B SN 225 HESI LATEST
UPDATED EXAM 2025 ( 212
QUESTIONS W ITH 100%
CORRECT ANSW ERS ALREADY
GRADED A+)
Benefits of daily exercise for pt with type two diabetes
improves blood circulation
reduces the need for insulin
lowers serum cholesterol and triglyceride levels
W hen assessing a client w ith an indw elling ur in ar y
catheter , w hich obser vation r equir es the m ost
im m ediate inter vention by the nu r se?
The drainage tubing is secured over the siderail.
The clamp on the urinary drainage bag is open.
There are no dependent loops in the drainage tubing.
The urinary drainage bag is attached to the bed frame.
The clamp on the urinary drainage bag is open
Rationale
,Maintaining a closed ur in ar y dr ainage system is
im por tant to pr event infection, so the m ost im m ediate
pr ior ity is to close the clam p (B ) to r educe the r isk for
ascending m icr oor ganism s. If the dr ain age tubing is
secur ed over the sider ail (A), ur in e w ill not be able to
fl ow out of the bladder , so the n ur se should next
r eposition the tubing. (C and D) indicate cor r ect car e of
the ur inar y dr ain age system , so docum entation of an
intact system is the last inter vention needed.
W e have an exper t-w r itten solution to this pr oblem !
The nur se encounter s r esistance w hen inser ting the
tubing into a client's r ectum for a tap w ater en em a.
W hat action should the nu r se im plem ent?
Withdraw the tube and apply additional lubricant to the tube.
Encourage the client to bear down and continue to insert the tube.
Remove the tube and check the client for a fecal impaction.
Ask the client to relax and run a small amount of fluid into the
rectum.
Ask the client to relax and run a small amount of fluid into the
rectum.
Rationale
,If r esistance is encounter ed dur ing the initial inser tion
of an en em a tube, the client should be instr ucted to r elax
w hile a sm all am ount of solution r uns thr ough the tube
into the r ectum (D) to pr om ote dilation. (A) is unlikely
to r esolve the pr oblem . (B ) m ay cause injur y. (C) should
not be im plem ented until other , less invasive actions,
such as (D) have been taken.
W hich statem ent is an exam ple of a cor r ectly w r itten
nu r sing diagnosis statem ent?
Altered tissue perfusion related to congestive heart failure.
Altered urinary elimination related to urinary tract infection.
Risk for impaired tissue integrity related to client's refusal to turn.
Ineffective coping related to response to positive biopsy test
results.
Ineffective coping related to response to positive biopsy test
results
Rationale
The fi r st par t of the nur sin g diagnosis statem ent is the
" diagnostic label" and is follow ed by " r elated to" the
cause, w hich should dir ect the nur se to the appr opr iate
inter ventions. (D) best fi ts this cr iter ia. (A and B )
contain a m edical diagnosis. (C) includes an obser vable
cause, but (D) focuses on the client's "r esponse," w hich
the nur se can pr ovide suppor t, r efl ection, and dialogu e.
, A client w ho has m oder ate, per sistent, chr onic
n eur opathic pain due to diabetic neur opathy takes
gabapentin (Neur ontin) and ibupr ofen (Motr in, Advil)
daily. If Step 2 of the W or ld Health Or ganization (W HO)
pain r elief ladder is pr escr ibed, w hich dr ug pr otocol
should be im plem ented?
Continue gabapentin.
Discontinue ibuprofen.
Add aspirin to the protocol.
Add oral methadone to the protocol.
Continue gabapentin.
Rationale
B ased on the W HO pain r elief ladder , adju nct
m edications, such as gabapentin (Neur ontin ), an
antiseizur e m edication, m ay be used at any step for
anxiety and pain m anagem ent, so (A) should be
im plem ented. Nonopiod analgesics, such as ibupr ofen
(A) and aspir in (C) ar e Step 1 dr u gs. Step 2 and 3 include
opioid nar cotics (D), and to m aintain fr eedom fr om
pain, dr ugs should be given “ ar ound the clock” r ather
than by the client’s PRN r equ ests.
W e have an exper t-w r itten solution to this pr oblem !
UPDATED EXAM 2025 ( 212
QUESTIONS W ITH 100%
CORRECT ANSW ERS ALREADY
GRADED A+)
Benefits of daily exercise for pt with type two diabetes
improves blood circulation
reduces the need for insulin
lowers serum cholesterol and triglyceride levels
W hen assessing a client w ith an indw elling ur in ar y
catheter , w hich obser vation r equir es the m ost
im m ediate inter vention by the nu r se?
The drainage tubing is secured over the siderail.
The clamp on the urinary drainage bag is open.
There are no dependent loops in the drainage tubing.
The urinary drainage bag is attached to the bed frame.
The clamp on the urinary drainage bag is open
Rationale
,Maintaining a closed ur in ar y dr ainage system is
im por tant to pr event infection, so the m ost im m ediate
pr ior ity is to close the clam p (B ) to r educe the r isk for
ascending m icr oor ganism s. If the dr ain age tubing is
secur ed over the sider ail (A), ur in e w ill not be able to
fl ow out of the bladder , so the n ur se should next
r eposition the tubing. (C and D) indicate cor r ect car e of
the ur inar y dr ain age system , so docum entation of an
intact system is the last inter vention needed.
W e have an exper t-w r itten solution to this pr oblem !
The nur se encounter s r esistance w hen inser ting the
tubing into a client's r ectum for a tap w ater en em a.
W hat action should the nu r se im plem ent?
Withdraw the tube and apply additional lubricant to the tube.
Encourage the client to bear down and continue to insert the tube.
Remove the tube and check the client for a fecal impaction.
Ask the client to relax and run a small amount of fluid into the
rectum.
Ask the client to relax and run a small amount of fluid into the
rectum.
Rationale
,If r esistance is encounter ed dur ing the initial inser tion
of an en em a tube, the client should be instr ucted to r elax
w hile a sm all am ount of solution r uns thr ough the tube
into the r ectum (D) to pr om ote dilation. (A) is unlikely
to r esolve the pr oblem . (B ) m ay cause injur y. (C) should
not be im plem ented until other , less invasive actions,
such as (D) have been taken.
W hich statem ent is an exam ple of a cor r ectly w r itten
nu r sing diagnosis statem ent?
Altered tissue perfusion related to congestive heart failure.
Altered urinary elimination related to urinary tract infection.
Risk for impaired tissue integrity related to client's refusal to turn.
Ineffective coping related to response to positive biopsy test
results.
Ineffective coping related to response to positive biopsy test
results
Rationale
The fi r st par t of the nur sin g diagnosis statem ent is the
" diagnostic label" and is follow ed by " r elated to" the
cause, w hich should dir ect the nur se to the appr opr iate
inter ventions. (D) best fi ts this cr iter ia. (A and B )
contain a m edical diagnosis. (C) includes an obser vable
cause, but (D) focuses on the client's "r esponse," w hich
the nur se can pr ovide suppor t, r efl ection, and dialogu e.
, A client w ho has m oder ate, per sistent, chr onic
n eur opathic pain due to diabetic neur opathy takes
gabapentin (Neur ontin) and ibupr ofen (Motr in, Advil)
daily. If Step 2 of the W or ld Health Or ganization (W HO)
pain r elief ladder is pr escr ibed, w hich dr ug pr otocol
should be im plem ented?
Continue gabapentin.
Discontinue ibuprofen.
Add aspirin to the protocol.
Add oral methadone to the protocol.
Continue gabapentin.
Rationale
B ased on the W HO pain r elief ladder , adju nct
m edications, such as gabapentin (Neur ontin ), an
antiseizur e m edication, m ay be used at any step for
anxiety and pain m anagem ent, so (A) should be
im plem ented. Nonopiod analgesics, such as ibupr ofen
(A) and aspir in (C) ar e Step 1 dr u gs. Step 2 and 3 include
opioid nar cotics (D), and to m aintain fr eedom fr om
pain, dr ugs should be given “ ar ound the clock” r ather
than by the client’s PRN r equ ests.
W e have an exper t-w r itten solution to this pr oblem !
