BSN 366 exit HESI Questions with Verified
Correct Answers
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
Correct Answers
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
