BSN 366 EXIT HESI (SPRING '25) QUESTIONS &
ANSWERS
The nurse is planning discharge instructions for a client with type 2 diabetes who will be
starting Exenatide. Which information should be included in the discharge instructions?
A. Exenatide acts in the same way as insulin in lowering blood glucose.
B. Inject exenatide within 30 minutes before or after a meal.
C. There are no precautions when taking Exenatide with other medications.
D. Notify your healthcare provider if you start having abdominal pain. - Answers -D.
Notify your healthcare provider if you start having abdominal pain.
Case Study: The client is in the hospital after her house collapsed during a hurricane.
She has been in the intensive care unit for 2 weeks and moved today to the surgical
floor to continue monitoring her respiratory function and to complete intravenous
antibiotic administration.
1. Click to highlight the aspects of the assessment that require urgent attention:
The client's pain is 2/10. The client requests sleeping medication for the night. She
states she has horrible thoughts and memories about the house collapsing all the time,
and that it is keeping her from falling asleep. She states "I used to be so happy before
all of this happened. Now I can;t seem to get out of this funk I am in." The client would
also prefer to be in a quieter area of the unit as she is currently by the nurses station
and hears talking and alarms constantly. - Answers --She states she has horrible
thoughts and memories about the house collapsing all the time.
- it is keeping her from falling asleep.
-prefers to be in a quieter area of the unit.
Case Study: The client is in the hospital after her house collapsed during a hurricane.
She has been in the intensive care unit for 2 weeks and moved today to the surgical
floor to continue monitoring her respiratory function and to complete intravenous
antibiotic administration.
2. Drag from the options to complete the sentence:
After listening to the clients symptoms, the nurse realizes that she likely
has______________ related to _______________ - Answers -Acute Stress Disorder,
Traumatic Stress exposure
Case Study: The client is in the hospital after her house collapsed during a hurricane.
She has been in the intensive care unit for 2 weeks and moved today to the surgical
floor to continue monitoring her respiratory function and to complete intravenous
antibiotic administration.
,3. Click to specify which client statement of behaviors is most likely associated with
each of the listed defense mechanism. Some statements or behaviors may be
consistent with more than one mechanism. Each column must have at least one but
may have more than one answer selected. - Answers -
Case Study: The client is in the hospital after her house collapsed during a hurricane.
She has been in the intensive care unit for 2 weeks and moved today to the surgical
floor to continue monitoring her respiratory function and to complete intravenous
antibiotic administration.
4. What nursing reviews the physicians orders for Clonazepam and gives the
medication as ordered. (SATA)
a. monitor calcium levels
b. assist the client to the bathroom
c. screen for orthostatic hypotension
d. assess mental status regularly
e. provide oral care at least twice a day
f. have an opioid agonist at the bedside - Answers -b. assist the client to the bathroom
d. assess mental status regularly
Case Study: The client is in the hospital after her house collapsed during a hurricane.
She has been in the intensive care unit for 2 weeks and moved today to the surgical
floor to continue monitoring her respiratory function and to complete intravenous
antibiotic administration.
5. What other treatment might be helpful for this client? SATA
a. animal therapy
b. administration of lithium
c. consciousness-raising
d. phototherapy
e. electroconvulsive therapy
f. cognitive behavioral therapy - Answers -a. animal therapy
c. consciousness-raising
f. cognitive behavioral therapy
Case Study: The client is in the hospital after her house collapsed during a hurricane.
She has been in the intensive care unit for 2 weeks and moved today to the surgical
floor to continue monitoring her respiratory function and to complete intravenous
antibiotic administration.
6. For each client statement, click to highlight the statement(s) below that require follow
up teaching by the nurse.
a. "this diagnosis means that I am crazy"
b. " I can learn to manage my thoughts better through therapy"
c. "I can use holistic approaches like medication to help my symptoms"
d. "Many people have the same response to a stressful situation as I am having right"
,e. "I am at high risk for post-traumatic-stress disorder because I have acute stress
disorder"
f. " I will probably need to be on medication for the rest of my life" - Answers -a. "this
diagnosis means that I am crazy"
b. " I can learn to manage my thoughts better through therapy"
f. " I will probably need to be on medication for the rest of my life"
A client with foul-smelling drainage from an incision on the upper left arm is admitted
with a suspected methicillin-resistant Staphylococcus aureus (MRSA). What nursing
interventions should the nurse include in the plan of care? Select all that apply
a. Explain the purpose of a low-bacteria diet
b. Send wound drainage for culture and sensitivity
c. Institute contact precautions for staff and visitors
d. Use standard precautions and wear a mask
e. Monitor the clients white blood cell count - Answers -b. Send wound drainage for
culture and sensitivity
c. Institute contact precautions for staff and visitors
e. Monitor the clients white blood cell count
An older adult client who has difficulty hearing is being discharged form surgery
following cataract extraction and lens implantation. Which intervention is most important
for the nurse to implement to ensure the clients compliance with self-care.
a. Provide written instructions for eye drop administration
b. Speak clearly and face the client for lip reading
c. Have the client vocalize the instructions provided
d. Ensure that someone will stay with the client for 24 hours - Answers -a. Provide
written instructions for eye drop administration
When assessing a client with an ionized calcium level of 15 mg/dL (4.25 mmol/L), which
intervention is most important for the nurse to implement Reference Range Ionized
calcium [ adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)
a. Compare muscle strength bilaterally b. Assess strength of deep tendon reflexes
c. Determine apical pulse rate and rhythm
d. Observe color and amount of urine - Answers -c. Determine apical pulse rate and
rhythm
While changing a client postoperative dressing, the nurse observes purulent drainage at
the wound. Before reporting this to the healthcare provider, the nurse should note which
of the client's laboratory results
a. Creatinine level
b. Platelet count
c. Hematocrit
, d. White blood cell (WBC) count - Answers -d. White blood cell (WBC) count
A client receiving "Heparin sodium 25,000 units in 250 mL 5% dextrose" IV at 7 ml/hour.
The healthcare provider changes the prescription to 900 units/hour. The nurse should
program the infusion pump to deliver at how many mL/hour? - Answers -Answer: 9
The nurse is caring for a client with pneumonia who now develops initial signs of septic
shock and multi-organ failure. The healthcare provider prescribes a sepsis protocol.
Which intervention is most important for the nurse to include in the plan of care?
a. Maintain a strict intake and output
b. Keep head of bed raised to 45 degrees
c. Assess warmth in extremities
d. Monitor blood glucose levels - Answers -a. Maintain a strict intake and output
A client is receiving Mesalamine 800 mg PO three times a day. Which assessment
should the nurse perform to assess the effectiveness of the medication?
A. Bowel patterns
B. Pupillary response
C. Peripheral pulses
D. Oxygen saturation - Answers -A. Bowel patterns
The nurse if providing teaching to a client with type 2 diabetes (DM) about managing
care at home. Which information provided by the client indicates an understanding of
the teaching?
a. Ensure carbohydrate intake to be 35 % of total calories
b. Get an eye examination with an ophthalmologist annually.
c. Using salt, herbs, and spices will improve the flavor of foods
d. Check blood sugar levels every 4 to 6 hours every day. - Answers -b. Get an eye
examination with an ophthalmologist annually.
Which is the best approach for the nurse to use when interviewing the client for sexual
abuse?
a. Ask the question in a vague, non-specific format
b. Get the most difficult questions over with first
c. Begin with questions that are less sensitive in nature
d. Share personal values to put the client at ease - Answers -c. Begin with questions
that are less sensitive in nature.
A client is admitted with an exacerbation of heart failure secondary to COPD. Which
observations by the nurse require immediate intervention to reduce the likelihood of
harm to this client? Select all that apply
ANSWERS
The nurse is planning discharge instructions for a client with type 2 diabetes who will be
starting Exenatide. Which information should be included in the discharge instructions?
A. Exenatide acts in the same way as insulin in lowering blood glucose.
B. Inject exenatide within 30 minutes before or after a meal.
C. There are no precautions when taking Exenatide with other medications.
D. Notify your healthcare provider if you start having abdominal pain. - Answers -D.
Notify your healthcare provider if you start having abdominal pain.
Case Study: The client is in the hospital after her house collapsed during a hurricane.
She has been in the intensive care unit for 2 weeks and moved today to the surgical
floor to continue monitoring her respiratory function and to complete intravenous
antibiotic administration.
1. Click to highlight the aspects of the assessment that require urgent attention:
The client's pain is 2/10. The client requests sleeping medication for the night. She
states she has horrible thoughts and memories about the house collapsing all the time,
and that it is keeping her from falling asleep. She states "I used to be so happy before
all of this happened. Now I can;t seem to get out of this funk I am in." The client would
also prefer to be in a quieter area of the unit as she is currently by the nurses station
and hears talking and alarms constantly. - Answers --She states she has horrible
thoughts and memories about the house collapsing all the time.
- it is keeping her from falling asleep.
-prefers to be in a quieter area of the unit.
Case Study: The client is in the hospital after her house collapsed during a hurricane.
She has been in the intensive care unit for 2 weeks and moved today to the surgical
floor to continue monitoring her respiratory function and to complete intravenous
antibiotic administration.
2. Drag from the options to complete the sentence:
After listening to the clients symptoms, the nurse realizes that she likely
has______________ related to _______________ - Answers -Acute Stress Disorder,
Traumatic Stress exposure
Case Study: The client is in the hospital after her house collapsed during a hurricane.
She has been in the intensive care unit for 2 weeks and moved today to the surgical
floor to continue monitoring her respiratory function and to complete intravenous
antibiotic administration.
,3. Click to specify which client statement of behaviors is most likely associated with
each of the listed defense mechanism. Some statements or behaviors may be
consistent with more than one mechanism. Each column must have at least one but
may have more than one answer selected. - Answers -
Case Study: The client is in the hospital after her house collapsed during a hurricane.
She has been in the intensive care unit for 2 weeks and moved today to the surgical
floor to continue monitoring her respiratory function and to complete intravenous
antibiotic administration.
4. What nursing reviews the physicians orders for Clonazepam and gives the
medication as ordered. (SATA)
a. monitor calcium levels
b. assist the client to the bathroom
c. screen for orthostatic hypotension
d. assess mental status regularly
e. provide oral care at least twice a day
f. have an opioid agonist at the bedside - Answers -b. assist the client to the bathroom
d. assess mental status regularly
Case Study: The client is in the hospital after her house collapsed during a hurricane.
She has been in the intensive care unit for 2 weeks and moved today to the surgical
floor to continue monitoring her respiratory function and to complete intravenous
antibiotic administration.
5. What other treatment might be helpful for this client? SATA
a. animal therapy
b. administration of lithium
c. consciousness-raising
d. phototherapy
e. electroconvulsive therapy
f. cognitive behavioral therapy - Answers -a. animal therapy
c. consciousness-raising
f. cognitive behavioral therapy
Case Study: The client is in the hospital after her house collapsed during a hurricane.
She has been in the intensive care unit for 2 weeks and moved today to the surgical
floor to continue monitoring her respiratory function and to complete intravenous
antibiotic administration.
6. For each client statement, click to highlight the statement(s) below that require follow
up teaching by the nurse.
a. "this diagnosis means that I am crazy"
b. " I can learn to manage my thoughts better through therapy"
c. "I can use holistic approaches like medication to help my symptoms"
d. "Many people have the same response to a stressful situation as I am having right"
,e. "I am at high risk for post-traumatic-stress disorder because I have acute stress
disorder"
f. " I will probably need to be on medication for the rest of my life" - Answers -a. "this
diagnosis means that I am crazy"
b. " I can learn to manage my thoughts better through therapy"
f. " I will probably need to be on medication for the rest of my life"
A client with foul-smelling drainage from an incision on the upper left arm is admitted
with a suspected methicillin-resistant Staphylococcus aureus (MRSA). What nursing
interventions should the nurse include in the plan of care? Select all that apply
a. Explain the purpose of a low-bacteria diet
b. Send wound drainage for culture and sensitivity
c. Institute contact precautions for staff and visitors
d. Use standard precautions and wear a mask
e. Monitor the clients white blood cell count - Answers -b. Send wound drainage for
culture and sensitivity
c. Institute contact precautions for staff and visitors
e. Monitor the clients white blood cell count
An older adult client who has difficulty hearing is being discharged form surgery
following cataract extraction and lens implantation. Which intervention is most important
for the nurse to implement to ensure the clients compliance with self-care.
a. Provide written instructions for eye drop administration
b. Speak clearly and face the client for lip reading
c. Have the client vocalize the instructions provided
d. Ensure that someone will stay with the client for 24 hours - Answers -a. Provide
written instructions for eye drop administration
When assessing a client with an ionized calcium level of 15 mg/dL (4.25 mmol/L), which
intervention is most important for the nurse to implement Reference Range Ionized
calcium [ adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)
a. Compare muscle strength bilaterally b. Assess strength of deep tendon reflexes
c. Determine apical pulse rate and rhythm
d. Observe color and amount of urine - Answers -c. Determine apical pulse rate and
rhythm
While changing a client postoperative dressing, the nurse observes purulent drainage at
the wound. Before reporting this to the healthcare provider, the nurse should note which
of the client's laboratory results
a. Creatinine level
b. Platelet count
c. Hematocrit
, d. White blood cell (WBC) count - Answers -d. White blood cell (WBC) count
A client receiving "Heparin sodium 25,000 units in 250 mL 5% dextrose" IV at 7 ml/hour.
The healthcare provider changes the prescription to 900 units/hour. The nurse should
program the infusion pump to deliver at how many mL/hour? - Answers -Answer: 9
The nurse is caring for a client with pneumonia who now develops initial signs of septic
shock and multi-organ failure. The healthcare provider prescribes a sepsis protocol.
Which intervention is most important for the nurse to include in the plan of care?
a. Maintain a strict intake and output
b. Keep head of bed raised to 45 degrees
c. Assess warmth in extremities
d. Monitor blood glucose levels - Answers -a. Maintain a strict intake and output
A client is receiving Mesalamine 800 mg PO three times a day. Which assessment
should the nurse perform to assess the effectiveness of the medication?
A. Bowel patterns
B. Pupillary response
C. Peripheral pulses
D. Oxygen saturation - Answers -A. Bowel patterns
The nurse if providing teaching to a client with type 2 diabetes (DM) about managing
care at home. Which information provided by the client indicates an understanding of
the teaching?
a. Ensure carbohydrate intake to be 35 % of total calories
b. Get an eye examination with an ophthalmologist annually.
c. Using salt, herbs, and spices will improve the flavor of foods
d. Check blood sugar levels every 4 to 6 hours every day. - Answers -b. Get an eye
examination with an ophthalmologist annually.
Which is the best approach for the nurse to use when interviewing the client for sexual
abuse?
a. Ask the question in a vague, non-specific format
b. Get the most difficult questions over with first
c. Begin with questions that are less sensitive in nature
d. Share personal values to put the client at ease - Answers -c. Begin with questions
that are less sensitive in nature.
A client is admitted with an exacerbation of heart failure secondary to COPD. Which
observations by the nurse require immediate intervention to reduce the likelihood of
harm to this client? Select all that apply
