BSN366 EXIT HESI Actual Exam Latest Updated 2025
With Well Elaborated Questions And Detailed
Answers Graded A+
The nurse is caring for a client who arrives to the ED with reports of experiencing
dizziness and difficulty walking to the bathroom. The nurse observes R-sided weakness
and sluggish enunciation of speech. The nurse should immediately take which action?
A) Maintain elevated positioning of the dependent joints on the affected side.
B) Keep the bed in the lowest position and initiate seizure and fall precautions
C) Place an indwelling urinary catheter and measure strict I/Os
D) Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic
therapy. - ANSWERS-D) Start two large-bore IV catheters and review inclusion criteria
for IV fibrinolytic therapy
A male client with a brain tumor is scheduled for a biopsy in the morning. During the
admission procedure, the client has a tonic colonic seizure that last 50 seconds.
Following the seizure, the client is lethargic and confused, and his wife tells the nurse
that her husband has never had a seizure before and has always been alert and
communicative. Which action should the nurse take?
A) ask the wife to wait outside the room until the nurse can talk with her.
B) keep orienting the client the client to time in space until he is less confused
C) notify the emergency response team of the client's seizure
D) explain the postictal state that usually follows seizures - ANSWERS-D) explain the
postical state that usually follows seizures
A nurse is providing lifestyle change education for a client to slow the progression of
coronary artery disease. Which statement made by the client should the nurse
recognize as needing additional education?
A) Keep a food diary.
B) Eat more canned vegetables.
C) Consume foods with saturated fat.
D) Walk 30 minutes per day.
E) Include oatmeal for breakfast.
F) Use a salt substitute - ANSWERS-B) Eat more canned vegetables.
C) Consume foods with saturated fats.
While caring for a toddler receiving oxygen via facemask, the nurse observes that the
child's lips and nares are dry and cracked. Which intervention should the nurse
implement?
,A) Use a water-soluble lubricant on affected oral and nasal mucosa.
B) Use a topical lidocaine analgesic for cracked lips.
C) Ask the mother what she usually uses on the child's lips and nose.
D) Apply a petroleum jelly to the child's nose and lips. - ANSWERS-A) use a water-
soluble lubricant on affected oral and nasal mucosa
When assessing a multigravida on the first postpartum day, the nurse finds a moderate
amount of lochia rubra, with the uterus firm, and three finger breaths above the
umbilicus. What action should the nurse implement first?
A) Increase IV infusion.
B) Massage the uterus to decrease attorney.
C) Review the hemoglobin to determine hemorrhage.
D)Check for a distended bladder. - ANSWERS-D) Check for a distended bladder
The nurse is providing teaching to a client with type 2 DM about important points for
disease and symptom management. Which statement by the client indicates
understanding?
A) Using salt, herbs, and spices will improve the flavor of foods
B) Get an eye exam with an opthalmologist annually
C) Arrange diet schedule around three regular meals a day
D) Inspect feet every month for ingrown nails, cuts, and caluses - ANSWERS-B) Get an
eye exam with an opthalmologist annually
The nurse is providing educations to a client who experiences recurrent levels of
moderate anxiety to situations and perceived stress. In addition to informations about
prescribed medications and administration, which instruction should the nurse include in
the teaching?
A) Center attention on positive upbeat music
B) Find outlets for more social interaction
C) Practice using muscle relaxation techniques
D) Think about reasons the episodes occur - ANSWERS-C) Practice using muscle
relaxation techniques
The charge nurse is planning for the shift and has a RN and a PN on the team. Which
client should the charge nurse assign to the RN?
A) A 75-year old client with renal calculi who requires urine straining
B) A 64-year old client who had a total hip replacement the preious day
C) A 30-year old depresses client who admits to suicide ideation
D) An adolescent with multiple contusions due to a fall that occurred 2 days ago -
ANSWERS-C) A 30-year old depresses client who admits to suicide ideation
,NGN: (Nurses Notes)
1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother,
who was diagnosed with gestational diabetes. Following a spontaneous vaginal birth,
she received Apgar scores of seven at one minute and eight at five minutes. The client
weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a moderate
amount of subcutaneous fat. She is noted to be slightly jittery at 30min of age. Axillary
temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin seven, fontanelles
soft, mongolian spot noted on lower back, Ballard maturity rating 37 weeks. (For each
assessment finding, click to indicate whether the findings are associated with an infant
of a diabetic mother or normal presentation.)
Soft Fontanelles
Blood Glucose 35
Axillary temp. 96F
Acrocyanosis
Ballard score maturity rating 37 - ANSWERS-Diabetic Findings:
BG 35
Axillary temp 96
Ballard score maturity rating 37
???????
Normal Presentation:
Soft Fontanelles
Acrocyanosis
(normal findings include acrocyanosis, soft fontanelles, mongolian spots, and Apgar
scores 7 to 10)
NGN: (Nurses Notes)
1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother,
who was diagnosed with gestational diabetes. Following a spontaneous vaginal birth,
she received Apgar scores of seven at one minute and eight at five minutes. The client
weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a moderate
amount of subcutaneous fat. She is noted to be slightly jittery at 30min of age. Axillary
temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin seven, fontanelles
soft, mongolian spot noted on lower back, Ballard maturity rating 37 weeks.
The nurse recognizes that the infant of a diabetic mother is at risk for _________ ,
_____________ , and _________________ - ANSWERS-Hyperbilirubinemia ,
Resppiratory Distress Syndrome , and Cardiomyopathy
NGN: Orders
Breast-feed immediately once stable then on demand. If unstable, may feed breastmilk
via orogastric tube. If two feeding attempts failed to increase the glucose levels or if
symptoms of hypoglycemia develop, apply dextrose gel inside the babies cheek. If the
above are ineffective, IV glucose should be administered to maintain glucose levels
, above 45. Bolus of 2mL/kg glucose 10% IV, hello by a continuous glucose perfusion of
6 to 8mg/kg/min, maintain glycemic levels over 40.
Which 6 orders take priority?
A) Feed Immediately
B) Monitor for respiratory distress
C) Apply dextrose gell inside the baby's cheek
D) Keep in warmer with bilirubin lights
E) Monitor temp every 30 min
F) Bolus 2 mL/kg glucose 10% IV
G) Contact RT for ABG and oxygen therapy
H) Echo
I) Transfer to NICU
J) Blood glucose level - ANSWERS-A) Feed Immedicately
B) Monitor for Respiratory Distress
D) Keep in warmer with bili lights
E) Monitor temp q30min
G) Contact RT for ABG and O2 therapy
J) Blood glucose level
NGN Laboratory Results (same case of patient who just gave birth)
Which actions are appropriate for the nurse to take at this time? SATA
A) Keep infant in warmer with bili lights to maintain temp of 97.6F
B) Monitor Temp
C) Continue to monitor glucose level
D) Tell the mother that she will need to discuss this with the neonatologist
E) Explain to the mother that the babys RR needs to be below 60
F) Inform the mother that the baby is stable enought to take out of the warmer
G) Observe for signs of respiratory distress and monitor O2 with pulse ox - ANSWERS-
A) Keep infant in warmer with bili lights to maintain temp of 97F
E) Explain to the mother that the babys RR need to be below 60
F) Inform the mother that the baby is stable enough to take out of the warmer
G) Observe for signs of respiratory distress and monitor oxygenation by pulse ox
NGN: 1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P 1
mother, who was diagnosed with gestational diabetes. Following a spontaneous vaginal
birth, she received Apgar scores of seven at one minute and eight at five minutes. The
client weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a moderate
amount of subcutaneous fat. She is noted to be slightly jittery at 30min of age. Axillary
temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin seven, fontanelles
soft, mongolian spot noted on lower back, Ballard maturity rating 37 weeks.
(The day shift nurse reviews the nurses notes, labs, and flow sheet from the night
before. The nurse plans on providing health teaching for the client and her family in
preparation for discharge.)
With Well Elaborated Questions And Detailed
Answers Graded A+
The nurse is caring for a client who arrives to the ED with reports of experiencing
dizziness and difficulty walking to the bathroom. The nurse observes R-sided weakness
and sluggish enunciation of speech. The nurse should immediately take which action?
A) Maintain elevated positioning of the dependent joints on the affected side.
B) Keep the bed in the lowest position and initiate seizure and fall precautions
C) Place an indwelling urinary catheter and measure strict I/Os
D) Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic
therapy. - ANSWERS-D) Start two large-bore IV catheters and review inclusion criteria
for IV fibrinolytic therapy
A male client with a brain tumor is scheduled for a biopsy in the morning. During the
admission procedure, the client has a tonic colonic seizure that last 50 seconds.
Following the seizure, the client is lethargic and confused, and his wife tells the nurse
that her husband has never had a seizure before and has always been alert and
communicative. Which action should the nurse take?
A) ask the wife to wait outside the room until the nurse can talk with her.
B) keep orienting the client the client to time in space until he is less confused
C) notify the emergency response team of the client's seizure
D) explain the postictal state that usually follows seizures - ANSWERS-D) explain the
postical state that usually follows seizures
A nurse is providing lifestyle change education for a client to slow the progression of
coronary artery disease. Which statement made by the client should the nurse
recognize as needing additional education?
A) Keep a food diary.
B) Eat more canned vegetables.
C) Consume foods with saturated fat.
D) Walk 30 minutes per day.
E) Include oatmeal for breakfast.
F) Use a salt substitute - ANSWERS-B) Eat more canned vegetables.
C) Consume foods with saturated fats.
While caring for a toddler receiving oxygen via facemask, the nurse observes that the
child's lips and nares are dry and cracked. Which intervention should the nurse
implement?
,A) Use a water-soluble lubricant on affected oral and nasal mucosa.
B) Use a topical lidocaine analgesic for cracked lips.
C) Ask the mother what she usually uses on the child's lips and nose.
D) Apply a petroleum jelly to the child's nose and lips. - ANSWERS-A) use a water-
soluble lubricant on affected oral and nasal mucosa
When assessing a multigravida on the first postpartum day, the nurse finds a moderate
amount of lochia rubra, with the uterus firm, and three finger breaths above the
umbilicus. What action should the nurse implement first?
A) Increase IV infusion.
B) Massage the uterus to decrease attorney.
C) Review the hemoglobin to determine hemorrhage.
D)Check for a distended bladder. - ANSWERS-D) Check for a distended bladder
The nurse is providing teaching to a client with type 2 DM about important points for
disease and symptom management. Which statement by the client indicates
understanding?
A) Using salt, herbs, and spices will improve the flavor of foods
B) Get an eye exam with an opthalmologist annually
C) Arrange diet schedule around three regular meals a day
D) Inspect feet every month for ingrown nails, cuts, and caluses - ANSWERS-B) Get an
eye exam with an opthalmologist annually
The nurse is providing educations to a client who experiences recurrent levels of
moderate anxiety to situations and perceived stress. In addition to informations about
prescribed medications and administration, which instruction should the nurse include in
the teaching?
A) Center attention on positive upbeat music
B) Find outlets for more social interaction
C) Practice using muscle relaxation techniques
D) Think about reasons the episodes occur - ANSWERS-C) Practice using muscle
relaxation techniques
The charge nurse is planning for the shift and has a RN and a PN on the team. Which
client should the charge nurse assign to the RN?
A) A 75-year old client with renal calculi who requires urine straining
B) A 64-year old client who had a total hip replacement the preious day
C) A 30-year old depresses client who admits to suicide ideation
D) An adolescent with multiple contusions due to a fall that occurred 2 days ago -
ANSWERS-C) A 30-year old depresses client who admits to suicide ideation
,NGN: (Nurses Notes)
1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother,
who was diagnosed with gestational diabetes. Following a spontaneous vaginal birth,
she received Apgar scores of seven at one minute and eight at five minutes. The client
weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a moderate
amount of subcutaneous fat. She is noted to be slightly jittery at 30min of age. Axillary
temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin seven, fontanelles
soft, mongolian spot noted on lower back, Ballard maturity rating 37 weeks. (For each
assessment finding, click to indicate whether the findings are associated with an infant
of a diabetic mother or normal presentation.)
Soft Fontanelles
Blood Glucose 35
Axillary temp. 96F
Acrocyanosis
Ballard score maturity rating 37 - ANSWERS-Diabetic Findings:
BG 35
Axillary temp 96
Ballard score maturity rating 37
???????
Normal Presentation:
Soft Fontanelles
Acrocyanosis
(normal findings include acrocyanosis, soft fontanelles, mongolian spots, and Apgar
scores 7 to 10)
NGN: (Nurses Notes)
1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother,
who was diagnosed with gestational diabetes. Following a spontaneous vaginal birth,
she received Apgar scores of seven at one minute and eight at five minutes. The client
weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a moderate
amount of subcutaneous fat. She is noted to be slightly jittery at 30min of age. Axillary
temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin seven, fontanelles
soft, mongolian spot noted on lower back, Ballard maturity rating 37 weeks.
The nurse recognizes that the infant of a diabetic mother is at risk for _________ ,
_____________ , and _________________ - ANSWERS-Hyperbilirubinemia ,
Resppiratory Distress Syndrome , and Cardiomyopathy
NGN: Orders
Breast-feed immediately once stable then on demand. If unstable, may feed breastmilk
via orogastric tube. If two feeding attempts failed to increase the glucose levels or if
symptoms of hypoglycemia develop, apply dextrose gel inside the babies cheek. If the
above are ineffective, IV glucose should be administered to maintain glucose levels
, above 45. Bolus of 2mL/kg glucose 10% IV, hello by a continuous glucose perfusion of
6 to 8mg/kg/min, maintain glycemic levels over 40.
Which 6 orders take priority?
A) Feed Immediately
B) Monitor for respiratory distress
C) Apply dextrose gell inside the baby's cheek
D) Keep in warmer with bilirubin lights
E) Monitor temp every 30 min
F) Bolus 2 mL/kg glucose 10% IV
G) Contact RT for ABG and oxygen therapy
H) Echo
I) Transfer to NICU
J) Blood glucose level - ANSWERS-A) Feed Immedicately
B) Monitor for Respiratory Distress
D) Keep in warmer with bili lights
E) Monitor temp q30min
G) Contact RT for ABG and O2 therapy
J) Blood glucose level
NGN Laboratory Results (same case of patient who just gave birth)
Which actions are appropriate for the nurse to take at this time? SATA
A) Keep infant in warmer with bili lights to maintain temp of 97.6F
B) Monitor Temp
C) Continue to monitor glucose level
D) Tell the mother that she will need to discuss this with the neonatologist
E) Explain to the mother that the babys RR needs to be below 60
F) Inform the mother that the baby is stable enought to take out of the warmer
G) Observe for signs of respiratory distress and monitor O2 with pulse ox - ANSWERS-
A) Keep infant in warmer with bili lights to maintain temp of 97F
E) Explain to the mother that the babys RR need to be below 60
F) Inform the mother that the baby is stable enough to take out of the warmer
G) Observe for signs of respiratory distress and monitor oxygenation by pulse ox
NGN: 1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P 1
mother, who was diagnosed with gestational diabetes. Following a spontaneous vaginal
birth, she received Apgar scores of seven at one minute and eight at five minutes. The
client weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a moderate
amount of subcutaneous fat. She is noted to be slightly jittery at 30min of age. Axillary
temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin seven, fontanelles
soft, mongolian spot noted on lower back, Ballard maturity rating 37 weeks.
(The day shift nurse reviews the nurses notes, labs, and flow sheet from the night
before. The nurse plans on providing health teaching for the client and her family in
preparation for discharge.)
