BSN366 EXIT HESI
What is the most effective way to implement a teaching plan?
1. Teach the information that the client wants to learn first.
2. Streamline the teaching plan to include only essential information.
3. Present to the client all the information necessary to meet the objectives.
4. Provide the client with written material to review before teaching sessions. - ✔️✔️1.
Teach the information that the client wants to learn first.
The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood
pressure is typically 120/60 in the same arm. What action should the nurse implement
first?
1. Use an electronic sphygmomanometer to take the BP every 30 minutes.
2. Retake the blood pressure in the same arm, deflating the cuff slowly.
3. Ask another nurse to recheck the blood pressure to compare results.
4. Obtain another blood pressure cuff and retake the blood pressure. - ✔️✔️2. Retake
the blood pressure in the same arm, deflating the cuff slowly.
A male client on a psychiatric unit becomes extremely agitated and begins to smash his
head against doors. He seems frightened, and his verbalizations suggest he is
experiencing distorted sensory perceptions. What action should the nurse take first?
1. Place the client in mechanical restraints until calm.
2. Administer a PRN dose of haloperidol (Haldol) IM.
3. Use a calm, soothing voice to diffuse the situation.
4. Encourage the client to focus on his feelings of anger. - ✔️✔️1. Place the client in
mechanical restraints until calm
Designated funds are received to address the healthcare needs of a community's
vulnerable populations. Which group qualifies for this funding?
1. African-American women who are 30 to 35 years of age.
2. Survivors of violence that occurred at least 5 years ago.
3. Active armed forces reserve unit returning from Europe.
4. Full-time students who are attending public colleges. - ✔️✔️2. Survivors of violence
that occurred at least 5 years ago
The nurse is caring for a client with a nursing problem of, "Infection, risk for, related to
inadequate primary defenses as evidenced by surgical incision and IV access." What
nursing intervention should the nurse implement?
1. Limit visitors to immediate family to decrease exposure to infection.
2. Maintain "clean" technique in the change of wound dressing and IV site.
3. Assess and document skin condition around the incision and IV site at each shift.
4. Require the use of a face mask by staff when providing care requiring close contact. -
✔️✔️3. Assess and document skin condition around the incision and IV site at each
,shift.
A client with ulcerative colitis is scheduled for surgical creation of an ileoanal reservoir
(J pouch). As part of preoperative teaching, what information should the nurse provide?
1. The transverse loop ostomy is permanent.
2. Easily removable appliances allow independence in self-care.
3. Daily irrigation is started after the J pouch heals.
4. Stool is eventually expelled through the rectum. - ✔️✔️4. Stool is eventually
expelled through the rectum.
The nurse inflates the cuff on a tracheostomy tube to minimal occlusion pressure for a
client who is breathing spontaneously. Which action should the nurse follow?
1. Check the pilot balloon to ensure that it is firm.
2. Verify the healthcare provider's prescription for the required cuff pressure.
3. Use a manometer to maintain cuff pressure between 25 and 30 mmHg.
4. Inject air until no air is auscultated over the larynx during a deep breath. - ✔️✔️4.
Inject air until no air is auscultated over the larynx during a deep breath.
A 60-year-old homeless man who complains of a cough, late-afternoon fever, and night
sweats has a 10 mm induration after receiving a purified protein derivative (PPD) skin
test. Which action should the nurse implement?
1. Refer for further diagnostic evaluation.
2. Determine exposure of others to the tuberculosis.
3. Begin anti-tubercular drug therapy.
4. Quarantine or isolate to control communicability. - ✔️✔️1. Refer for further
diagnostic evaluation.
Which contextual factors are considered external environmental influences in the
framework for occupational health programs and services? (Select all that apply.)
Select all that apply
1. Economics.
2. Workforce.
3. Technology.
4. Interventions.
5. Socio-economic status.
6. Legislation/regulation. - ✔️✔️1. Economics.
3. Technology.
6. Legislation/regulation.
The nurse is analyzing the waveforms of a client's electrocardiogram. What finding
indicates a disturbance in electrical conduction in the ventricles?
1. T wave of 0.16 second.
2. PR interval of 0.18 second.
3. QT interval of 0.34 second.
4. QRS interval of 0.14 second. - ✔️✔️4. QRS interval of 0.14 second.
, The nurse is assigned a client with numerous treatments and decides it is not possible
to complete all the needed treatments in the time scheduled for this shift. Which process
should the nurse use?
1. Delegate tasks to competent team members.
2. Prioritize tasks with the most crucial needs first.
3. Report the incomplete treatments to next shift nurse.
4. Start with the easiest treatment first. - ✔️✔️2. Prioritize tasks with the most crucial
needs first.
A male client is on contact precautions due to an infected draining wound and is being
discharged home. The client lives at home with his wife and their adolescent daughter.
What discharge instruction should the nurse include for the client?
1. Use disposable plates and utensils.
2. Stay in a room with the door closed.
3. Dispose of soiled dressings in plastic bags that are securely closed.
4. Others who are in the same room with the client should wear a mask. - ✔️✔️3.
Dispose of soiled dressings in plastic bags that are securely closed.
A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has
not been sleeping well lately and is experiencing labored breathing. List the client's
problems in order of priority for the nurse. (Rank in the priority order from highest to
lowest.)
1. Airway and breathing.
2. Pain management.
3. Definitive therapy.
4. Sleep and rest. - ✔️✔️1.Airway and breathing. 2.Pain management. 3.Sleep and
rest. 4.Definitive therapy.
Which biological practices are federally regulated for healthcare workers? (Select all
that apply.)
Select all that apply
1.Standard precautions.
2. N-95 tuberculosis standard.
3. Blood-borne pathogen standard.
4. Biological product exposure limit (BPEL).
5. Resource Conservation and Recovery Act (RCRA).
6. As Low as Reasonably Allowable standard (ALARA). - ✔️✔️3. Blood-borne
pathogen standard.
5. Resource Conservation and Recovery Act (RCRA)
A client with severe depression tells the nurse, "I do not know why you bother with me
or give me pills. I am never going to get well." What is the most therapeutic response?
1. "You need to stop thinking negative thoughts. They get in the way of your recovery."
2. "You are no bother to me or to the staff. We want you to get well and not feel sad
anymore."
What is the most effective way to implement a teaching plan?
1. Teach the information that the client wants to learn first.
2. Streamline the teaching plan to include only essential information.
3. Present to the client all the information necessary to meet the objectives.
4. Provide the client with written material to review before teaching sessions. - ✔️✔️1.
Teach the information that the client wants to learn first.
The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood
pressure is typically 120/60 in the same arm. What action should the nurse implement
first?
1. Use an electronic sphygmomanometer to take the BP every 30 minutes.
2. Retake the blood pressure in the same arm, deflating the cuff slowly.
3. Ask another nurse to recheck the blood pressure to compare results.
4. Obtain another blood pressure cuff and retake the blood pressure. - ✔️✔️2. Retake
the blood pressure in the same arm, deflating the cuff slowly.
A male client on a psychiatric unit becomes extremely agitated and begins to smash his
head against doors. He seems frightened, and his verbalizations suggest he is
experiencing distorted sensory perceptions. What action should the nurse take first?
1. Place the client in mechanical restraints until calm.
2. Administer a PRN dose of haloperidol (Haldol) IM.
3. Use a calm, soothing voice to diffuse the situation.
4. Encourage the client to focus on his feelings of anger. - ✔️✔️1. Place the client in
mechanical restraints until calm
Designated funds are received to address the healthcare needs of a community's
vulnerable populations. Which group qualifies for this funding?
1. African-American women who are 30 to 35 years of age.
2. Survivors of violence that occurred at least 5 years ago.
3. Active armed forces reserve unit returning from Europe.
4. Full-time students who are attending public colleges. - ✔️✔️2. Survivors of violence
that occurred at least 5 years ago
The nurse is caring for a client with a nursing problem of, "Infection, risk for, related to
inadequate primary defenses as evidenced by surgical incision and IV access." What
nursing intervention should the nurse implement?
1. Limit visitors to immediate family to decrease exposure to infection.
2. Maintain "clean" technique in the change of wound dressing and IV site.
3. Assess and document skin condition around the incision and IV site at each shift.
4. Require the use of a face mask by staff when providing care requiring close contact. -
✔️✔️3. Assess and document skin condition around the incision and IV site at each
,shift.
A client with ulcerative colitis is scheduled for surgical creation of an ileoanal reservoir
(J pouch). As part of preoperative teaching, what information should the nurse provide?
1. The transverse loop ostomy is permanent.
2. Easily removable appliances allow independence in self-care.
3. Daily irrigation is started after the J pouch heals.
4. Stool is eventually expelled through the rectum. - ✔️✔️4. Stool is eventually
expelled through the rectum.
The nurse inflates the cuff on a tracheostomy tube to minimal occlusion pressure for a
client who is breathing spontaneously. Which action should the nurse follow?
1. Check the pilot balloon to ensure that it is firm.
2. Verify the healthcare provider's prescription for the required cuff pressure.
3. Use a manometer to maintain cuff pressure between 25 and 30 mmHg.
4. Inject air until no air is auscultated over the larynx during a deep breath. - ✔️✔️4.
Inject air until no air is auscultated over the larynx during a deep breath.
A 60-year-old homeless man who complains of a cough, late-afternoon fever, and night
sweats has a 10 mm induration after receiving a purified protein derivative (PPD) skin
test. Which action should the nurse implement?
1. Refer for further diagnostic evaluation.
2. Determine exposure of others to the tuberculosis.
3. Begin anti-tubercular drug therapy.
4. Quarantine or isolate to control communicability. - ✔️✔️1. Refer for further
diagnostic evaluation.
Which contextual factors are considered external environmental influences in the
framework for occupational health programs and services? (Select all that apply.)
Select all that apply
1. Economics.
2. Workforce.
3. Technology.
4. Interventions.
5. Socio-economic status.
6. Legislation/regulation. - ✔️✔️1. Economics.
3. Technology.
6. Legislation/regulation.
The nurse is analyzing the waveforms of a client's electrocardiogram. What finding
indicates a disturbance in electrical conduction in the ventricles?
1. T wave of 0.16 second.
2. PR interval of 0.18 second.
3. QT interval of 0.34 second.
4. QRS interval of 0.14 second. - ✔️✔️4. QRS interval of 0.14 second.
, The nurse is assigned a client with numerous treatments and decides it is not possible
to complete all the needed treatments in the time scheduled for this shift. Which process
should the nurse use?
1. Delegate tasks to competent team members.
2. Prioritize tasks with the most crucial needs first.
3. Report the incomplete treatments to next shift nurse.
4. Start with the easiest treatment first. - ✔️✔️2. Prioritize tasks with the most crucial
needs first.
A male client is on contact precautions due to an infected draining wound and is being
discharged home. The client lives at home with his wife and their adolescent daughter.
What discharge instruction should the nurse include for the client?
1. Use disposable plates and utensils.
2. Stay in a room with the door closed.
3. Dispose of soiled dressings in plastic bags that are securely closed.
4. Others who are in the same room with the client should wear a mask. - ✔️✔️3.
Dispose of soiled dressings in plastic bags that are securely closed.
A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has
not been sleeping well lately and is experiencing labored breathing. List the client's
problems in order of priority for the nurse. (Rank in the priority order from highest to
lowest.)
1. Airway and breathing.
2. Pain management.
3. Definitive therapy.
4. Sleep and rest. - ✔️✔️1.Airway and breathing. 2.Pain management. 3.Sleep and
rest. 4.Definitive therapy.
Which biological practices are federally regulated for healthcare workers? (Select all
that apply.)
Select all that apply
1.Standard precautions.
2. N-95 tuberculosis standard.
3. Blood-borne pathogen standard.
4. Biological product exposure limit (BPEL).
5. Resource Conservation and Recovery Act (RCRA).
6. As Low as Reasonably Allowable standard (ALARA). - ✔️✔️3. Blood-borne
pathogen standard.
5. Resource Conservation and Recovery Act (RCRA)
A client with severe depression tells the nurse, "I do not know why you bother with me
or give me pills. I am never going to get well." What is the most therapeutic response?
1. "You need to stop thinking negative thoughts. They get in the way of your recovery."
2. "You are no bother to me or to the staff. We want you to get well and not feel sad
anymore."
