BSN366 EXIT HESI
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 ANS: 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 ANS: 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 ANS: 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 ANS: 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
_________________ ANS: 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 ANS: 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 ANS: 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.)
For each teaching point, click to indicate whether it is indicated or contraindicated. Only one right
option per row.
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 ANS: 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 ANS: 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 ANS: 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 ANS: 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
_________________ ANS: 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 ANS: 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 ANS: 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.)
For each teaching point, click to indicate whether it is indicated or contraindicated. Only one right
option per row.
