Exit Hesi (BSN 366- V3)
A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures
prior to leaving the unit for the operating room. What would be the most appropriate intervention by
the nurse? CORRECT ANS: Ask the client if the preference would be to remove the dentures in the
operating room receiving area
The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic.
Which form of evaluation would best measure learning? CORRECT ANS: Reported behavioral changes
The nurse is planning care for an 18 month-old child. Which action should be included in the child's
care? CORRECT ANS: Encourage the child to feed himself finger food
A partner is concerned because the client frequently daydreams about moving to Arizona to get away
from the pollution and crowding in southern California. The nurse explains that CORRECT ANS: Such
fantasies can gratify unconscious wishes or prepare for anticipated future events
An appropriate goal for a client with anxiety would be to CORRECT ANS: Learn self-help techniques
While the nurse is administering medications to a client, the client states "I do not want to take that
medicine today." Which of the following responses by the nurse would be best? CORRECT ANS: "Is there
a reason why you don't want to take your medicine?"
While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the
following assessments is appropriate for the nurse to perform? CORRECT ANS: Auscultate the mass
A client is admitted to the hospital with a history of confusion. The client has difficulty remembering
recent events and becomes disoriented when away from home. Which statement would provide the
best reality orientation for this client? CORRECT ANS: "Good morning. You're in the hospital. I am your
nurse Elaine Jones."
,The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of
fluids for an infant until about 12 months of age? CORRECT ANS: Formula or breast milk
The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be affected by
the injury. Which statement is true concerning long bone fractures in children? CORRECT ANS:
Epiphyseal fractures often interrupt a child's normal growth pattern
The nurse is assessing a client who states her last menstrual period was March 16, and she has missed
one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What
will the nurse calculate as the estimated date of delivery (EDD)? CORRECT ANS: December 23
When screening children for scoliosis, at what time of development would the nurse expect early signs
to appear? CORRECT ANS: During the preadolescent growth spurt
A client with congestive heart failure is newly admitted to home health care. The nurse discovers that
the client has not been following the prescribed diet. What would be the most appropriate nursing
action? CORRECT ANS: Discuss diet with the client to learn the reasons for not following the diet
A client states, "People think I'm no good, you know what I mean?" Which of these responses would be
most therapeutic? CORRECT ANS: "I'm not sure what you mean. Tell me a bit more about that."
A client being treated for hypertension returns to the community clinic for follow up. The client says, "I
know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living,
and I can't be stopping every 20 minutes to go to the bathroom." Which of these is the best nursing
diagnosis? CORRECT ANS: Noncompliance related to medication side effects
When teaching effective stress management techniques to a client 1 hour before surgery, which of the
following should the nurse recommend? CORRECT ANS: Deep breathing
When observing 4 year-old children playing in the hospital playroom, what activity would the nurse
expect to see the children participating in? CORRECT ANS: Playing cooperatively with other preschoolers
, The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding?
CORRECT ANS: Hold a rattle
When teaching a 10 year-old child about their impending heart surgery, which form of explanation
meets the developmental needs of this age child? CORRECT ANS: Explain the surgery using a model of
the heart
The parents of a child who has suddenly been hospitalized for an acute illness state that they should
have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with
the parents' comments? CORRECT ANS: Accept their feelings without judgment
When caring for a client who is receiving a thrombolytic agent to open a clot occluded coronary artery
after a myocardial infarction, which finding would be of greatest concern to the nurse? CORRECT ANS:
Hematemesis
When caring for a client with total parenteral nutrition (TPN), what is the most important action on the
part of the nurse? CORRECT ANS: Sterile technique for dressing change at IV site
A 52 year-old client is being transfused with one unit of packed cells. A half hour after the transfusion
was initiated, the client complains of chills and headache. Which action should the nurse implement
first? CORRECT ANS: Stop the transfusion
An adolescent client is hospitalized with menarthrosis from a Hemophilia A bleeding episode. Which
order should be questioned by the nurse? CORRECT ANS: Aspirin for pain management
The nurse is giving instructions to the mother of a newborn infant with oral candidiasis. Which
statement by the mother would indicate the need for further teaching? CORRECT ANS: "The therapy can
be discontinued when the spots disappear."
A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures
prior to leaving the unit for the operating room. What would be the most appropriate intervention by
the nurse? CORRECT ANS: Ask the client if the preference would be to remove the dentures in the
operating room receiving area
The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic.
Which form of evaluation would best measure learning? CORRECT ANS: Reported behavioral changes
The nurse is planning care for an 18 month-old child. Which action should be included in the child's
care? CORRECT ANS: Encourage the child to feed himself finger food
A partner is concerned because the client frequently daydreams about moving to Arizona to get away
from the pollution and crowding in southern California. The nurse explains that CORRECT ANS: Such
fantasies can gratify unconscious wishes or prepare for anticipated future events
An appropriate goal for a client with anxiety would be to CORRECT ANS: Learn self-help techniques
While the nurse is administering medications to a client, the client states "I do not want to take that
medicine today." Which of the following responses by the nurse would be best? CORRECT ANS: "Is there
a reason why you don't want to take your medicine?"
While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the
following assessments is appropriate for the nurse to perform? CORRECT ANS: Auscultate the mass
A client is admitted to the hospital with a history of confusion. The client has difficulty remembering
recent events and becomes disoriented when away from home. Which statement would provide the
best reality orientation for this client? CORRECT ANS: "Good morning. You're in the hospital. I am your
nurse Elaine Jones."
,The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of
fluids for an infant until about 12 months of age? CORRECT ANS: Formula or breast milk
The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be affected by
the injury. Which statement is true concerning long bone fractures in children? CORRECT ANS:
Epiphyseal fractures often interrupt a child's normal growth pattern
The nurse is assessing a client who states her last menstrual period was March 16, and she has missed
one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What
will the nurse calculate as the estimated date of delivery (EDD)? CORRECT ANS: December 23
When screening children for scoliosis, at what time of development would the nurse expect early signs
to appear? CORRECT ANS: During the preadolescent growth spurt
A client with congestive heart failure is newly admitted to home health care. The nurse discovers that
the client has not been following the prescribed diet. What would be the most appropriate nursing
action? CORRECT ANS: Discuss diet with the client to learn the reasons for not following the diet
A client states, "People think I'm no good, you know what I mean?" Which of these responses would be
most therapeutic? CORRECT ANS: "I'm not sure what you mean. Tell me a bit more about that."
A client being treated for hypertension returns to the community clinic for follow up. The client says, "I
know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living,
and I can't be stopping every 20 minutes to go to the bathroom." Which of these is the best nursing
diagnosis? CORRECT ANS: Noncompliance related to medication side effects
When teaching effective stress management techniques to a client 1 hour before surgery, which of the
following should the nurse recommend? CORRECT ANS: Deep breathing
When observing 4 year-old children playing in the hospital playroom, what activity would the nurse
expect to see the children participating in? CORRECT ANS: Playing cooperatively with other preschoolers
, The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding?
CORRECT ANS: Hold a rattle
When teaching a 10 year-old child about their impending heart surgery, which form of explanation
meets the developmental needs of this age child? CORRECT ANS: Explain the surgery using a model of
the heart
The parents of a child who has suddenly been hospitalized for an acute illness state that they should
have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with
the parents' comments? CORRECT ANS: Accept their feelings without judgment
When caring for a client who is receiving a thrombolytic agent to open a clot occluded coronary artery
after a myocardial infarction, which finding would be of greatest concern to the nurse? CORRECT ANS:
Hematemesis
When caring for a client with total parenteral nutrition (TPN), what is the most important action on the
part of the nurse? CORRECT ANS: Sterile technique for dressing change at IV site
A 52 year-old client is being transfused with one unit of packed cells. A half hour after the transfusion
was initiated, the client complains of chills and headache. Which action should the nurse implement
first? CORRECT ANS: Stop the transfusion
An adolescent client is hospitalized with menarthrosis from a Hemophilia A bleeding episode. Which
order should be questioned by the nurse? CORRECT ANS: Aspirin for pain management
The nurse is giving instructions to the mother of a newborn infant with oral candidiasis. Which
statement by the mother would indicate the need for further teaching? CORRECT ANS: "The therapy can
be discontinued when the spots disappear."
