BSN HESI 366 RN EXIT EXAM (NEW 2025 UPDATE)
QUESTIONS AND VERIFIED ANSWERS|100%
CORRECT| GRADE A+ - NIGHTINGALE
A Neonate who has congenital adrenal hyperplasia CAH presents with ambiguous
genitalia what is the primary nursing consideration when supporting the parents
of the child with this anomaly
offer information about u/s and genotyping to determine sex assignment
The nurse is preparing a teaching plan for an older female client diagnosed with
osteoporosis, which expected outcome has the highest priority
Names three home safely hazards to be resolved immediately
The nurse preparing a client who had a BKA (below the knee amp) for discharge
to home. Which recommendations should the nurse provide this client? (select all
that apply
Inspect skin for redness
●
Use a residual limb shrinker
●
Wash the stump with soap and water
A client's morning assessment includes bounding peripheral pulses, weight gain
of 2 lbs (0.91kg) pitting ankle edema, and moist crackles bilaterally. Which
intervention is most important for the nurse to include in this clien'ts plan of care
Administer prescribed diuretic
The home health nurse visits a client who has cancer. The client reports having a
good appetite but experiencing nausea when smelling food cooking. Which
action should the nurse implement?
Encourage family member to cook meals outdoors and bring the cooked food inside
A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is
admitted with hyponatremia. Which intervention is most important for the nurse
to include in the plan of care to protect the client from injury
Limit fluid intake
The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride
1,000 ml to be infused intravenously over 4 hours. The Iv administration set
delivers 10 gtt/ml. How many gtt/minute should the nurse regulate the infusion
42 1000/4=250 250/60*10
Four hours following surgical repair of a compound fracture of the right ulna, the
nurse is unable to palpate the client's right radial pulse. Which action should the
nurse take first
Elevate the client's right hand on one or two pillows
After placing a 36- week- gestation newborn in an isolette and drying the infant
with several blankets, what should the nurse implement next?
Remove the wet blankets and linen from the isolette
,A client in the third trimester of pregnancy complains of frequent nasal stiffness
and occasional nosebleeds. Her chest circumference has increased by 5 cm
during the pregnancy, and she uses thoracic breathing. Her diaphragm is
elevated and she has an increased costal angle. Which intervention should the
nurse implement?
Record the respiratory finding in the clients chart as normal
A terminally ill male hospice client who is at home is showing decreased
awareness of his surroundings. His appetite is poor and he often refuses oral
intake of solids and liquids. For the past several days he has been unable to get
out of bed. Which action should the hospice nurse implement?
Instruct family to offer client only soft bland foods
A woman was admitted yesterday afternoon with severe abdominal pain. Her
pregnancy test and ultrasound were negative, so an exploratory laparotomy was
completed during the night. When coffee ground materials is observed in the
drainage from the nasogastric tube (NGT), which intervention should the nurse
implement?
Verify correct placement of the nasogastric tube
The nurse is reviewing the laboratory values for a client with acute pancreatitis
who reports of the abdominal pain is not as severe as it was on admission. Which
laboratory test should the nurse review to evaluate the clients clinical recovery?
Lipase
While assessing a client who had a laparotomy the previous day, the nurse
notices that 300 mL of dark red fluid has drained from the nasogastric tube in the
last hour. Which action should the nurse take first?
take vital signs
The nurse is reviewing the recommended preventative care for clients with
asthma, chronic bronchitis, and emphysema. Which health care measure is most
important for the nurse to recommend to these clients?
Avoid large crowded areas during the colder months of the year
The mother of a one-moth-old infant calls the clinic to report that the back of her
infant's head is flat. How should the nurse respond?
Position the infant on the stomach occasionally when awake and active
A woman is brought to the labor and delivery unti after delivering a term infant
and the placenta in the hospital parking lot 10 minutes ago. Which action should
the nurse perform first?
Perform a fundal massage
A client has a new prescription for the maximum recommended dosage of
pipercillin/tazobactam for nosocomial pneumonia. The nurse should report which
laboratory finding to the healthcare provider before administering the prescribed
dose?
Decrease serum creatine
A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating
Kussmaul breathing and has a severe headache along with nausea. Her arterial
blood gases (ABG) are: pH 7.50; PaCO2 30 mmHg; HCO3 24 mEq/L (24mmol/L).
Which assessment finding warrants immediate intervention by the nurse?
Fruity breath
, When performing postural drainage on a client with Chronic Obstructive
Pulmonary disease (COPD), which approach should the nurse use?
Explain that the client may be placed in five positions
A young male client with testicular cancer has a living will that describes his
desire that no extraordinary measures be taken to save his life. The healthcare
provider knows the client has a good prognosis and refuses to write a "do not
resuscitate" (DNR) prescription. Which action should the nurse take?
Initiate an ethics committee review
In observing a clients face, which assessment finding requires the most
immediate intervention by the nurse?
Oral mucosa is cyanotic Blue lips
The nurse is assessing a client with cirrhosis and notes that the client has a
positive Babinski reflex. Which action should the nurse take in response to the
finding?
Complete a thorough neurological assessment
Which action should the nurse take first after obtaining a urine specimen for
culture and sensitivity from an indwelling urinary catheter?
Ensure continued sterility of the specimen container
The home health nurse observes an older client with unilateral weakness place
the walker in front of the chair for support while rising to a standing position.
Which action should the nurse take?
Hold the walker securely to prevent slipping while the client raises
A client with cancer complains of fever, chills, malaise, and headache following
administration of a colony-stimulating factor. Which nursing intervention is most
beneficial in helping to reduce the flu like symptoms?
Monitor lab values for an increase in WBCs
Which laboratory value should the nurse review prior to administering the initial
dose of a statin medication?
Serum liver enzymes
Following a lumbar puncture, a client voices several concerns. Which concern
indicates to the nurse that the client is experiencing a complication of the
procedure?
I have a headache that gets worse when I sit up
The nurse is caring for a client withdrawing from a fentanyl citrate addiction. The
client receives a prescription for clonidine 0.2 mg PO taken twice daily. Which
action should the nurse take?
Advise to sit up slowly from a reclining position
A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic
fever. In obtaining a health history form the child's mother, the recent occurrence
of what illness is most significant?
Sore throat
Following discharge teaching, a client with a duodenal ulcer tells the nurse of
plans to eat plenty of dairy products, such as milk, to help coat and protect their
ulcer. Which is the best follow-up action by the nurse?
Review with the client the need to avoid foods that are rich in milk and cream
QUESTIONS AND VERIFIED ANSWERS|100%
CORRECT| GRADE A+ - NIGHTINGALE
A Neonate who has congenital adrenal hyperplasia CAH presents with ambiguous
genitalia what is the primary nursing consideration when supporting the parents
of the child with this anomaly
offer information about u/s and genotyping to determine sex assignment
The nurse is preparing a teaching plan for an older female client diagnosed with
osteoporosis, which expected outcome has the highest priority
Names three home safely hazards to be resolved immediately
The nurse preparing a client who had a BKA (below the knee amp) for discharge
to home. Which recommendations should the nurse provide this client? (select all
that apply
Inspect skin for redness
●
Use a residual limb shrinker
●
Wash the stump with soap and water
A client's morning assessment includes bounding peripheral pulses, weight gain
of 2 lbs (0.91kg) pitting ankle edema, and moist crackles bilaterally. Which
intervention is most important for the nurse to include in this clien'ts plan of care
Administer prescribed diuretic
The home health nurse visits a client who has cancer. The client reports having a
good appetite but experiencing nausea when smelling food cooking. Which
action should the nurse implement?
Encourage family member to cook meals outdoors and bring the cooked food inside
A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is
admitted with hyponatremia. Which intervention is most important for the nurse
to include in the plan of care to protect the client from injury
Limit fluid intake
The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride
1,000 ml to be infused intravenously over 4 hours. The Iv administration set
delivers 10 gtt/ml. How many gtt/minute should the nurse regulate the infusion
42 1000/4=250 250/60*10
Four hours following surgical repair of a compound fracture of the right ulna, the
nurse is unable to palpate the client's right radial pulse. Which action should the
nurse take first
Elevate the client's right hand on one or two pillows
After placing a 36- week- gestation newborn in an isolette and drying the infant
with several blankets, what should the nurse implement next?
Remove the wet blankets and linen from the isolette
,A client in the third trimester of pregnancy complains of frequent nasal stiffness
and occasional nosebleeds. Her chest circumference has increased by 5 cm
during the pregnancy, and she uses thoracic breathing. Her diaphragm is
elevated and she has an increased costal angle. Which intervention should the
nurse implement?
Record the respiratory finding in the clients chart as normal
A terminally ill male hospice client who is at home is showing decreased
awareness of his surroundings. His appetite is poor and he often refuses oral
intake of solids and liquids. For the past several days he has been unable to get
out of bed. Which action should the hospice nurse implement?
Instruct family to offer client only soft bland foods
A woman was admitted yesterday afternoon with severe abdominal pain. Her
pregnancy test and ultrasound were negative, so an exploratory laparotomy was
completed during the night. When coffee ground materials is observed in the
drainage from the nasogastric tube (NGT), which intervention should the nurse
implement?
Verify correct placement of the nasogastric tube
The nurse is reviewing the laboratory values for a client with acute pancreatitis
who reports of the abdominal pain is not as severe as it was on admission. Which
laboratory test should the nurse review to evaluate the clients clinical recovery?
Lipase
While assessing a client who had a laparotomy the previous day, the nurse
notices that 300 mL of dark red fluid has drained from the nasogastric tube in the
last hour. Which action should the nurse take first?
take vital signs
The nurse is reviewing the recommended preventative care for clients with
asthma, chronic bronchitis, and emphysema. Which health care measure is most
important for the nurse to recommend to these clients?
Avoid large crowded areas during the colder months of the year
The mother of a one-moth-old infant calls the clinic to report that the back of her
infant's head is flat. How should the nurse respond?
Position the infant on the stomach occasionally when awake and active
A woman is brought to the labor and delivery unti after delivering a term infant
and the placenta in the hospital parking lot 10 minutes ago. Which action should
the nurse perform first?
Perform a fundal massage
A client has a new prescription for the maximum recommended dosage of
pipercillin/tazobactam for nosocomial pneumonia. The nurse should report which
laboratory finding to the healthcare provider before administering the prescribed
dose?
Decrease serum creatine
A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating
Kussmaul breathing and has a severe headache along with nausea. Her arterial
blood gases (ABG) are: pH 7.50; PaCO2 30 mmHg; HCO3 24 mEq/L (24mmol/L).
Which assessment finding warrants immediate intervention by the nurse?
Fruity breath
, When performing postural drainage on a client with Chronic Obstructive
Pulmonary disease (COPD), which approach should the nurse use?
Explain that the client may be placed in five positions
A young male client with testicular cancer has a living will that describes his
desire that no extraordinary measures be taken to save his life. The healthcare
provider knows the client has a good prognosis and refuses to write a "do not
resuscitate" (DNR) prescription. Which action should the nurse take?
Initiate an ethics committee review
In observing a clients face, which assessment finding requires the most
immediate intervention by the nurse?
Oral mucosa is cyanotic Blue lips
The nurse is assessing a client with cirrhosis and notes that the client has a
positive Babinski reflex. Which action should the nurse take in response to the
finding?
Complete a thorough neurological assessment
Which action should the nurse take first after obtaining a urine specimen for
culture and sensitivity from an indwelling urinary catheter?
Ensure continued sterility of the specimen container
The home health nurse observes an older client with unilateral weakness place
the walker in front of the chair for support while rising to a standing position.
Which action should the nurse take?
Hold the walker securely to prevent slipping while the client raises
A client with cancer complains of fever, chills, malaise, and headache following
administration of a colony-stimulating factor. Which nursing intervention is most
beneficial in helping to reduce the flu like symptoms?
Monitor lab values for an increase in WBCs
Which laboratory value should the nurse review prior to administering the initial
dose of a statin medication?
Serum liver enzymes
Following a lumbar puncture, a client voices several concerns. Which concern
indicates to the nurse that the client is experiencing a complication of the
procedure?
I have a headache that gets worse when I sit up
The nurse is caring for a client withdrawing from a fentanyl citrate addiction. The
client receives a prescription for clonidine 0.2 mg PO taken twice daily. Which
action should the nurse take?
Advise to sit up slowly from a reclining position
A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic
fever. In obtaining a health history form the child's mother, the recent occurrence
of what illness is most significant?
Sore throat
Following discharge teaching, a client with a duodenal ulcer tells the nurse of
plans to eat plenty of dairy products, such as milk, to help coat and protect their
ulcer. Which is the best follow-up action by the nurse?
Review with the client the need to avoid foods that are rich in milk and cream
