BSN 366 HESI EXIT EXAM V2 QUESTIONS &
ANSWERS
The nurse knows that which statement by the mother indicates that the mother
understands safety precautions with her four month-old infant and her 4 year-old child?
- Answers -I have the four year-old hold and help feed the four month-old a bottle in the
kitchen
Upon completing the admission documents, the nurse learns that the 87 year-old client
does not have an advance directive. What action should the nurse take? - Answers -
Give information about advance directives
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after
the immunization was given, the client complains of itchy and watery eyes, increased
anxiety, and difficulty breathing. The nurse expects that the first action in the sequence
of care for this client will be to: - Answers -Administer epinephrine 1:1000 as ordered
Which of these children at the site of a disaster at a child day care center would the
triage nurse put in the "treat last" category? - Answers -A toddler with severe deep
abrasions over 98% of the body
When admitting a client to an acute care facility, an identification bracelet is sent up with
the admission form. In the event these do not match, the nurse's best action is to -
Answers -Notify the admissions office and wait to apply the bracelet
The nurse is having difficulty reading the health care provider's written order that was
written right before the shift change. What action should be taken? - Answers -Call the
provider for clarification
An adult client is found to be unresponsive on morning rounds. After checking for
responsiveness and calling for help, the next action that should be taken by the nurse is
to: - Answers -Open the client's airway
A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers
that 800 ml has been infused after 4 hours. What is the priority nursing action? -
Answers -Auscultate the lungs
Following change-of-shift report on an orthopedic unit, which client should the nurse see
first? - Answers -72 year old recovering from surgery after a hip replacement 2 hours
ago
A nurse observes a family member administer a rectal suppository by having the client
lie on the left side for the administration. The family member pushed the suppository
until the finger went up to the second knuckle. After 10 minutes the client was told by
, the family member to turn to the right side and the client did this. What is the
appropriate comment for the nurse to make? - Answers -That was done correctly. Did
you have any problems with the insertion?
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has
died. Which type of precautions is the appropriate type to use when performing
postmortem care? - Answers -Contact Precautions
The nurse is reviewing with a client how to collect a clean catch urine specimen. Which
sequence is appropriate teaching? - Answers -Clean the meatus, begin voiding, then
catch urine stream
The provider orders Lanoxin (digoxin) 125 mg PO and furosomide 40 mg everyday.
Which of these foods would the nurse reinforce for the client to eat at least daily? -
Answers -watermelon
A nurse is stuck in the hand by an exposed needle. What immediate action should the
nurse take? - Answers -Immediately wash the hands with vigor
As the nurse observes the student nurse during the administration of a narcotic
analgesic IM injection, the nurse notes that the student begins to give the medication
without first aspirating. What should the nurse do? - Answers -Walk up and whisper in
the student's ear "Stop. Aspirate. Then inject."
A client with Guillain Barre is in a non responsive state, yet vital signs are stable and
breathing is independent. What should the nurse document to most accurately describe
the client's condition? - Answers -Glascow Coma Scale 8, respirations regular
A client enters the emergency department unconscious via ambulance from the client's
work place. What document should be given priority to guide the direction of care for
this client? - Answers -A notarized original of advance directives brought in by the
partner
The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive
personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by
the nurse manager? - Answers -An admission at the change of shifts with atrial
fibrillation and heart failure - PN
A mother brings her 3 month-old into the clinic, complaining that the child seems to be
spitting up all the time and has a lot of gas. The nurse expects to find which of the
following on the initial history and physical assessment? - Answers -Restlessness and
increased mucus production
As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the
parents require follow-up and are consistent with the diagnosis? - Answers -"Clothes
are becoming tighter across her abdomen."
ANSWERS
The nurse knows that which statement by the mother indicates that the mother
understands safety precautions with her four month-old infant and her 4 year-old child?
- Answers -I have the four year-old hold and help feed the four month-old a bottle in the
kitchen
Upon completing the admission documents, the nurse learns that the 87 year-old client
does not have an advance directive. What action should the nurse take? - Answers -
Give information about advance directives
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after
the immunization was given, the client complains of itchy and watery eyes, increased
anxiety, and difficulty breathing. The nurse expects that the first action in the sequence
of care for this client will be to: - Answers -Administer epinephrine 1:1000 as ordered
Which of these children at the site of a disaster at a child day care center would the
triage nurse put in the "treat last" category? - Answers -A toddler with severe deep
abrasions over 98% of the body
When admitting a client to an acute care facility, an identification bracelet is sent up with
the admission form. In the event these do not match, the nurse's best action is to -
Answers -Notify the admissions office and wait to apply the bracelet
The nurse is having difficulty reading the health care provider's written order that was
written right before the shift change. What action should be taken? - Answers -Call the
provider for clarification
An adult client is found to be unresponsive on morning rounds. After checking for
responsiveness and calling for help, the next action that should be taken by the nurse is
to: - Answers -Open the client's airway
A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers
that 800 ml has been infused after 4 hours. What is the priority nursing action? -
Answers -Auscultate the lungs
Following change-of-shift report on an orthopedic unit, which client should the nurse see
first? - Answers -72 year old recovering from surgery after a hip replacement 2 hours
ago
A nurse observes a family member administer a rectal suppository by having the client
lie on the left side for the administration. The family member pushed the suppository
until the finger went up to the second knuckle. After 10 minutes the client was told by
, the family member to turn to the right side and the client did this. What is the
appropriate comment for the nurse to make? - Answers -That was done correctly. Did
you have any problems with the insertion?
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has
died. Which type of precautions is the appropriate type to use when performing
postmortem care? - Answers -Contact Precautions
The nurse is reviewing with a client how to collect a clean catch urine specimen. Which
sequence is appropriate teaching? - Answers -Clean the meatus, begin voiding, then
catch urine stream
The provider orders Lanoxin (digoxin) 125 mg PO and furosomide 40 mg everyday.
Which of these foods would the nurse reinforce for the client to eat at least daily? -
Answers -watermelon
A nurse is stuck in the hand by an exposed needle. What immediate action should the
nurse take? - Answers -Immediately wash the hands with vigor
As the nurse observes the student nurse during the administration of a narcotic
analgesic IM injection, the nurse notes that the student begins to give the medication
without first aspirating. What should the nurse do? - Answers -Walk up and whisper in
the student's ear "Stop. Aspirate. Then inject."
A client with Guillain Barre is in a non responsive state, yet vital signs are stable and
breathing is independent. What should the nurse document to most accurately describe
the client's condition? - Answers -Glascow Coma Scale 8, respirations regular
A client enters the emergency department unconscious via ambulance from the client's
work place. What document should be given priority to guide the direction of care for
this client? - Answers -A notarized original of advance directives brought in by the
partner
The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive
personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by
the nurse manager? - Answers -An admission at the change of shifts with atrial
fibrillation and heart failure - PN
A mother brings her 3 month-old into the clinic, complaining that the child seems to be
spitting up all the time and has a lot of gas. The nurse expects to find which of the
following on the initial history and physical assessment? - Answers -Restlessness and
increased mucus production
As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the
parents require follow-up and are consistent with the diagnosis? - Answers -"Clothes
are becoming tighter across her abdomen."
