BSN366 EXIT HESI EXAM QUESTIONS
AND ANSWERS49
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
AND ANSWERS49
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
