Exit Hesi (BSN 366- V2) (Latest Update )
Questions and Verified Answers | 100% Correct |
Grade A - Nightingale
The nurse knows that which statement by the mother indicates that the mother understands
safety precautions with her four month-old infant and her 4 year-old child? - ~ ~ ANSWER
~~ "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen
while I make supper."
Upon completing the admission documents, the nurse learns that the 87 year-old client does
not have an advance directive. What action should the nurse take? - ~ ~ ANSWER ~~
Give information about advance directives
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the
immunization was given, the client complains of itchy and watery eyes, increased anxiety, and
difficulty breathing. The nurse expects that the first action in the sequence of care for this client
will be to - ~ ANSWER ~ Administer epinephrine 1:1000 as ordered
Which of these children at the site of a disaster at a child day care center would the triage nurse
put in the "treat last" category? - ~ ANSWER ~ A toddler with severe deep abrasions
over 98% of the body
,When admitting a client to an acute care facility, an identification bracelet is sent up with the
admission form. In the event these do not match, the nurse's best action is to - ~ ANSWER ~
Notify the admissions office and wait to apply the bracelet
The nurse is having difficulty reading the health care provider's written order that was written
right before the shift change. What action should be taken? - ~ ANSWER ~ Call the
provider for clarification
An adult client is found to be unresponsive on morning rounds. After checking for
responsiveness and calling for help, the next action that should be taken by the nurse is to: -
~ ANSWER ~ open the client's airway
A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml
has been infused after 4 hours. What is the priority nursing action? - ~ ANSWER ~
Auscultate the lungs
Following change-of-shift report on an orthopedic unit, which client should the nurse see first? -
~ ANSWER ~ 72 year-old recovering from surgery after a hip replacement 2 hours ago
,A nurse observes a family member administer a rectal suppository by having the client lie on the
left side for the administration. The family member pushed the suppository until the finger
went up to the second knuckle. After 10 minutes the client was told by the family member to
turn to the right side and the client did this. What is the appropriate comment for the nurse to
make? - ~ ANSWER ~ That was done correctly. Did you have any problems with the
insertion?
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which
type of precautions is the appropriate type to use when performing postmortem care? - ~
ANSWER ~ contact precautions
The nurse is reviewing with a client how to collect a clean catch urine specimen. Which
sequence is appropriate teaching? - ~ ANSWER ~ clean the meatus, begin voiding,
then catch urine stream
The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40 mg every day. Which of
these foods would the nurse reinforce for the client to eat at least daily? - ~ ANSWER ~
watermelon
A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse
take? - ~ ANSWER ~ Immediately wash the hands with vigor
, As the nurse observes the student nurse during the administration of a narcotic analgesic IM
injection, the nurse notes that the student begins to give the medication without first
aspirating. What should the nurse do? - ~ ANSWER ~ Walk up and whisper in the
student's ear "Stop. Aspirate. Then inject."
A client with Guillain Barre is in a non responsive state, yet vital signs are stable and breathing is
independent. What should the nurse document to most accurately describe the client's
condition? - ~ ANSWER ~ Glascow Coma Scale 8, respirations regular
A client enters the emergency department unconscious via ambulance from the client's work
place. What document should be given priority to guide the direction of care for this client? -
~ ANSWER ~ A notarized original of advance directives brought in by the partner
The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel
(UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse
manager? - ~ ANSWER ~ An admission at the change of shifts with atrial fibrillation
and heart failure - PN
A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting
up all the time and has a lot of gas. The nurse expects to find which of the following on the
initial history and physical assessment? - ~ ANSWER ~ Restlessness and increased
mucus production
Questions and Verified Answers | 100% Correct |
Grade A - Nightingale
The nurse knows that which statement by the mother indicates that the mother understands
safety precautions with her four month-old infant and her 4 year-old child? - ~ ~ ANSWER
~~ "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen
while I make supper."
Upon completing the admission documents, the nurse learns that the 87 year-old client does
not have an advance directive. What action should the nurse take? - ~ ~ ANSWER ~~
Give information about advance directives
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the
immunization was given, the client complains of itchy and watery eyes, increased anxiety, and
difficulty breathing. The nurse expects that the first action in the sequence of care for this client
will be to - ~ ANSWER ~ Administer epinephrine 1:1000 as ordered
Which of these children at the site of a disaster at a child day care center would the triage nurse
put in the "treat last" category? - ~ ANSWER ~ A toddler with severe deep abrasions
over 98% of the body
,When admitting a client to an acute care facility, an identification bracelet is sent up with the
admission form. In the event these do not match, the nurse's best action is to - ~ ANSWER ~
Notify the admissions office and wait to apply the bracelet
The nurse is having difficulty reading the health care provider's written order that was written
right before the shift change. What action should be taken? - ~ ANSWER ~ Call the
provider for clarification
An adult client is found to be unresponsive on morning rounds. After checking for
responsiveness and calling for help, the next action that should be taken by the nurse is to: -
~ ANSWER ~ open the client's airway
A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml
has been infused after 4 hours. What is the priority nursing action? - ~ ANSWER ~
Auscultate the lungs
Following change-of-shift report on an orthopedic unit, which client should the nurse see first? -
~ ANSWER ~ 72 year-old recovering from surgery after a hip replacement 2 hours ago
,A nurse observes a family member administer a rectal suppository by having the client lie on the
left side for the administration. The family member pushed the suppository until the finger
went up to the second knuckle. After 10 minutes the client was told by the family member to
turn to the right side and the client did this. What is the appropriate comment for the nurse to
make? - ~ ANSWER ~ That was done correctly. Did you have any problems with the
insertion?
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which
type of precautions is the appropriate type to use when performing postmortem care? - ~
ANSWER ~ contact precautions
The nurse is reviewing with a client how to collect a clean catch urine specimen. Which
sequence is appropriate teaching? - ~ ANSWER ~ clean the meatus, begin voiding,
then catch urine stream
The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40 mg every day. Which of
these foods would the nurse reinforce for the client to eat at least daily? - ~ ANSWER ~
watermelon
A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse
take? - ~ ANSWER ~ Immediately wash the hands with vigor
, As the nurse observes the student nurse during the administration of a narcotic analgesic IM
injection, the nurse notes that the student begins to give the medication without first
aspirating. What should the nurse do? - ~ ANSWER ~ Walk up and whisper in the
student's ear "Stop. Aspirate. Then inject."
A client with Guillain Barre is in a non responsive state, yet vital signs are stable and breathing is
independent. What should the nurse document to most accurately describe the client's
condition? - ~ ANSWER ~ Glascow Coma Scale 8, respirations regular
A client enters the emergency department unconscious via ambulance from the client's work
place. What document should be given priority to guide the direction of care for this client? -
~ ANSWER ~ A notarized original of advance directives brought in by the partner
The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel
(UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse
manager? - ~ ANSWER ~ An admission at the change of shifts with atrial fibrillation
and heart failure - PN
A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting
up all the time and has a lot of gas. The nurse expects to find which of the following on the
initial history and physical assessment? - ~ ANSWER ~ Restlessness and increased
mucus production
