nurse is assessing the feet of a client with type 1 diabetes
mellitus. Which finding requires immediate intervention by the
nurse?
a. Decreased response to pain discrimination on the dorsal surface
of the foot.
b. Erythema and edema at the base of the left great toe.
c. Hard, painless nodule over the metatarsophalangeal joint of the
first toe.
d. Painful corns and calluses over hammer toes on both feet.
Answer: a. Decreased response to pain discrimination on the dorsal
surface of the foot.
◉ The nurse is planning to assess the client's oxygen saturation to
determine if additional oxygen is needed via nasal cannula. The
client has bilateral below the-knee amputations and radial 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 client's hands for five minutes prior to
obtaining a reading from the finger.
c. Increase the oxygen based on the client's breathing patterns and
lung sounds.
d. Place the oximeter clip on the earlobe to obtain the oxygen
saturation reading.
SCENARIOS AND NURSING INTERVENTIONS
◉ The family of an older adult client who received a lung transplant
asks if the 2-year-old grandchild can visit. Which response should
the nurse offer?
a. "Yes, grandchildren offer emotional support and positive
diversion."
b. "No, protective precautions are required after a lung transplant."
c. "No, small children are often carriers of infectious organisms."
d. "Yes, if the child is not ill or has not recently received a live
vaccine."
Answer: d. "Yes, if the child is not ill or has not recently received a
live vaccine."
◉ The nurse is using a straight urinary catheter kit to collect a
sterile urine specimen from a female client. After positioning and
prepping the client, rank the actions in the sequence they should be
implemented. (place the first action at the top, and last action at the
bottom)
a. Place the distal end of the catheter in a sterile specimen cup and
insert catheter into meatus Open
,b. Cleans the urinary meatus using the solution, swabs, and forceps
c. Don sterile gloves and prepare the sterile field
d. the sterile catheter kit close to the clients perineum
Answer: d. the sterile catheter kit close to the clients perineum
c. Don sterile gloves and prepare the sterile field
b. Cleans the urinary meatus using the solution, swabs, and forceps
a. Place the distal end of the catheter in a sterile specimen cup and
insert the catheter into the meatus Open
◉ An older adult client presents to the emergency department with
abdominal pain due to constipation. The nurse is providing a list of
high-fiber foods to the client that the healthcare provider has
recommended. Which action should the nurse implement when
reviewing the list of foods?
a. Provide handouts written at a 12th grade reading level.
b. Use background music to promote relaxation.
c. Turn on overhead lights while giving instructions.
d. Stand behind the client to avoid intimidation.
Answer: c. Turn on overhead lights while giving instructions.
◉ After receiving report on an inpatient acute care unit , which
client should the nurse assess first ?
,a. The client with an obstruction of the large intestine who is
experiencing abdominal distention.
b. The client who had surgery yesterday and is experiencing a
paralytic ileus with absent bowel sounds
c. The client with a small bowel obstruction who has a nasogastric
tube that is draining greenish fluid.
d. The client with a bowel obstruction due to a volvulus who is
experiencing abdominal rigidity.
Answer: d. The client with a bowel obstruction due to a volvulus
who is experiencing abdominal rigidity.
◉ A client who underwent an uncomplicated gastric bypass surgery
has difficulty with diet management. What dietary instruction is
most important for the nurse to explain to the client?
a. Chew food slowly and thoroughly before attempting to swallow
b. Plan volume-controlled evenly-spaced meals throughout the day
c. Sip fluid slowly with each meal and between meals
d. Eliminate or reduce intake of fatty and gas-forming food
Answer: b. Plan volume-controlled evenly-spaced meals throughout
the day
, ◉ The nurse is assessing the feet of a client with type 1 diabetes
mellitus. Which finding requires immediate intervention by the
nurse?
a. Decreased response to pain discrimination on the dorsal surface
of the foot.
b. Erythema and edema at the base of the left great toe.
c. Hard, painless nodule over the metatarsophalangeal joint of the
first toe.
d. Painful corns and calluses over hammer toes on both feet.
Answer: a. Decreased response to pain discrimination on the dorsal
surface of the foot.
◉ The nurse is planning to assess the client's oxygen saturation to
determine if additional oxygen is needed via nasal cannula. The
client has bilateral below the-knee amputations and radial 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 client's hands for five minutes prior to
obtaining a reading from the finger.
c. Increase the oxygen based on the client's breathing patterns and
lung sounds.
d. Place the oximeter clip on the earlobe to obtain the oxygen
saturation reading.
