BSN 225 ACTUAL HESI PREP EXAM 200+ QUESTIONS
AND CORRECT ANSWERS |A+ GRADED | ALL VERIFIED
ANSWERS | JUST RELEASED|PROFESSOR
VERIFIED|WITH RATIONALES
A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student
states, "Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to
help my friend prepare for tomorrow's clinical." What response should the nurse provide first?
Explain that the records are hospital property and may not be removed.
Rationale
The nurse should deal with the issue immediately and explain that a client's records are the property of the hospital and
cannot be removed (D), even with the client's permission (C). Next, the clinical instructor should be notified (B) so that all
students can be educated regarding copying and removing clinical records from the healthcare agency. The nursing
supervisor (A) should also be alerted to ensure appropriate supervision of students as well as protection of client information.
After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has
not been signed. What action should the nurse implement?
Notify the surgeon that the consent form has not been signed.
Rationale
Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not possible, so the
nurse must notify the surgeon (A). (B, C, and D) are not legally viable options for ensuring informed consent.
A healthcare provider is performing a sterile procedure at a client’s bedside. Near the end of the procedure, the nurse
observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to
implement?
,Identify the break in surgical asepsis and provide another set of sterile supplies.
Rationale
Any possible break in surgical asepsis that is identified when others are unaware should be considered contaminated and
new sterile supplies added to maintain the sterile field (D). Reporting the healthcare provider is not indicated (A). When
sterility is suspect during aseptic technique, it should not be questioned (C) but all members of the team should move forward
with reestablishing a sterile field. Allowing the procedure to progress under unsterile conditions (B) places the client at risk
for infection and is an act of omission (negligence) by the nurse and other healthcare team members.
On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the
nurse implement to promote bowel elimination?
Provide warm prune juice before the client goes to bed at night.
Rationale
Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice (B) facilitates peristalsis. (A) is also
helpful in promoting peristalsis but is less likely to relieve the client's constipation. (C) reduces discomfort during ambulation,
but will not help relieve the client's constipation. Defecation is not painful following most surgeries, and many analgesics
used postoperatively cause constipation, so (D) is contraindicated.
.
While caring for a child and mother from Cambodia, what action should the nurse implement to accommodate the clients'
cultural needs?
Speak initially with the oldest family member to show respect.
Rationale
,Members of the Asian culture have high respect for others, especially those in positions of authority. Extended family
members need to be included in the nursing care plan (A). Southeast Asians do not necessarily refuse Western medications
(B). Asians also believe that touching strangers is not acceptable, particularly health professionals whom they have not
previously known, so the husband should be allowed to remain with his wife during the pelvic exam (C). Provided that the
presence of other family members is not harmful to the client’s well-being, (D) is not correct.
Which standard of practice is the nurse performing when applying a cold compress to a patient's sprained ankle and instructing
the patient to elevate the leg?
C. Implementation
The nurse is delivering care to the patient; therefore, the standard practiced by the nurse is implementation. Developing a
nursing diagnosis involves analyzing the assessed data. Evaluation refers to determining the effectiveness of the implemented
patient care in meeting the patient's goals. Assessment is the process of collecting data related to the health and illness of the
patient
which standard of practice is being performed when a nurse administers the prescribed medicated nebulizer treatment to a
patient who has developed wheezing and shortness of breath in the emergency department?
D. implementation
the implementation phase is where the nurse follows through on the decided plan of action. Once the patient and the nurse on
the diagnosis, a plan of action can be developed. Each problem is assigned a clear, measurable goal for the expected outcome.
Once all nusing intervention actions have taken place, the nurse completes an evaluation to determine if the patient's goals
have been met. The first step of the nursing process is assessment. During this phase, the nurse gathers information about a
patient's psychological, physiologic, sociologic, and spiritual status.
.
Which trait of critical thinking is the nurse exhibiting when instructing the parents of a malnourished child to make the child's
food colorful and attractive?
D. creativity
Nurses require various traits such as creativity, fairness, risk taking, curiousity, discipline, and perseverance. In this case the
nurseis trying to stimulate the appetite of the child by instructing the parents to make the food colorful and attractive. This
shows that the nurse is using the trait of creativity. Fairness is the trait of a nurse who avoids personal bias while caring for a
patient/ Curiosity is the trait of a critical thinking nurse who always tries to ask "why?" A disciplined nurse follows a systemativ
approach to plan and achieve goals.
, Which Quality and Safety in the Education of Nurses (QSEN) competency is the nurse exhibiting by working with a couple to
determine what they know about their medications and helping them decide on one care provider rather than two when caring
for an older-adult couple in a community-based assisted living facility?
B. safety
Helping patients understand the consequences and complications of multiple health care providers and multiple medications
helps ensure patient safety. Informatics is a multidisciplinary field that uses health inforamtion technology to improve health
care via any combination of high quality, higher efficiency, and new opportunities. Patient-centered care focuses on direct care
rendered to patients. Teamwork and collaboration seeks information or help from other health care professions and disciplines
A 40-year-old patient is experiencing poorly controlled hypertension. The dietitian recommends several dietary modifications to
the patient. The patient tries to explain the reason for her poor dietary compliance; she says she works extra hours and does not
have the time to cook. The patient further adds that she has diabetes. The patient expresses that it is difficult for her to choos a
diet that is low in sugar and low in salt and carbohydrates. The nurse communicates this to the dietitian using SBAR technique.
Which patient information would be addressed first?
C. Current medical conditions of chronic diabetes w/ hypertension
When using SBAR communication protocol, the nurse should first identify the patient's situation. In this case, that means the
nurse should convey that the patient is suffering from chronic diabetes and hypertension. The nurse then should further address
the breakdown of the situation and ask the dietitian to consider revising the diet. Following the dietary assessment and consult,
the recommendations for dietary changes-- including low-salt and low-sugar meals--should be made.
Which body mass index (BMI) would require hospitalization?
A. 12.5 kg/m2
Patients whose BMI is less than 13 kg/m2 are considered severely malnourished and require highly skilled nursing care w/
hospitalization. A BMI of 18.5 to 24.9 kg/m2 indicates that the patient has normal weight and does not require nursing care and
hospitalization
Which action would the nurse take when unable to find information about the medication in any of the hospital databases or
electronic health records when attempting to decrease the patient's adverse reactions to prescribed medications?
B. contact the hospital pharmacist
When a primary health care provider prescribes a mediation, the nurse is knowledgeable of its use, the expected outcome, and
any adverse effects and drug interactions. The nurse requests the information form the pharmacist when the informatio nis not
AND CORRECT ANSWERS |A+ GRADED | ALL VERIFIED
ANSWERS | JUST RELEASED|PROFESSOR
VERIFIED|WITH RATIONALES
A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student
states, "Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to
help my friend prepare for tomorrow's clinical." What response should the nurse provide first?
Explain that the records are hospital property and may not be removed.
Rationale
The nurse should deal with the issue immediately and explain that a client's records are the property of the hospital and
cannot be removed (D), even with the client's permission (C). Next, the clinical instructor should be notified (B) so that all
students can be educated regarding copying and removing clinical records from the healthcare agency. The nursing
supervisor (A) should also be alerted to ensure appropriate supervision of students as well as protection of client information.
After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has
not been signed. What action should the nurse implement?
Notify the surgeon that the consent form has not been signed.
Rationale
Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not possible, so the
nurse must notify the surgeon (A). (B, C, and D) are not legally viable options for ensuring informed consent.
A healthcare provider is performing a sterile procedure at a client’s bedside. Near the end of the procedure, the nurse
observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to
implement?
,Identify the break in surgical asepsis and provide another set of sterile supplies.
Rationale
Any possible break in surgical asepsis that is identified when others are unaware should be considered contaminated and
new sterile supplies added to maintain the sterile field (D). Reporting the healthcare provider is not indicated (A). When
sterility is suspect during aseptic technique, it should not be questioned (C) but all members of the team should move forward
with reestablishing a sterile field. Allowing the procedure to progress under unsterile conditions (B) places the client at risk
for infection and is an act of omission (negligence) by the nurse and other healthcare team members.
On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the
nurse implement to promote bowel elimination?
Provide warm prune juice before the client goes to bed at night.
Rationale
Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice (B) facilitates peristalsis. (A) is also
helpful in promoting peristalsis but is less likely to relieve the client's constipation. (C) reduces discomfort during ambulation,
but will not help relieve the client's constipation. Defecation is not painful following most surgeries, and many analgesics
used postoperatively cause constipation, so (D) is contraindicated.
.
While caring for a child and mother from Cambodia, what action should the nurse implement to accommodate the clients'
cultural needs?
Speak initially with the oldest family member to show respect.
Rationale
,Members of the Asian culture have high respect for others, especially those in positions of authority. Extended family
members need to be included in the nursing care plan (A). Southeast Asians do not necessarily refuse Western medications
(B). Asians also believe that touching strangers is not acceptable, particularly health professionals whom they have not
previously known, so the husband should be allowed to remain with his wife during the pelvic exam (C). Provided that the
presence of other family members is not harmful to the client’s well-being, (D) is not correct.
Which standard of practice is the nurse performing when applying a cold compress to a patient's sprained ankle and instructing
the patient to elevate the leg?
C. Implementation
The nurse is delivering care to the patient; therefore, the standard practiced by the nurse is implementation. Developing a
nursing diagnosis involves analyzing the assessed data. Evaluation refers to determining the effectiveness of the implemented
patient care in meeting the patient's goals. Assessment is the process of collecting data related to the health and illness of the
patient
which standard of practice is being performed when a nurse administers the prescribed medicated nebulizer treatment to a
patient who has developed wheezing and shortness of breath in the emergency department?
D. implementation
the implementation phase is where the nurse follows through on the decided plan of action. Once the patient and the nurse on
the diagnosis, a plan of action can be developed. Each problem is assigned a clear, measurable goal for the expected outcome.
Once all nusing intervention actions have taken place, the nurse completes an evaluation to determine if the patient's goals
have been met. The first step of the nursing process is assessment. During this phase, the nurse gathers information about a
patient's psychological, physiologic, sociologic, and spiritual status.
.
Which trait of critical thinking is the nurse exhibiting when instructing the parents of a malnourished child to make the child's
food colorful and attractive?
D. creativity
Nurses require various traits such as creativity, fairness, risk taking, curiousity, discipline, and perseverance. In this case the
nurseis trying to stimulate the appetite of the child by instructing the parents to make the food colorful and attractive. This
shows that the nurse is using the trait of creativity. Fairness is the trait of a nurse who avoids personal bias while caring for a
patient/ Curiosity is the trait of a critical thinking nurse who always tries to ask "why?" A disciplined nurse follows a systemativ
approach to plan and achieve goals.
, Which Quality and Safety in the Education of Nurses (QSEN) competency is the nurse exhibiting by working with a couple to
determine what they know about their medications and helping them decide on one care provider rather than two when caring
for an older-adult couple in a community-based assisted living facility?
B. safety
Helping patients understand the consequences and complications of multiple health care providers and multiple medications
helps ensure patient safety. Informatics is a multidisciplinary field that uses health inforamtion technology to improve health
care via any combination of high quality, higher efficiency, and new opportunities. Patient-centered care focuses on direct care
rendered to patients. Teamwork and collaboration seeks information or help from other health care professions and disciplines
A 40-year-old patient is experiencing poorly controlled hypertension. The dietitian recommends several dietary modifications to
the patient. The patient tries to explain the reason for her poor dietary compliance; she says she works extra hours and does not
have the time to cook. The patient further adds that she has diabetes. The patient expresses that it is difficult for her to choos a
diet that is low in sugar and low in salt and carbohydrates. The nurse communicates this to the dietitian using SBAR technique.
Which patient information would be addressed first?
C. Current medical conditions of chronic diabetes w/ hypertension
When using SBAR communication protocol, the nurse should first identify the patient's situation. In this case, that means the
nurse should convey that the patient is suffering from chronic diabetes and hypertension. The nurse then should further address
the breakdown of the situation and ask the dietitian to consider revising the diet. Following the dietary assessment and consult,
the recommendations for dietary changes-- including low-salt and low-sugar meals--should be made.
Which body mass index (BMI) would require hospitalization?
A. 12.5 kg/m2
Patients whose BMI is less than 13 kg/m2 are considered severely malnourished and require highly skilled nursing care w/
hospitalization. A BMI of 18.5 to 24.9 kg/m2 indicates that the patient has normal weight and does not require nursing care and
hospitalization
Which action would the nurse take when unable to find information about the medication in any of the hospital databases or
electronic health records when attempting to decrease the patient's adverse reactions to prescribed medications?
B. contact the hospital pharmacist
When a primary health care provider prescribes a mediation, the nurse is knowledgeable of its use, the expected outcome, and
any adverse effects and drug interactions. The nurse requests the information form the pharmacist when the informatio nis not
