BSN 366 EXIT HESI COMPREHENSIVE STUDY
NOTES AND RATIONALES
◉ A client receives a prescription for acetaminophen 1,000 mg by
mouth every 8 hours as needed for pain. The bottle is labeled
"Acetaminophen for Oral Suspension, USP 500 mg per 15 mL." How
many tablespoons should the nurse instruct the client to take with
each dose? (Enter numerical value only.)
Answer: 2
◉ the nurse observes a client prepare a meal in the kitchen of a
rehabilitation facility prior to discharge. which behaviors indicate
the client understands how to maintain balance safely?
a. brings a heavy can close to body before lifting
b. locks knees while preparing food on the counter
c. widens stance while working near the sink
d. bends from the waist to pick trash off the floor
e. leans forward to pull a pan from a high shelf
Answer: a. brings a heavy can close to body before lifting
c. widens stance while working near the sink
,◉ The RN is assigned to care for four surgical clients. After receiving
the report, which client should the nurse see first?
a. Two days postoperative bladder surgery with continuous bladder
irrigation infusing.
b. One-day postoperative laparoscopic cholecystectomy requesting
pain medication.
c. Three days postoperative colon resection receiving a transfusion
of packed RBCs.
d. Preoperative, in buck's traction, and scheduled for hip
arthroplasty within the next 12 hours
Answer: c. Three days postoperative colon resection receiving a
transfusion of packed RBCs. .
◉ A client is receiving a continuous infusion of the anticoagulant,
heparin, for treatment of a deep vein thrombosis of the right calf.
Which goal should the nurse include in this client's plan of care?
a. No further thrombus will form.
b. The client's INR (international normalized ratio) will be 2.
c. The existing thrombosis will dissolve. d. The circumference of the
client's right calf will decrease.
Answer: a. No further thrombus will form.
,◉ Which information is more important for the nurse to obtain
when determining a client's risk for (OSAS)?
a. Body mass index
b. Level of consciousness
c. Self-description of pain
d. Breath sounds
Answer: a. Body mass index
◉ A client with a prescription for "do not resuscitate" (DNR) begins
to manifest signs of impending death. After notifying the family of
the client's status, what priority action should the nurse implement?
a. The impending signs of death should be documented
b. The client's status should be conveyed to the chaplain
c. The client's need for pain medication should be determined
d. The nurse manager should be updated on the client's status
Answer: c. The client's need for pain medication should be
determined
◉ Which information is more important for the nurse to obtain
when determining a client's risk for (OSAS)?
a. Body mass index
, b. Level of consciousness
c. Self-description of pain
d. Breath sounds
Answer: Body mass index.
◉ The nurse is preparing to obtain a rapid COVID-19 test for a client
who was exposed to the virus eight days ago. The client is
experiencing fever, cough, and shortness of breath. Which action is
the most important for the nurse to take?
a. Counsel family members to monitor for illness symptoms for 2
weeks after last contact with patient
b. Assist the client to recall everyone possibly exposed since onset of
symptoms
c. Start an intravenous infusion for antiviral drug to be administered
for positive COVID-19 test results.
d. Move the client to a private room, keep the door closed, and
initiate droplet precautions.
Answer: d. Move the client to a private room, keep the door closed,
and initiate droplet precautions.
◉ The nurse is preparing an adult with Addison's disease for self-
management. Which information should the nurse include in the
client's instructions?
NOTES AND RATIONALES
◉ A client receives a prescription for acetaminophen 1,000 mg by
mouth every 8 hours as needed for pain. The bottle is labeled
"Acetaminophen for Oral Suspension, USP 500 mg per 15 mL." How
many tablespoons should the nurse instruct the client to take with
each dose? (Enter numerical value only.)
Answer: 2
◉ the nurse observes a client prepare a meal in the kitchen of a
rehabilitation facility prior to discharge. which behaviors indicate
the client understands how to maintain balance safely?
a. brings a heavy can close to body before lifting
b. locks knees while preparing food on the counter
c. widens stance while working near the sink
d. bends from the waist to pick trash off the floor
e. leans forward to pull a pan from a high shelf
Answer: a. brings a heavy can close to body before lifting
c. widens stance while working near the sink
,◉ The RN is assigned to care for four surgical clients. After receiving
the report, which client should the nurse see first?
a. Two days postoperative bladder surgery with continuous bladder
irrigation infusing.
b. One-day postoperative laparoscopic cholecystectomy requesting
pain medication.
c. Three days postoperative colon resection receiving a transfusion
of packed RBCs.
d. Preoperative, in buck's traction, and scheduled for hip
arthroplasty within the next 12 hours
Answer: c. Three days postoperative colon resection receiving a
transfusion of packed RBCs. .
◉ A client is receiving a continuous infusion of the anticoagulant,
heparin, for treatment of a deep vein thrombosis of the right calf.
Which goal should the nurse include in this client's plan of care?
a. No further thrombus will form.
b. The client's INR (international normalized ratio) will be 2.
c. The existing thrombosis will dissolve. d. The circumference of the
client's right calf will decrease.
Answer: a. No further thrombus will form.
,◉ Which information is more important for the nurse to obtain
when determining a client's risk for (OSAS)?
a. Body mass index
b. Level of consciousness
c. Self-description of pain
d. Breath sounds
Answer: a. Body mass index
◉ A client with a prescription for "do not resuscitate" (DNR) begins
to manifest signs of impending death. After notifying the family of
the client's status, what priority action should the nurse implement?
a. The impending signs of death should be documented
b. The client's status should be conveyed to the chaplain
c. The client's need for pain medication should be determined
d. The nurse manager should be updated on the client's status
Answer: c. The client's need for pain medication should be
determined
◉ Which information is more important for the nurse to obtain
when determining a client's risk for (OSAS)?
a. Body mass index
, b. Level of consciousness
c. Self-description of pain
d. Breath sounds
Answer: Body mass index.
◉ The nurse is preparing to obtain a rapid COVID-19 test for a client
who was exposed to the virus eight days ago. The client is
experiencing fever, cough, and shortness of breath. Which action is
the most important for the nurse to take?
a. Counsel family members to monitor for illness symptoms for 2
weeks after last contact with patient
b. Assist the client to recall everyone possibly exposed since onset of
symptoms
c. Start an intravenous infusion for antiviral drug to be administered
for positive COVID-19 test results.
d. Move the client to a private room, keep the door closed, and
initiate droplet precautions.
Answer: d. Move the client to a private room, keep the door closed,
and initiate droplet precautions.
◉ The nurse is preparing an adult with Addison's disease for self-
management. Which information should the nurse include in the
client's instructions?
