BSN366 EXIT HESI Actual Exam 2025
Well Elaborated Questions and All
Correct Answers Newest and 100% A+
Graded
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 client’s 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. - CORRECT ANSWER A) Apply the
client’s positive airway pressure device.
The nurse leading a care team on a medical surgical unit is assigning client care to a
practical nurse and some unlicensed assistive personnel. Which tasks should the nurse
have 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. - CORRECT ANSWER
B) Titrate oxygen to prescribed parameters.
The nurse is planning to assess a client’s 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 thread. 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 a client’s breathing patterns and lung sounds.
D) Place the oximeter clip on the earlobe to obtain the oxygen saturation reading. -
CORRECT ANSWER D) Place the oximeter clip on the earlobe to obtain the oxygen
saturation reading.
Some unlicensed assistive personnel are assigned to provide personal care for the
client who is prescribed activity is bedrest with bedside commode use. The UAP reports
to the nurse that the client is so obese that the UAP feels unable to safely assist the
client in transferring from the bed to the bedside commode. How should the nurse
respond?
,A) Determine the clients level of mobility and need for assistance.
B) Instruct the UAP that all clients deserve equal care.
C) Advise the client to maintain bedrest so that safety can be ensured.
D) Assign another UAP to care for the client. - CORRECT ANSWER C) Advise the
client to maintain bedrest so that safety can be ensured.
The nurse is providing teaching to a client with type 2 DM about important points for
disease and symptom management. Which statement by the client indicates
understanding?
A) Using salt, herbs, and spices will improve the flavor of foods
B) Get an eye exam with an opthalmologist annually
C) Arrange diet schedule around three regular meals a day
D) Inspect feet every month for ingrown nails, cuts, and calluses - CORRECT ANSWER
B) Get an eye exam with an opthalmologist annually
The nurse is providing educations to a client who experiences recurrent levels of
moderate anxiety to situations and perceived stress. In addition to information’s 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 - CORRECT ANSWER 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 previous 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 -
CORRECT ANSWER 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 - CORRECT ANSWER 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 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 nurse recognizes that the infant of a diabetic mother is at risk for _________,
_____________, and _________________ - CORRECT ANSWER Hyperbilirubinemia,
Respiratory Distress Syndrome, and Cardiomyopathy
NGN: Orders
Breast-feed immediately once stable then on demand. If unstable, may feed breastmilk
via or gastric tube. If two feeding attempts failed to increase the glucose levels or if
symptoms of hypoglycemia develop, apply dextrose gel inside the baby’s cheek. If the
above are ineffective, IV glucose should be administered to maintain glucose levels
above 45. Bolus of 2mL/kg glucose 10% IV, hello by a continuous glucose perfusion of
6 to 8mg/kg/min, maintain glycemic levels over 40.
Which 6 orders take priority?
A) Feed Immediately
B) Monitor for respiratory distress
C) Apply dextrose gel inside the baby's cheek
D) Keep in warmer with bilirubin lights
E) Monitor temp every 30 min
F) Bolus 2 mL/kg glucose 10% IV
G) Contact RT for ABG and oxygen therapy
, H) Echo
I) Transfer to NICU
J) Blood glucose level - CORRECT ANSWER A) Feed Immediately
B) Monitor for Respiratory Distress
D) Keep in warmer with bile 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 bile 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 baby’s RR needs 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 O2 with pulse ox - CORRECT
ANSWER A) Keep infant in warmer with bile lights to maintain temp of 97F
E) Explain to the mother that the baby’s 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 nurse’s 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 see - CORRECT ANSWER 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
Well Elaborated Questions and All
Correct Answers Newest and 100% A+
Graded
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 client’s 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. - CORRECT ANSWER A) Apply the
client’s positive airway pressure device.
The nurse leading a care team on a medical surgical unit is assigning client care to a
practical nurse and some unlicensed assistive personnel. Which tasks should the nurse
have 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. - CORRECT ANSWER
B) Titrate oxygen to prescribed parameters.
The nurse is planning to assess a client’s 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 thread. 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 a client’s breathing patterns and lung sounds.
D) Place the oximeter clip on the earlobe to obtain the oxygen saturation reading. -
CORRECT ANSWER D) Place the oximeter clip on the earlobe to obtain the oxygen
saturation reading.
Some unlicensed assistive personnel are assigned to provide personal care for the
client who is prescribed activity is bedrest with bedside commode use. The UAP reports
to the nurse that the client is so obese that the UAP feels unable to safely assist the
client in transferring from the bed to the bedside commode. How should the nurse
respond?
,A) Determine the clients level of mobility and need for assistance.
B) Instruct the UAP that all clients deserve equal care.
C) Advise the client to maintain bedrest so that safety can be ensured.
D) Assign another UAP to care for the client. - CORRECT ANSWER C) Advise the
client to maintain bedrest so that safety can be ensured.
The nurse is providing teaching to a client with type 2 DM about important points for
disease and symptom management. Which statement by the client indicates
understanding?
A) Using salt, herbs, and spices will improve the flavor of foods
B) Get an eye exam with an opthalmologist annually
C) Arrange diet schedule around three regular meals a day
D) Inspect feet every month for ingrown nails, cuts, and calluses - CORRECT ANSWER
B) Get an eye exam with an opthalmologist annually
The nurse is providing educations to a client who experiences recurrent levels of
moderate anxiety to situations and perceived stress. In addition to information’s 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 - CORRECT ANSWER 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 previous 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 -
CORRECT ANSWER 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 - CORRECT ANSWER 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 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 nurse recognizes that the infant of a diabetic mother is at risk for _________,
_____________, and _________________ - CORRECT ANSWER Hyperbilirubinemia,
Respiratory Distress Syndrome, and Cardiomyopathy
NGN: Orders
Breast-feed immediately once stable then on demand. If unstable, may feed breastmilk
via or gastric tube. If two feeding attempts failed to increase the glucose levels or if
symptoms of hypoglycemia develop, apply dextrose gel inside the baby’s cheek. If the
above are ineffective, IV glucose should be administered to maintain glucose levels
above 45. Bolus of 2mL/kg glucose 10% IV, hello by a continuous glucose perfusion of
6 to 8mg/kg/min, maintain glycemic levels over 40.
Which 6 orders take priority?
A) Feed Immediately
B) Monitor for respiratory distress
C) Apply dextrose gel inside the baby's cheek
D) Keep in warmer with bilirubin lights
E) Monitor temp every 30 min
F) Bolus 2 mL/kg glucose 10% IV
G) Contact RT for ABG and oxygen therapy
, H) Echo
I) Transfer to NICU
J) Blood glucose level - CORRECT ANSWER A) Feed Immediately
B) Monitor for Respiratory Distress
D) Keep in warmer with bile 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 bile 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 baby’s RR needs 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 O2 with pulse ox - CORRECT
ANSWER A) Keep infant in warmer with bile lights to maintain temp of 97F
E) Explain to the mother that the baby’s 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 nurse’s 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 see - CORRECT ANSWER 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
