BSN 366- V3 Exit Hesi Exam Graded A+
A 1 year-old child is receiving temporary total parental nutrition (TPN) through a central
venous line. This is the first day of TPN therapy. Although all of the following nursing
actions must be included in the plan of care of this child, which one would be a priority
at this time? - ANSWER-Monitor serum glucose levels
A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would
expect the client to have - ANSWER-Heaviness in the affected testicle
A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred
from the hospital to a long term care facility. To which o staff members should the
charge nurse assign the client? - ANSWER-RN
A 52 year-old client is being transfused with one unit of packed cells. A half hour after
the transfusion was initiated, the client complains of chills and headache. Which action
should the nurse implement first? - ANSWER-Stop the transfusion
A 6 year-old child diagnosed with acute glomerulonephritis (AGN) is experiencing
anorexia, moderate edema and elevated blood urea nitrogen (BUN) levels. The child
requests a peanut butter sandwich for lunch. What would the nurse's best response to
this request? - ANSWER-"I know that is your favorite, but let me help you pick another
lunch."
A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a
set of dentures prior to leaving the unit for the operating room. What would be the most
appropriate intervention by the nurse? - ANSWER-Ask the client if the preference would
be to remove the dentures in the operating room receiving area
A 9 year-old is taken to the emergency room with right lower quadrant pain and
vomiting. When preparing the child for an emergency appendectomy, what must the
nurse expect to be the child's greatest fear? - ANSWER-Perceived loss of control
A charge nurse working in a long term care facility is making out assignments. Which
assignment to an unlicensed assistive personnel (UAP), if made by the nurse, requires
intervention by the supervisor? - ANSWER-Teaching a family intermittent (bolus)
feedings via G-tube before discharge
A child is sent to the school nurse by a teacher who has a written note that Fifth's
disease is suspected. Which characteristic would the nurse expect to find? - ANSWER-
Erythema on the face, primarily on cheeks giving a "slapped face" appearance
A child is treated with edetate calcium disodium (Calcium EDTA) for lead poisoning.
Which of these should the nurse assess first ? - ANSWER-Urinary output
, A client admits to benzodiazepine dependence for several years. She is now in an
outpatient detoxification program. The nurse must understand that a priority during
withdrawal is - ANSWER-Avoid alcohol use during this time
A client being treated for hypertension returns to the community clinic for follow up. The
client says, "I know these pills are important, but I just can't take these water pills
anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to
the bathroom." Which of these is the best nursing diagnosis? - ANSWER-
Noncompliance related to medication side effects
A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the
appropriate first action by the nurse? - ANSWER-Maintain the client on bed rest
A client experiences intense anxiety after the home was destroyed by a fire. The client
escaped from the fire with only minor injuries. The nurse knows that the most important
initial intervention would be to: - ANSWER-Determine available community and
personal resources
A client has been admitted with complaints of lower abdominal pain, difficulty
swallowing, nausea, dizziness, headache and fatigue. The client is agitated, fearful,
tachycardic and complains of being "too sick to return to work." The client is diagnosed
as having somatoform disorder. In formulating a plan of care, the nurse must consider
that the client's behavior - ANSWER-Is controlled by their subconscious mind
A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task
could the RN safely delegate to unlicensed assistive personnel (UAP)? - ANSWER-
Perform routine tracheostomy dressing care
A client has just returned from the Post-Anesthesia Care Unit (PACU) to the surgical
unit after a cholecystectomy. When initial vital signs are taken the nurse notes a
temperature of 94.8 degrees Fahrenheit. Which first nursing action is appropriate? -
ANSWER-Apply a warm blanket and check the temperature in 10 minutes
A client is admitted to the hospital because of heart failure and digoxin toxicity. At home,
the client was taking digoxin (Lanoxin) and furosemide (Lasix). Which symptom would
the nurse anticipate finding on the initial assessment? - ANSWER-Muscle weakness
and cramping
A client is admitted to the hospital with a history of confusion. The client has difficulty
remembering recent events and becomes disoriented when away from home. Which
statement would provide the best reality orientation for this client? - ANSWER-"Good
morning. You're in the hospital. I am your nurse Elaine Jones."
A client is being discharged home today, and will be taking K-dur 20mEq per day by
mouth. The nurse should reinforce that potassium levels will be decreased by -
ANSWER-frequent daily snacks of black licorice
A 1 year-old child is receiving temporary total parental nutrition (TPN) through a central
venous line. This is the first day of TPN therapy. Although all of the following nursing
actions must be included in the plan of care of this child, which one would be a priority
at this time? - ANSWER-Monitor serum glucose levels
A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would
expect the client to have - ANSWER-Heaviness in the affected testicle
A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred
from the hospital to a long term care facility. To which o staff members should the
charge nurse assign the client? - ANSWER-RN
A 52 year-old client is being transfused with one unit of packed cells. A half hour after
the transfusion was initiated, the client complains of chills and headache. Which action
should the nurse implement first? - ANSWER-Stop the transfusion
A 6 year-old child diagnosed with acute glomerulonephritis (AGN) is experiencing
anorexia, moderate edema and elevated blood urea nitrogen (BUN) levels. The child
requests a peanut butter sandwich for lunch. What would the nurse's best response to
this request? - ANSWER-"I know that is your favorite, but let me help you pick another
lunch."
A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a
set of dentures prior to leaving the unit for the operating room. What would be the most
appropriate intervention by the nurse? - ANSWER-Ask the client if the preference would
be to remove the dentures in the operating room receiving area
A 9 year-old is taken to the emergency room with right lower quadrant pain and
vomiting. When preparing the child for an emergency appendectomy, what must the
nurse expect to be the child's greatest fear? - ANSWER-Perceived loss of control
A charge nurse working in a long term care facility is making out assignments. Which
assignment to an unlicensed assistive personnel (UAP), if made by the nurse, requires
intervention by the supervisor? - ANSWER-Teaching a family intermittent (bolus)
feedings via G-tube before discharge
A child is sent to the school nurse by a teacher who has a written note that Fifth's
disease is suspected. Which characteristic would the nurse expect to find? - ANSWER-
Erythema on the face, primarily on cheeks giving a "slapped face" appearance
A child is treated with edetate calcium disodium (Calcium EDTA) for lead poisoning.
Which of these should the nurse assess first ? - ANSWER-Urinary output
, A client admits to benzodiazepine dependence for several years. She is now in an
outpatient detoxification program. The nurse must understand that a priority during
withdrawal is - ANSWER-Avoid alcohol use during this time
A client being treated for hypertension returns to the community clinic for follow up. The
client says, "I know these pills are important, but I just can't take these water pills
anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to
the bathroom." Which of these is the best nursing diagnosis? - ANSWER-
Noncompliance related to medication side effects
A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the
appropriate first action by the nurse? - ANSWER-Maintain the client on bed rest
A client experiences intense anxiety after the home was destroyed by a fire. The client
escaped from the fire with only minor injuries. The nurse knows that the most important
initial intervention would be to: - ANSWER-Determine available community and
personal resources
A client has been admitted with complaints of lower abdominal pain, difficulty
swallowing, nausea, dizziness, headache and fatigue. The client is agitated, fearful,
tachycardic and complains of being "too sick to return to work." The client is diagnosed
as having somatoform disorder. In formulating a plan of care, the nurse must consider
that the client's behavior - ANSWER-Is controlled by their subconscious mind
A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task
could the RN safely delegate to unlicensed assistive personnel (UAP)? - ANSWER-
Perform routine tracheostomy dressing care
A client has just returned from the Post-Anesthesia Care Unit (PACU) to the surgical
unit after a cholecystectomy. When initial vital signs are taken the nurse notes a
temperature of 94.8 degrees Fahrenheit. Which first nursing action is appropriate? -
ANSWER-Apply a warm blanket and check the temperature in 10 minutes
A client is admitted to the hospital because of heart failure and digoxin toxicity. At home,
the client was taking digoxin (Lanoxin) and furosemide (Lasix). Which symptom would
the nurse anticipate finding on the initial assessment? - ANSWER-Muscle weakness
and cramping
A client is admitted to the hospital with a history of confusion. The client has difficulty
remembering recent events and becomes disoriented when away from home. Which
statement would provide the best reality orientation for this client? - ANSWER-"Good
morning. You're in the hospital. I am your nurse Elaine Jones."
A client is being discharged home today, and will be taking K-dur 20mEq per day by
mouth. The nurse should reinforce that potassium levels will be decreased by -
ANSWER-frequent daily snacks of black licorice
