BSN366 EXIT HESI QUESTIONS AND
ANSWERS RATED A+
A child with peripheral edema who weighs 44 pounds receives a prescription for
furosemide 2 mg/kg IV every 12 hours. The vile is labeled 10 mg/mL. How many
milliliters should the nurse administer? (Enter numeric value only) - ANSWER-4mL
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. - ANSWER-A) Current
diagnosis of hepatitis B.
A client is being discharged with a prescription for warfarin. Which instruction should the
nurse provide this client regarding diet?
A) Avoid eating of foods that contain any vitamin K because it is an antagonist of
warfarin.
B) Increase the intake of dark green leafy vegetables while taking warfarin.
C) Eat approximately the same amount of leafy green vegetables daily so the amount of
vitamin K consumed is consistent.
D) Eat two servings of raw dark green leafy vegetables daily and continue for 30 days
after warfarin therapy is completed. - ANSWER-C) Eat approximately the same amount
of leafy green vegetables daily so the amount of vitamin K consumed is consistent.
A client is receiving lactulose for signs of hepatic and cephalopathy. To evaluate the
clients therapeutic response to this medication, which assessment should the nurse
obtain?
A) Blood glucose level.
B) Percussion of abdomen.
C) Serum electrolytes.
D) Level of consciousness. - ANSWER-D) Level of consciousness.
A client receives a prescription for norepinephrine three MCG per minute IV. The IV bag
contains norepinephrine 4 mg in dextrose 5% in water 1000 mL (D5W). How many
milliliters per hour should the nurse program the infusion pump? (Enter numerical value
only) - ANSWER-45
,A client recovering from pneumonia who has a history of severe chronic obstructive
pulmonary disease and peripheral vascular disease is being discharged from the skilled
nursing facility. Which action is most important for the nurse to implement?
A) Explain exercise daily regimen.
B) Demonstrate specific strengthening exercises.
C) Provide typed instructions for healthy diet selection.
D) Reinforce need for adequate hydration. - ANSWER-C) Provide typed instructions for
healthy diet selection.
A client who is hypotensive is receiving dopamine, an adrenergic agonist, ivy at the rate
of 8mcg/kg/min. Which intervention should the nurse implement while administering this
medication?
A) Measure urinary output every hour.
B) Initiate seizure precautions.
C) Monitor serum potassium frequently.
D) Assess pupillary response to light hourly. - ANSWER-A) Measure urinary output
every hour.
A client who weighs 176 pounds receives a prescription for enoxaparin sodium
1.5mg/kg/day subcutaneously. The medication is available in 120mg/0.8mL prefilled
syringe. How many milliliters should the nurse administer? Enter numerical value only. -
ANSWER-0.8
A client with a history of dementia has become increasingly confused at night and is
picking at an abdominal surgical dressing and the tape securing the IV line. The
abdominal dressing is no longer inclusive, and the IV insertion site is pink. Which
intervention should the nurse implement?
A) Leave the lights on in the room at night.
B) Re-dress the abdominal incision.
C) Apply soft bilateral wrist restraints.
D) Replace the IV site with a smaller gauge. - ANSWER-B) Re-dress the abdominal
incision.
A client with a prescription for do not resuscitate begins to manifest signs of impending
death. After notifying the family of the client status, what priority action should the nurse
implement?
A) The nurse manager should be updated on the client status.
B) The client status should be conveyed to the chaplain.
C) The impending signs of death should be documented.
D) The clients need for pain medication should be determined. - ANSWER-D) The
clients need for pain medication should be determined.
,A client with cancer develops tumor lysis syndrome following chemotherapy. Which
nursing action has the highest priority in responding to the symptoms of the syndrome?
A) Instruct the client to take analgesics on a regular schedule.
B) Encouraged the client to verbalize anxiety and grief.
C) Maintain IV therapy.
D) Identify potential sources of infection. - ANSWER-C) Maintain IV therapy.
A client with cirrhosis of the liver is admitted with complications related to end-stage
liver disease. Which interventions should the nurse implement? SATA.
A) Report serum albumin and globulin levels.
B) Provide diet low in phosphorus.
C) Increase oral fluid intake to 1500 mL daily.
D) No signs of swelling and edema.
E) Monitor abdominal girth. - ANSWER-A) Report serum albumin and globulin levels.
D) No signs of swelling and edema.
E) Monitor abdominal girth.
A client with influenza needs help in transferring to the bedside commode. The nurse
observes the unlicensed assistive personnel donning gloves and a gown to assist the
client. Which action should the nurse take?
A) Remind the UP to apply a fitted respirator mask before entering the clients room.
B) Assign the UP to provide care for another client and assume full care of the client.
C) Instruct the UP to notify the nurse of any changes in the clients respiratory status.
D) Review the need for the UPA to wear a facemask while in close contact with the
client - ANSWER-D) Review the need for the UPA to wear a facemask while in close
contact with the client
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. - ANSWER-A) Apply the clients positive
airway pressure device.
A client with pancreatitis complains of severe epigastric pain, so the nurse administers a
prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and
leaning forward. Which intervention should the nurse implement?
A) Rains HOB to 90 degrees
B) Position bedside table so the client can lean across it
C) Place bed in a reverse tren posiiton
, D) Encourage rest until the analgesic becomes effective. - ANSWER-B) Position
bedside table so the client can lean across it
A client with schizophrenia reports auditory hallucinations when admitted to the hospital.
What question is most important for the nurse to include in the assessment of this
client?
A) What are the voices saying?
B) Which medication works best?
C) When do you hear voices?
D) How do you cope with the voices? - ANSWER-A) What are the voices saying?
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. - ANSWER-B) Arrange an appointment
with a pain specialist.
A male client admitted with chronic pulmonary obstruction disease exacerbation is
receiving assisted ventilation with continuous positive airway pressure. His vital signs
are temperature 98.8 F, heart rate 118 bpm, respirations 46 breaths per minute, blood
pressure 176/92. While completing the pulmonary assessment, his oxygen saturation
reading is 78% and he is difficult to arouse. Which action should the nurse implement?
A) Prepare for rapid sequence intubation.
B) Increase the oxygen delivery by 10%.
C) Administer PRN nebulizer treatment.
D) Complete neurological assessment. - ANSWER-A) Prepare for rapid sequence
intubation.
A male client is admitted for the removal of an internal fix ation device that was inserted
for a fractured ankle. During the clients admission history, he tells the nurse that he
recently received vancomycin for a methicillin-resistant staphylococcus aureus (MRSA)
wound infection. Which actions should the nurse take? SATA.
A) Collect multiple site screening cultures for MRSA.
B) Place the client on contact transmission precautions.
C) Call healthcare provider for a prescription of linezolid.
D) Obtain a sputum specimen for culture and sensitivity.
E) Continue to monitor the client for signs of an infection - ANSWER-A) Collect multiple
site screening cultures for MRSA.
B) Place the client on contact transmission precautions.
ANSWERS RATED A+
A child with peripheral edema who weighs 44 pounds receives a prescription for
furosemide 2 mg/kg IV every 12 hours. The vile is labeled 10 mg/mL. How many
milliliters should the nurse administer? (Enter numeric value only) - ANSWER-4mL
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. - ANSWER-A) Current
diagnosis of hepatitis B.
A client is being discharged with a prescription for warfarin. Which instruction should the
nurse provide this client regarding diet?
A) Avoid eating of foods that contain any vitamin K because it is an antagonist of
warfarin.
B) Increase the intake of dark green leafy vegetables while taking warfarin.
C) Eat approximately the same amount of leafy green vegetables daily so the amount of
vitamin K consumed is consistent.
D) Eat two servings of raw dark green leafy vegetables daily and continue for 30 days
after warfarin therapy is completed. - ANSWER-C) Eat approximately the same amount
of leafy green vegetables daily so the amount of vitamin K consumed is consistent.
A client is receiving lactulose for signs of hepatic and cephalopathy. To evaluate the
clients therapeutic response to this medication, which assessment should the nurse
obtain?
A) Blood glucose level.
B) Percussion of abdomen.
C) Serum electrolytes.
D) Level of consciousness. - ANSWER-D) Level of consciousness.
A client receives a prescription for norepinephrine three MCG per minute IV. The IV bag
contains norepinephrine 4 mg in dextrose 5% in water 1000 mL (D5W). How many
milliliters per hour should the nurse program the infusion pump? (Enter numerical value
only) - ANSWER-45
,A client recovering from pneumonia who has a history of severe chronic obstructive
pulmonary disease and peripheral vascular disease is being discharged from the skilled
nursing facility. Which action is most important for the nurse to implement?
A) Explain exercise daily regimen.
B) Demonstrate specific strengthening exercises.
C) Provide typed instructions for healthy diet selection.
D) Reinforce need for adequate hydration. - ANSWER-C) Provide typed instructions for
healthy diet selection.
A client who is hypotensive is receiving dopamine, an adrenergic agonist, ivy at the rate
of 8mcg/kg/min. Which intervention should the nurse implement while administering this
medication?
A) Measure urinary output every hour.
B) Initiate seizure precautions.
C) Monitor serum potassium frequently.
D) Assess pupillary response to light hourly. - ANSWER-A) Measure urinary output
every hour.
A client who weighs 176 pounds receives a prescription for enoxaparin sodium
1.5mg/kg/day subcutaneously. The medication is available in 120mg/0.8mL prefilled
syringe. How many milliliters should the nurse administer? Enter numerical value only. -
ANSWER-0.8
A client with a history of dementia has become increasingly confused at night and is
picking at an abdominal surgical dressing and the tape securing the IV line. The
abdominal dressing is no longer inclusive, and the IV insertion site is pink. Which
intervention should the nurse implement?
A) Leave the lights on in the room at night.
B) Re-dress the abdominal incision.
C) Apply soft bilateral wrist restraints.
D) Replace the IV site with a smaller gauge. - ANSWER-B) Re-dress the abdominal
incision.
A client with a prescription for do not resuscitate begins to manifest signs of impending
death. After notifying the family of the client status, what priority action should the nurse
implement?
A) The nurse manager should be updated on the client status.
B) The client status should be conveyed to the chaplain.
C) The impending signs of death should be documented.
D) The clients need for pain medication should be determined. - ANSWER-D) The
clients need for pain medication should be determined.
,A client with cancer develops tumor lysis syndrome following chemotherapy. Which
nursing action has the highest priority in responding to the symptoms of the syndrome?
A) Instruct the client to take analgesics on a regular schedule.
B) Encouraged the client to verbalize anxiety and grief.
C) Maintain IV therapy.
D) Identify potential sources of infection. - ANSWER-C) Maintain IV therapy.
A client with cirrhosis of the liver is admitted with complications related to end-stage
liver disease. Which interventions should the nurse implement? SATA.
A) Report serum albumin and globulin levels.
B) Provide diet low in phosphorus.
C) Increase oral fluid intake to 1500 mL daily.
D) No signs of swelling and edema.
E) Monitor abdominal girth. - ANSWER-A) Report serum albumin and globulin levels.
D) No signs of swelling and edema.
E) Monitor abdominal girth.
A client with influenza needs help in transferring to the bedside commode. The nurse
observes the unlicensed assistive personnel donning gloves and a gown to assist the
client. Which action should the nurse take?
A) Remind the UP to apply a fitted respirator mask before entering the clients room.
B) Assign the UP to provide care for another client and assume full care of the client.
C) Instruct the UP to notify the nurse of any changes in the clients respiratory status.
D) Review the need for the UPA to wear a facemask while in close contact with the
client - ANSWER-D) Review the need for the UPA to wear a facemask while in close
contact with the client
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. - ANSWER-A) Apply the clients positive
airway pressure device.
A client with pancreatitis complains of severe epigastric pain, so the nurse administers a
prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and
leaning forward. Which intervention should the nurse implement?
A) Rains HOB to 90 degrees
B) Position bedside table so the client can lean across it
C) Place bed in a reverse tren posiiton
, D) Encourage rest until the analgesic becomes effective. - ANSWER-B) Position
bedside table so the client can lean across it
A client with schizophrenia reports auditory hallucinations when admitted to the hospital.
What question is most important for the nurse to include in the assessment of this
client?
A) What are the voices saying?
B) Which medication works best?
C) When do you hear voices?
D) How do you cope with the voices? - ANSWER-A) What are the voices saying?
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. - ANSWER-B) Arrange an appointment
with a pain specialist.
A male client admitted with chronic pulmonary obstruction disease exacerbation is
receiving assisted ventilation with continuous positive airway pressure. His vital signs
are temperature 98.8 F, heart rate 118 bpm, respirations 46 breaths per minute, blood
pressure 176/92. While completing the pulmonary assessment, his oxygen saturation
reading is 78% and he is difficult to arouse. Which action should the nurse implement?
A) Prepare for rapid sequence intubation.
B) Increase the oxygen delivery by 10%.
C) Administer PRN nebulizer treatment.
D) Complete neurological assessment. - ANSWER-A) Prepare for rapid sequence
intubation.
A male client is admitted for the removal of an internal fix ation device that was inserted
for a fractured ankle. During the clients admission history, he tells the nurse that he
recently received vancomycin for a methicillin-resistant staphylococcus aureus (MRSA)
wound infection. Which actions should the nurse take? SATA.
A) Collect multiple site screening cultures for MRSA.
B) Place the client on contact transmission precautions.
C) Call healthcare provider for a prescription of linezolid.
D) Obtain a sputum specimen for culture and sensitivity.
E) Continue to monitor the client for signs of an infection - ANSWER-A) Collect multiple
site screening cultures for MRSA.
B) Place the client on contact transmission precautions.
