1 2
BSN BSN
What nursing intervention is particularly indicated for the second stage of
labor?
BSN HESI 366 RN EXIT EXAM (NEW 2025 UPDATE)
QUESTIONS AND VERIFIED ANSWERS|100% CORRECT|
A) Assessing the fetal heart rate and pattern for signs of fetal distress.
GRADE A- NIGHTINGALE
B) Monitoring effects of oxytocin administration to help achieve cervical
dilation.
An adult client experiences a gasoline tank fire when riding a motorcycle
and is admitted to the emergency department (ED) with full thickness C) Providing pain medication to increase the clients tolerance of labor
burns to all surfaces of both lower extremities. What percentage of body pains.
surface area should the nurse document in the electronic medical record D) Assisting the client to push effectively so that expulsion of the fetus can
(EMR)? be achieved. - ANS ✓D) Assisting the client to push effectively so that expulsion
of the fetus can be achieved.
A) 9%
B) 36% A child with peripheral edema who weighs 44 pounds receives a
prescription for furosemide 2 mg/kg IV every 12 hours. The vile is labeled
C) 18%
10 mg/mL. How many milliliters should the nurse administer? (Enter
D) 45% - ANS ✓B) 36% numeric value only) - ANS ✓4mL
An unlicensed assistive personnel leaves the unit without notifying the Laboratory results should the nurse closely monitor in a client who has
staff. In which order should the unit manager implement these end-stage renal disease?
interventions to address the UP's behavior? (Please to actions in order
from first on top to last on bottom)
A) Erythrocytes, hemoglobin, and hematocrit.
B) Serum potassium, calcium, and phosphorus.
Discuss the issue privately with the UAP
C) Blood pressure, heart rate, and temperature.
Plan for scheduled break times
D) Leukocytes, neutrophils, and thyroxine. - ANS ✓B) Serum potassium,
Evaluate the UP for signs of improvement
calcium, and phosphorus.
Note date and time of the behavior - ANS ✓Note date and time of the behavior.
Discuss the issue privately with a UAP.
A client with a history of dementia has become increasingly confused at
Plan for scheduled break times. night and is picking at an abdominal surgical dressing and the tape
securing the IV line. The abdominal dressing is no longer inclusive, and the
Evaluate the UPC for signs of improvement.
IV insertion site is pink. Which intervention should the nurse implement?
NO QUESTION 32 - ANS ✓ A) Leave the lights on in the room at night.
BSN HESI BSN HESI
, 3 4
BSN BSN
B) Re-dress the abdominal incision. C) Perform a 12 lead electro cardiogram.
C) Apply soft bilateral wrist restraints. D) Take an initial respiratory rate.
D) Replace the IV site with a smaller gauge. - ANS ✓B) Re-dress the abdominal E) Suction the client to clear the airway.
incision.
F) Restrain the client with soft restraints. - ANS ✓B) Ask the client about other
medication's she takes.
The nurse is planning care for a client who admits to having suicidal D) Take an initial respiratory rate.
thoughts. Which client behavior indicates the highest risk for the client
??????
acting on the suicidal thoughts?
NGN: a client is a 42 year old female who had a right above the knee
A) Begins to show signs of improvement in effect.
amputation for osteomyelitis. The client has a drain in place in a surgical
B) Expresses feelings of sadness and loneliness. dressing that will need to be changed by the surgeon on postop day. (what
other medication's would the nurse expect the surgeon to prescribe along
C) Neglects personal hygiene and has no appetite.
with morphine? SATA)
D) Lacks interest in the activities of family and friends. - ANS ✓A) Begins to
show signs of improvement in effect.
A) Docusate sodium
B) Methadone
NGN: The client is a 42-year-old female who had a right above the knee
amputation for osteomyelitis. The client has a drain in place in the surgical C) Propofol
dressing that will need to be changed by the surgeon on postop day. D) Naloxone
(Choose the most likely options for the information missing from the E) Senna
statement.)
F) Ibuprofen - ANS ✓A) Docusate sodium (for constipation)
D) Naloxone (PRN for respiratory depression)
Morphine is a ______________ and it activates ________________ receptors and is
used to relieve ______________. - ANS ✓Agonist-antagonist opioid , beta , pain? F) Ibuprofen (help maintain breakthrough pain)
NGN: a client is a 42 year old female who had a right above the knee NGN: a client is a 42 year old female who had a right above the knee
amputation for osteomyelitis. The client has a drain in place in a surgical amputation for osteomyelitis. The client has a drain in place in a surgical
dressing that will need to be changed by the surgeon on postop day. (What dressing that will need to be changed by the surgeon on postop day. (what
actions should the nurse take to assure safety during morphine side effects of morphine could contribute to this client's fall risk?)
administration? SATA)
A) urinary retention
A) Have a manual resuscitation bag at the bedside. B) seizures
B) Ask the client about other medication's she takes. C) orthostatic hypotension
BSN HESI BSN HESI
, 5 6
BSN BSN
D) sedation (for each statement, click to indicate whether the statements by the student
nurse indicates understanding or no understanding of naloxone.)
E) nausea
F) itching
-"If the first dose does not work you can give as many doses as needed to
G) euphoria - ANS ✓C) orthostatic hypotension
reverse respiratory depression."
D) sedation -"Naloxone works best on pure agonist opioids."
E) nausea -"Naloxone will not affect the clients level of pain."
???????? -"You can give naloxone IV, IM or subcutaneously."
-"When given IV in the lock zone starts working immediately and can last
NGN: a client is a 42 year old female who had a right above the knee several hours." - ANS ✓-"If the first dose does not work you can give as many
amputation for osteomyelitis. The client has a drain in place in a surgical doses as needed to reverse respiratory depression." (UNDERSTANDING)
dressing that will need to be changed by the surgeon on postop day.
-"Naloxone works best on pure agonist opioids." (UNDERSTANDING)
ORDERS: 1400 admit to the surgical floor. Clear liquid diet, advance as
-"Naloxone will not affect the clients level of pain." (NOT UNDERSTANDING)
tolerated. Continuous cardio respiratory monitoring. Morphine 1 mg/h IV.
Alert surgeon to signs of bleeding or infection in the surgical site. 1500 -"You can give naloxone IV, IM or subcutaneously." (UNDERSTANDING)
docusate sodium 240 mg orally every a.m. Naloxone 2 mg IV as needed for
-"When given IV in the lock zone starts working immediately and can last
respiratory depression. Ibuprofen 600 mg orally every six hours.
several hours." (NOT UNDERSTANDING)
???????????
A) Provide rescue breaths with a manual ventilation bag.
B) Call for rapid response.
An older adult client with a history of cataracts is recovering from
C) Apply oxygen via nasal cannula. intraocular lens implant surgery to the left eye. During the post-procedure.,
Which intervention should the nurse implement?
D) Perform chest compressions.
E) Print an electrocardio gram strip.
A) Encourage deep breathing and coughing exercises.
F) Give naloxone 2 mg IV. - ANS ✓A) Provide rescue breaths with a manual
ventilation bag. B) Obtain vital signs every two hours during hospitalization.
B) Call for rapid response. C) Provide an eye shield to be worn while sleeping.
D) Perform chest compressions. D) Teach a family member to administer eyedrops. - ANS ✓C) Provide an eye
shield to be worn while sleeping.
F) Give naloxone 2 mg IV.
An adult client is admitted to the critical care unit with systemic
NGN: a client is a 42 year old female who had a right above the knee
inflammatory response syndrome (SIRS) as a result of a postbur infection.
amputation for osteomyelitis. The client has a drain in place in a surgical
The client has a long line peripherally inserted IV catheter for fluid and
dressing that will need to be changed by the surgeon on postop day.
medication administration and current vital signs include temperature
BSN HESI BSN HESI
BSN BSN
What nursing intervention is particularly indicated for the second stage of
labor?
BSN HESI 366 RN EXIT EXAM (NEW 2025 UPDATE)
QUESTIONS AND VERIFIED ANSWERS|100% CORRECT|
A) Assessing the fetal heart rate and pattern for signs of fetal distress.
GRADE A- NIGHTINGALE
B) Monitoring effects of oxytocin administration to help achieve cervical
dilation.
An adult client experiences a gasoline tank fire when riding a motorcycle
and is admitted to the emergency department (ED) with full thickness C) Providing pain medication to increase the clients tolerance of labor
burns to all surfaces of both lower extremities. What percentage of body pains.
surface area should the nurse document in the electronic medical record D) Assisting the client to push effectively so that expulsion of the fetus can
(EMR)? be achieved. - ANS ✓D) Assisting the client to push effectively so that expulsion
of the fetus can be achieved.
A) 9%
B) 36% A child with peripheral edema who weighs 44 pounds receives a
prescription for furosemide 2 mg/kg IV every 12 hours. The vile is labeled
C) 18%
10 mg/mL. How many milliliters should the nurse administer? (Enter
D) 45% - ANS ✓B) 36% numeric value only) - ANS ✓4mL
An unlicensed assistive personnel leaves the unit without notifying the Laboratory results should the nurse closely monitor in a client who has
staff. In which order should the unit manager implement these end-stage renal disease?
interventions to address the UP's behavior? (Please to actions in order
from first on top to last on bottom)
A) Erythrocytes, hemoglobin, and hematocrit.
B) Serum potassium, calcium, and phosphorus.
Discuss the issue privately with the UAP
C) Blood pressure, heart rate, and temperature.
Plan for scheduled break times
D) Leukocytes, neutrophils, and thyroxine. - ANS ✓B) Serum potassium,
Evaluate the UP for signs of improvement
calcium, and phosphorus.
Note date and time of the behavior - ANS ✓Note date and time of the behavior.
Discuss the issue privately with a UAP.
A client with a history of dementia has become increasingly confused at
Plan for scheduled break times. night and is picking at an abdominal surgical dressing and the tape
securing the IV line. The abdominal dressing is no longer inclusive, and the
Evaluate the UPC for signs of improvement.
IV insertion site is pink. Which intervention should the nurse implement?
NO QUESTION 32 - ANS ✓ A) Leave the lights on in the room at night.
BSN HESI BSN HESI
, 3 4
BSN BSN
B) Re-dress the abdominal incision. C) Perform a 12 lead electro cardiogram.
C) Apply soft bilateral wrist restraints. D) Take an initial respiratory rate.
D) Replace the IV site with a smaller gauge. - ANS ✓B) Re-dress the abdominal E) Suction the client to clear the airway.
incision.
F) Restrain the client with soft restraints. - ANS ✓B) Ask the client about other
medication's she takes.
The nurse is planning care for a client who admits to having suicidal D) Take an initial respiratory rate.
thoughts. Which client behavior indicates the highest risk for the client
??????
acting on the suicidal thoughts?
NGN: a client is a 42 year old female who had a right above the knee
A) Begins to show signs of improvement in effect.
amputation for osteomyelitis. The client has a drain in place in a surgical
B) Expresses feelings of sadness and loneliness. dressing that will need to be changed by the surgeon on postop day. (what
other medication's would the nurse expect the surgeon to prescribe along
C) Neglects personal hygiene and has no appetite.
with morphine? SATA)
D) Lacks interest in the activities of family and friends. - ANS ✓A) Begins to
show signs of improvement in effect.
A) Docusate sodium
B) Methadone
NGN: The client is a 42-year-old female who had a right above the knee
amputation for osteomyelitis. The client has a drain in place in the surgical C) Propofol
dressing that will need to be changed by the surgeon on postop day. D) Naloxone
(Choose the most likely options for the information missing from the E) Senna
statement.)
F) Ibuprofen - ANS ✓A) Docusate sodium (for constipation)
D) Naloxone (PRN for respiratory depression)
Morphine is a ______________ and it activates ________________ receptors and is
used to relieve ______________. - ANS ✓Agonist-antagonist opioid , beta , pain? F) Ibuprofen (help maintain breakthrough pain)
NGN: a client is a 42 year old female who had a right above the knee NGN: a client is a 42 year old female who had a right above the knee
amputation for osteomyelitis. The client has a drain in place in a surgical amputation for osteomyelitis. The client has a drain in place in a surgical
dressing that will need to be changed by the surgeon on postop day. (What dressing that will need to be changed by the surgeon on postop day. (what
actions should the nurse take to assure safety during morphine side effects of morphine could contribute to this client's fall risk?)
administration? SATA)
A) urinary retention
A) Have a manual resuscitation bag at the bedside. B) seizures
B) Ask the client about other medication's she takes. C) orthostatic hypotension
BSN HESI BSN HESI
, 5 6
BSN BSN
D) sedation (for each statement, click to indicate whether the statements by the student
nurse indicates understanding or no understanding of naloxone.)
E) nausea
F) itching
-"If the first dose does not work you can give as many doses as needed to
G) euphoria - ANS ✓C) orthostatic hypotension
reverse respiratory depression."
D) sedation -"Naloxone works best on pure agonist opioids."
E) nausea -"Naloxone will not affect the clients level of pain."
???????? -"You can give naloxone IV, IM or subcutaneously."
-"When given IV in the lock zone starts working immediately and can last
NGN: a client is a 42 year old female who had a right above the knee several hours." - ANS ✓-"If the first dose does not work you can give as many
amputation for osteomyelitis. The client has a drain in place in a surgical doses as needed to reverse respiratory depression." (UNDERSTANDING)
dressing that will need to be changed by the surgeon on postop day.
-"Naloxone works best on pure agonist opioids." (UNDERSTANDING)
ORDERS: 1400 admit to the surgical floor. Clear liquid diet, advance as
-"Naloxone will not affect the clients level of pain." (NOT UNDERSTANDING)
tolerated. Continuous cardio respiratory monitoring. Morphine 1 mg/h IV.
Alert surgeon to signs of bleeding or infection in the surgical site. 1500 -"You can give naloxone IV, IM or subcutaneously." (UNDERSTANDING)
docusate sodium 240 mg orally every a.m. Naloxone 2 mg IV as needed for
-"When given IV in the lock zone starts working immediately and can last
respiratory depression. Ibuprofen 600 mg orally every six hours.
several hours." (NOT UNDERSTANDING)
???????????
A) Provide rescue breaths with a manual ventilation bag.
B) Call for rapid response.
An older adult client with a history of cataracts is recovering from
C) Apply oxygen via nasal cannula. intraocular lens implant surgery to the left eye. During the post-procedure.,
Which intervention should the nurse implement?
D) Perform chest compressions.
E) Print an electrocardio gram strip.
A) Encourage deep breathing and coughing exercises.
F) Give naloxone 2 mg IV. - ANS ✓A) Provide rescue breaths with a manual
ventilation bag. B) Obtain vital signs every two hours during hospitalization.
B) Call for rapid response. C) Provide an eye shield to be worn while sleeping.
D) Perform chest compressions. D) Teach a family member to administer eyedrops. - ANS ✓C) Provide an eye
shield to be worn while sleeping.
F) Give naloxone 2 mg IV.
An adult client is admitted to the critical care unit with systemic
NGN: a client is a 42 year old female who had a right above the knee
inflammatory response syndrome (SIRS) as a result of a postbur infection.
amputation for osteomyelitis. The client has a drain in place in a surgical
The client has a long line peripherally inserted IV catheter for fluid and
dressing that will need to be changed by the surgeon on postop day.
medication administration and current vital signs include temperature
BSN HESI BSN HESI
