BSN HESI 366 RN Exit Exam V2 (Latest 2024/ 2025 Update) Questions and Verified Answers|100% Correct| Grade A- Nightingale

BSN HESI 366 RN Exit Exam V2 (Latest 2024/ 2025 Update) Questions and Verified Answers|100% Correct| Grade A- Nightingale Q: A client with a traumatic brain injury becomes progressively less respon- sive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UP) has stopped turning the client from side to side as previously scheduled. What action should the nurse take? A Encourage the UP to provide comfort care measures only. B Assign a practical nurse to assist the UP in turning the client. C Advise the UP to resume positioning the client on schedule. D Assume total care of the client to monitor neurologic function. Answer: C Advise the UP to resume positioning the client on schedule. - The DNR prescription does not mean the client should not receive routine care and interventions to maintain their comfort. Q: Which laboratory test result is most important for the nurse to report to the surgeon prior lo a client's scheduled hernia repair? Reference Ranges: Blood glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)] Serum creatinine [0.5 to 1.1 mg/dL (44 to 97 µmol/L)] Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)] Hemoglobin (Hgb) (12 to 16 g/dL (120 to 160 g/L)] A Blood glucose of 90 mg/dL (5 mmol/L). B Serum creatinine of 5 mg/d (442 µmol/L). C Potassium level of 4 mEq/L (4 mmol/L). D Hemoglobin level of 13 g/dL (130 g/L). Answer: B Serum creatinine of 5 mg/d (442 µmol/L). - A serum creatinine of 5 mg/dl is indicative of severe kidney failure, which could possibly prompt a delay of the surgery. Q: The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period? A Provide an eye shield to be worn while sleeping. B Encourage deep breathing and coughing exercises. C Teach a family member to administer eye drops. D Obtain vital signs every 2 hours during hospitalization. Answer: A Provide an eye shield to be worn while sleeping. - After retinal detachment surgery, it is crucial to protect the eye and the surgical repair site from accidental trauma or pressure. Providing an eye shield helps to shield the eye during sleep when the client may not have conscious control over their movements. Q: When teaching a group of school-aged children how to reduce the risk for Lyme disease, which Instruction should the camp nurse include? A Wear long sleeves and pants. B Avoid drinking lake water. C Wash hands frequently. D Do not share personal products. Answer: A Wear long sleeves and pants. - Lyme disease is transmitted through tick bites, and sleeves and pants can prevent tick bites.Typical symptoms include fever, headache, fatigue, and a characteristic skin rash called erythema migrans. Q: The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? Select all that apply. A White blood cell (WBC) count. B Red blood cell (RBC) count. C Sputum culture and sensitivity. D Urinalysis. E Blood urea nitrogen (BUN). F Serum potassium. Answer: A White blood cell (WBC) count. - A high WBC count can signify an infection or inflammation. If the treatment is effective, the WBC count should start to normalize as the infection is controlled. C Sputum culture and sensitivity. - This test identifies the specific bacteria causing the respiratory tract infection and determines which antibiotics are effective against it. Monitoring the results of sputum culture and sensitivity tests can help evaluate if the prescribed antibiotic is effective against the identified pathogen. Adjustments to the antibiotic regimen may be necessary based on these results. Q: The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take? A Suggest contacting the healthcare provider for a prescription for catheter insertion. B Recommend a complete bath to cleanse the perineal area more fully. C Evaluate the effectiveness of this measure to stimulate client voiding. D Instruct the PN that this technique promotes infection in elderly females. Answer: C Evaluate the effectiveness of this measure to stimulate client voiding. - Stimulation methods can include pulling on the pubic hairs, massaging the lower stomach, or the inner thighs. Provide the patient with routine voiding measures including privacy, normal voiding positions, or the sound of running water. Also lightly tapping over the bladder. Q: An older adult client arrives to the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement? A Provide protective undergarments for the client. B Obtain a clean, voided urine specimen for analysis. C Evaluate the client's response to bladder training efforts. D Encourage increased fluid intake for 24 hours. Answer: B Obtain a clean, voided urine specimen for analysis. - Urinalysis can help identify whether there is a urinary tract infection (UTI), hema- turia, or other abnormalities that may be contributing to the incontinence. The other options do not address the underlying cause. Q: The nurse-manager is involved in agency restructuring. During this re-en- gineering process, it is most important for the nurse to address which employ- ee concern? A Changes in job descriptions. B New management's expectations. C Potential changes in employee benefits. D Employees job security. Answer: D Employees job security. - Addressing job security can help to alleviate some of the stress and uncertainty that employees may feel during the restructuring process. By ensuring that employees feel secure in their jobs, the nurse-manager can maintain morale and productivity, which are crucial for a successful transition Q: A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the clients care? A Depression. B Peripheral neuropathy. C Confusion. D Right lower abdominal pain. Answer: C Confusion. - Wernicke's syndrome, part of Wernicke-Korsakoff syndrome, is primarily characterized by confusion due to brain damage, particularly in the lower parts of the brain such as the thalamus and hypothalamus, caused by a lack of vitamin B1 (thiamine). Symptoms of Wernicke encephalopathy include confusion and loss of mental activity that can progress to coma and death. Q: A pre-school age child with a congenital heart defect is brought to the clinic by the parent because of a fever and an earache. During the assessment, the parent asks the nurse why the child is at the 5th percentile for weight and height for age. Which response Is best for the nurse to provide? A "You should not worry about the growth tables. They are only averages for children." B "Haven't you been feeding according to recommended daily allowances for children?" C "Does your child seem mentally slower than his peers also?" D "The smaller size is probably due to the heart disease." Answer: D "The smaller size is probably due to the heart disease." - This can be due to several factors related to their heart condition, such as de- creased oxygen and nutrient delivery to tissues, increased energy expenditure, and possibly reduced food intake due to increased work of breathing or fatigue. Providing the parent with this information helps to address their concern with a valid medical explanation, reassuring them that the child's smaller size can be a common issue related to their heart condition and not necessarily indicative of inadequate care or other unrelated health issues. This response is informative and compassionate, aiming to alleviate the parent's worries by explaining a possible cause for the child's growth pattern. Q: A client has a prescription for the insertion of a nasogastric tube to low intermittent suction. When inserting the nasogastric tube, the nurse observes an immediate return of "coffee-ground" drainage. Which action should the nurse implement? A Immediately remove and then reinsert the nasogastric tube. B Connect the nasogastric tube to high continuous suction. C Connect the nasogastric tube to suction as prescribed. D Clamp the nasogastric tube and contact the healthcare provider. Answer: