BSN 366 HESI RN Exit Exam (Latest Update 2025 /
2026) Questions and Verified Answers | 100% Correct
| Grade A - Nightingale
A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The
client has not been sleeping well lately and is experiencing labored breathing. List
the client's problems in order of priority for the nurse. (Rank in the priority order
from highest to lowest.)
1.
Airway and breathing.
2.
Pain management.
3.
Definitive therapy.
4.
Sleep and rest. - ~ ANSWER ~ Correct Answer:
1.Airway and breathing. 2.Pain management. 3.Sleep and rest. 4.Definitive
therapy.
Rationale
First-level problems are immediate priorities (airway, breathing, and circulation).
In this scenario, airway and breathing are the first priority, followed by pain
management, Maslow's hierarchy of basic needs for rest and sleep, and then
definitive drug therapies.
Which biological practices are federally regulated for healthcare workers? (Select
all that apply.)
Select all that apply
1.Standard precautions.
2. N-95 tuberculosis standard.
3. Blood-borne pathogen standard.
4. Biological product exposure limit (BPEL).
5. Resource Conservation and Recovery Act (RCRA).
,6. As Low as Reasonably Allowable standard (ALARA). - ~ ANSWER ~
3. Blood-borne pathogen standard.
5. Resource Conservation and Recovery Act (RCRA)
Basic standards for healthcare workers, as delineated by Occupational Safety and
Health Administration (OSHA), include standard precautions, droplet precautions
using N-95 respiratory particulate masks when caring for a client who is positive
for tuberculosis, and required annual updates for healthcare workers about blood-
borne pathogen transmission, methods of minimizing exposure, and employee
rights. Other options [BPEL and ALARA ] are not federally regulated.
A client with severe depression tells the nurse, "I do not know why you bother with
me or give me pills. I am never going to get well." What is the most therapeutic
response?
1. "You need to stop thinking negative thoughts. They get in the way of your
recovery."
2. "You are no bother to me or to the staff. We want you to get well and not feel
sad anymore."
3. "I have known many clients with depression who have felt better after several
weeks of treatment."
4. "You are feeling very pessimistic, but that is part of your illness. It should go
away as you recover." - ~ ANSWER ~ 3. "I have known many clients
with depression who have felt better after several weeks of treatment."
Stating the observation that others have recovered can give a client hope. Telling a
person to stop negtive thinking is ineffective because the client must be taught
cognitive strategies to stop negative thinking. Stating the person is "no bother" is
arguing with the client's beliefs and attempting to tell him how to feel, both of
which are not therapeutic responses. Bring up pessimistic feelings interprets the
client's feelings and does not provide the same degree of hope.
The nurse is caring for a client with a nursing problem of, "Infection, risk for,
related to inadequate primary defenses as evidenced by surgical incision and IV
access." What nursing intervention should the nurse implement?
1. Limit visitors to immediate family to decrease exposure to infection.
2. Maintain "clean" technique in the change of wound dressing and IV site.
,3. Assess and document skin condition around the incision and IV site at each
shift.
4. Require the use of a face mask by staff when providing care requiring close
contact. - ~ ANSWER ~ 3. Assess and document skin condition around
the incision and IV site at each shift.
Early identification of infection leads to prompt treatment and decreased
nosocomial transmission to others, so the condition of any invasive lines or breaks
in the skin should be assessed and documented during each shift.
A client with ulcerative colitis is scheduled for surgical creation of an ileoanal
reservoir (J pouch). As part of preoperative teaching, what information should the
nurse provide?
1. The transverse loop ostomy is permanent.
2. Easily removable appliances allow independence in self-care.
3. Daily irrigation is started after the J pouch heals.
4. Stool is eventually expelled through the rectum. - ~ ANSWER ~ 4.
Stool is eventually expelled through the rectum.
An ileal pouch-anal anastomosis (also known as the J pouch) is a surgically created
ileoanal reservoir in the anal canal that preserves the rectal sphincter muscle, so
that passage of stool through the rectum is the eventual result. To promote healing
of the anastomosed parts of the colon, a temporary loop ostomy is created, not a
permanent one. Although appliances that are easy to use are advantageous, the
ostomy is reversed after healing takes place. Stool drains into the reservoir, so
daily irrigation is not usually indicated.
The nurse inflates the cuff on a tracheostomy tube to minimal occlusion pressure
for a client who is breathing spontaneously. Which action should the nurse follow?
1. Check the pilot balloon to ensure that it is firm.
2. Verify the healthcare provider's prescription for the required cuff pressure.
3. Use a manometer to maintain cuff pressure between 25 and 30 mmHg.
4. Inject air until no air is auscultated over the larynx during a deep breath. - ~
ANSWER ~ 4. Inject air until no air is auscultated over the larynx during a
deep breath.
, To achieve minimal pressure (minimal occlusion volume technique) against the
tracheal wall, inject air into the tracheostomy tube cuff while auscultating with a
stethoscope placed over the larynx (over the cuff) during inhalation. At the point
when sounds of air movement cease, inflation is stopped, indicating that the cuff is
sealed against the tracheal wall.
A 60-year-old homeless man who complains of a cough, late-afternoon fever, and
night sweats has a 10 mm induration after receiving a purified protein derivative
(PPD) skin test. Which action should the nurse implement?
1. Refer for further diagnostic evaluation.
2. Determine exposure of others to the tuberculosis.
3. Begin anti-tubercular drug therapy.
4. Quarantine or isolate to control communicability. - ~ ANSWER ~ 1.
Refer for further diagnostic evaluation.
The PPD skin test results is indicative of exposure or latent Mycobacterium
tuberculosis infection (LTBI), which this client is in a high-risk category for
exposure in a homeless environment. Although productive prolonged cough, fever,
and night sweats are common early symptoms, persons suspected of LTBI should
not begin treatment until active TB disease has been excluded. Further diagnostic
evaluation should be implemented. A dormant form that neither causes disease nor
is communicable.
Which contextual factors are considered external environmental influences in the
framework for occupational health programs and services? (Select all that apply.)
Select all that apply
1. Economics.
2. Workforce.
3. Technology.
4. Interventions.
5. Socio-economic status.
6. Legislation/regulation. - ~ ANSWER ~ 1. Economics.
3. Technology.
6. Legislation/regulation.
2026) Questions and Verified Answers | 100% Correct
| Grade A - Nightingale
A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The
client has not been sleeping well lately and is experiencing labored breathing. List
the client's problems in order of priority for the nurse. (Rank in the priority order
from highest to lowest.)
1.
Airway and breathing.
2.
Pain management.
3.
Definitive therapy.
4.
Sleep and rest. - ~ ANSWER ~ Correct Answer:
1.Airway and breathing. 2.Pain management. 3.Sleep and rest. 4.Definitive
therapy.
Rationale
First-level problems are immediate priorities (airway, breathing, and circulation).
In this scenario, airway and breathing are the first priority, followed by pain
management, Maslow's hierarchy of basic needs for rest and sleep, and then
definitive drug therapies.
Which biological practices are federally regulated for healthcare workers? (Select
all that apply.)
Select all that apply
1.Standard precautions.
2. N-95 tuberculosis standard.
3. Blood-borne pathogen standard.
4. Biological product exposure limit (BPEL).
5. Resource Conservation and Recovery Act (RCRA).
,6. As Low as Reasonably Allowable standard (ALARA). - ~ ANSWER ~
3. Blood-borne pathogen standard.
5. Resource Conservation and Recovery Act (RCRA)
Basic standards for healthcare workers, as delineated by Occupational Safety and
Health Administration (OSHA), include standard precautions, droplet precautions
using N-95 respiratory particulate masks when caring for a client who is positive
for tuberculosis, and required annual updates for healthcare workers about blood-
borne pathogen transmission, methods of minimizing exposure, and employee
rights. Other options [BPEL and ALARA ] are not federally regulated.
A client with severe depression tells the nurse, "I do not know why you bother with
me or give me pills. I am never going to get well." What is the most therapeutic
response?
1. "You need to stop thinking negative thoughts. They get in the way of your
recovery."
2. "You are no bother to me or to the staff. We want you to get well and not feel
sad anymore."
3. "I have known many clients with depression who have felt better after several
weeks of treatment."
4. "You are feeling very pessimistic, but that is part of your illness. It should go
away as you recover." - ~ ANSWER ~ 3. "I have known many clients
with depression who have felt better after several weeks of treatment."
Stating the observation that others have recovered can give a client hope. Telling a
person to stop negtive thinking is ineffective because the client must be taught
cognitive strategies to stop negative thinking. Stating the person is "no bother" is
arguing with the client's beliefs and attempting to tell him how to feel, both of
which are not therapeutic responses. Bring up pessimistic feelings interprets the
client's feelings and does not provide the same degree of hope.
The nurse is caring for a client with a nursing problem of, "Infection, risk for,
related to inadequate primary defenses as evidenced by surgical incision and IV
access." What nursing intervention should the nurse implement?
1. Limit visitors to immediate family to decrease exposure to infection.
2. Maintain "clean" technique in the change of wound dressing and IV site.
,3. Assess and document skin condition around the incision and IV site at each
shift.
4. Require the use of a face mask by staff when providing care requiring close
contact. - ~ ANSWER ~ 3. Assess and document skin condition around
the incision and IV site at each shift.
Early identification of infection leads to prompt treatment and decreased
nosocomial transmission to others, so the condition of any invasive lines or breaks
in the skin should be assessed and documented during each shift.
A client with ulcerative colitis is scheduled for surgical creation of an ileoanal
reservoir (J pouch). As part of preoperative teaching, what information should the
nurse provide?
1. The transverse loop ostomy is permanent.
2. Easily removable appliances allow independence in self-care.
3. Daily irrigation is started after the J pouch heals.
4. Stool is eventually expelled through the rectum. - ~ ANSWER ~ 4.
Stool is eventually expelled through the rectum.
An ileal pouch-anal anastomosis (also known as the J pouch) is a surgically created
ileoanal reservoir in the anal canal that preserves the rectal sphincter muscle, so
that passage of stool through the rectum is the eventual result. To promote healing
of the anastomosed parts of the colon, a temporary loop ostomy is created, not a
permanent one. Although appliances that are easy to use are advantageous, the
ostomy is reversed after healing takes place. Stool drains into the reservoir, so
daily irrigation is not usually indicated.
The nurse inflates the cuff on a tracheostomy tube to minimal occlusion pressure
for a client who is breathing spontaneously. Which action should the nurse follow?
1. Check the pilot balloon to ensure that it is firm.
2. Verify the healthcare provider's prescription for the required cuff pressure.
3. Use a manometer to maintain cuff pressure between 25 and 30 mmHg.
4. Inject air until no air is auscultated over the larynx during a deep breath. - ~
ANSWER ~ 4. Inject air until no air is auscultated over the larynx during a
deep breath.
, To achieve minimal pressure (minimal occlusion volume technique) against the
tracheal wall, inject air into the tracheostomy tube cuff while auscultating with a
stethoscope placed over the larynx (over the cuff) during inhalation. At the point
when sounds of air movement cease, inflation is stopped, indicating that the cuff is
sealed against the tracheal wall.
A 60-year-old homeless man who complains of a cough, late-afternoon fever, and
night sweats has a 10 mm induration after receiving a purified protein derivative
(PPD) skin test. Which action should the nurse implement?
1. Refer for further diagnostic evaluation.
2. Determine exposure of others to the tuberculosis.
3. Begin anti-tubercular drug therapy.
4. Quarantine or isolate to control communicability. - ~ ANSWER ~ 1.
Refer for further diagnostic evaluation.
The PPD skin test results is indicative of exposure or latent Mycobacterium
tuberculosis infection (LTBI), which this client is in a high-risk category for
exposure in a homeless environment. Although productive prolonged cough, fever,
and night sweats are common early symptoms, persons suspected of LTBI should
not begin treatment until active TB disease has been excluded. Further diagnostic
evaluation should be implemented. A dormant form that neither causes disease nor
is communicable.
Which contextual factors are considered external environmental influences in the
framework for occupational health programs and services? (Select all that apply.)
Select all that apply
1. Economics.
2. Workforce.
3. Technology.
4. Interventions.
5. Socio-economic status.
6. Legislation/regulation. - ~ ANSWER ~ 1. Economics.
3. Technology.
6. Legislation/regulation.
