BSN 366 EXIT HESI
The nurse is caring for a client admitted with an acute exacerbation of chronic
obstructive pulmonary disease {COPD) who reports a pounding headache. Which action
should the nurse take?
Obtain a manual blood pressure measurement.
3 multiple choice options
An older client comes to the clinic with a family member. When the nurse attempts to
take the client's health history, the client does not respond to questions in a clear
manner. Which action should the nurse implement first?
Assess the surroundings for noise and distractions.
3 multiple choice options
The nurse notices that a male client is particularly delusional one afternoon. He begins
to pace the floor and appears to be losing control of himself. Which intervention is best
for the nurse to implement?
Move the client to a quiet place on the unit.
3 multiple choice options
The nurse reviews the physician1s orders for clonazepam and gives the medication as
ordered. What nursing interventions are appropriate for the client starting clonazepam?
Select all that apply.
A. Screen for orthostatic hypotension
B. Provide oral care at least twice a day
C. Monitor calcium levels
D. Assess mental status regularly
E. Assist the client to the bathroom
F. Have an opioid agonist at the bedside
A. Screen for orthostatic hypotension
,B. Provide oral care at least twice a day
D. Assess mental status regularly
E. Assist the client to the bathroom
What other treatments might be helpful for this client? Select all that apply.
A. Phototherapy
B. Administration of lithium
C. Consciousness-raising
D. Cognitive behavioral therapy
E. Animal therapy
F. Electroconvulsivetherapy
D. Cognitive-behavioral therapy
E. Animal therapy
A client with a history of type 1 diabetes mellitus {DM) and asthma is readmitted to the
unit for the third time in two months with a current fasting blood sugar (FBS) is 325
mg/dL (18 mmol/L). The client describes to the nurse of not understanding why the
blood glucose level continues to be out of control. Which intervention{s) should the
nurse implement?
{Select all that apply.)
Blood Glucose Reference - 74 to 106 mg/dL {4.1 to 5.9 mmol/L)
A. Have the client demonstrate technique used to monitor blood glucose levels.
B. Evaluate the client's asthma medications that can elevate the blood glucose.
C. Ask the client if they want a different manufacturer's glucose monitoring device.
D. Have the client describe a typical day at work, home, and social activities.
E. Determine if the client is using a new insulin-led learning administration.
A. Have the client demonstrate technique used to monitor blood glucose levels.
B. Evaluate the client's asthma medications that can elevate the blood glucose.
D. Have the client describe a typical day at work, home, and social activities.
E. Determine if the client is using a new insulin-led learning administration.
,A client fell in the bathroom when left unattendeded by the unlicensed assistive
personnel (UAP). Which information should the nurse include in the client's health
record?
The client fell sustaining a fracture to the left hip.
3 multiple choice options
A young adult visits the clinic reporting symptoms associated with gastritis. Which
information in the client's history is most important for the nurse to address in the
teaching plan?
Snacks on foods with very high salt content on a daily basis
3 multiple choice options
A client who weighs 65 kg receives a prescription for lorazepam 44 mcg/kg
intravenously to be administered 20 minutes before a scheduled procedure. The
medication is available in 2 mg/mL vial. How many mL should the nurse administer?
(Enter numerical value only. If rounding is required, round to the nearest tenth.)
1.4 mL
An infant who weighs 22 pounds receives a prescription for amoxicillin 20 mg/kg/day by
mouth in divided doses every 8 hours. The bottle is labeled, "Amoxicillin for Oral
Suspension, USP 250 mg per 5 mL." How many mL should the nurse administer with
each dose? {Enter numerical value only. If rounding is necessary, round to the nearest
tenth.)
1.3 mL
A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet
count of 25,000/mm3 {25 x 109/L). Which intervention is most important for the nurse
to include in this client's plan of care?
Reference Range: Platelet Count 150,000 to 400,000/mm3 {156 400 x 109/L)
Assess urine and stool for occult blood.
3 multiple choice options
, An older client is taken to the clinic by the spouse, who appears extremely worried. The
spouse reports to the nurse that the client started to not make any sense and asked to
visit a brother who has been dead for many years. Which action{s) should the nurse
take? (Select all that apply.)
A. Obtain the client's tympanic temperature measurement.
B. Review the client's current food and medication allergies.
C. Ask if the client is experiencing any pain with urination.
D. Encourage increasing the intake of high-protein foods
E. Determine if the client has recently experienced a fall.
A. Obtain the client's tympanic temperature measurement.
C. Ask if the client is experiencing any pain with urination.
E. Determine if the client has recently experienced a fall.
The nurse is triaging several children as they present to the emergency room after a
school bus accident. Which child requires the most immediate intervention by the
nurse?
An 11-year-old with a headache, nausea, and projectile vomiting.
3 multiple choice options
When the parents of a 6-year-old boy with a brain tumor are told that his condition is
terminal, the mother shouts at the father, "This is your fault! It never would have
happened if we had sought treatment sooner!" Which intervention is best for the nurse
to implement?
Explain to the parents that anger is a common response to grief.
3 multiple choice options
When the nurse enters the room of a male client who was admitted for a fractured
femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no
spontaneous respirations and his carotid pulse is not palpable. Which intervention
should the nurse implement?
Begin chest compressions at 100/minute.
3 multiple choice options
The nurse is caring for a client admitted with an acute exacerbation of chronic
obstructive pulmonary disease {COPD) who reports a pounding headache. Which action
should the nurse take?
Obtain a manual blood pressure measurement.
3 multiple choice options
An older client comes to the clinic with a family member. When the nurse attempts to
take the client's health history, the client does not respond to questions in a clear
manner. Which action should the nurse implement first?
Assess the surroundings for noise and distractions.
3 multiple choice options
The nurse notices that a male client is particularly delusional one afternoon. He begins
to pace the floor and appears to be losing control of himself. Which intervention is best
for the nurse to implement?
Move the client to a quiet place on the unit.
3 multiple choice options
The nurse reviews the physician1s orders for clonazepam and gives the medication as
ordered. What nursing interventions are appropriate for the client starting clonazepam?
Select all that apply.
A. Screen for orthostatic hypotension
B. Provide oral care at least twice a day
C. Monitor calcium levels
D. Assess mental status regularly
E. Assist the client to the bathroom
F. Have an opioid agonist at the bedside
A. Screen for orthostatic hypotension
,B. Provide oral care at least twice a day
D. Assess mental status regularly
E. Assist the client to the bathroom
What other treatments might be helpful for this client? Select all that apply.
A. Phototherapy
B. Administration of lithium
C. Consciousness-raising
D. Cognitive behavioral therapy
E. Animal therapy
F. Electroconvulsivetherapy
D. Cognitive-behavioral therapy
E. Animal therapy
A client with a history of type 1 diabetes mellitus {DM) and asthma is readmitted to the
unit for the third time in two months with a current fasting blood sugar (FBS) is 325
mg/dL (18 mmol/L). The client describes to the nurse of not understanding why the
blood glucose level continues to be out of control. Which intervention{s) should the
nurse implement?
{Select all that apply.)
Blood Glucose Reference - 74 to 106 mg/dL {4.1 to 5.9 mmol/L)
A. Have the client demonstrate technique used to monitor blood glucose levels.
B. Evaluate the client's asthma medications that can elevate the blood glucose.
C. Ask the client if they want a different manufacturer's glucose monitoring device.
D. Have the client describe a typical day at work, home, and social activities.
E. Determine if the client is using a new insulin-led learning administration.
A. Have the client demonstrate technique used to monitor blood glucose levels.
B. Evaluate the client's asthma medications that can elevate the blood glucose.
D. Have the client describe a typical day at work, home, and social activities.
E. Determine if the client is using a new insulin-led learning administration.
,A client fell in the bathroom when left unattendeded by the unlicensed assistive
personnel (UAP). Which information should the nurse include in the client's health
record?
The client fell sustaining a fracture to the left hip.
3 multiple choice options
A young adult visits the clinic reporting symptoms associated with gastritis. Which
information in the client's history is most important for the nurse to address in the
teaching plan?
Snacks on foods with very high salt content on a daily basis
3 multiple choice options
A client who weighs 65 kg receives a prescription for lorazepam 44 mcg/kg
intravenously to be administered 20 minutes before a scheduled procedure. The
medication is available in 2 mg/mL vial. How many mL should the nurse administer?
(Enter numerical value only. If rounding is required, round to the nearest tenth.)
1.4 mL
An infant who weighs 22 pounds receives a prescription for amoxicillin 20 mg/kg/day by
mouth in divided doses every 8 hours. The bottle is labeled, "Amoxicillin for Oral
Suspension, USP 250 mg per 5 mL." How many mL should the nurse administer with
each dose? {Enter numerical value only. If rounding is necessary, round to the nearest
tenth.)
1.3 mL
A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet
count of 25,000/mm3 {25 x 109/L). Which intervention is most important for the nurse
to include in this client's plan of care?
Reference Range: Platelet Count 150,000 to 400,000/mm3 {156 400 x 109/L)
Assess urine and stool for occult blood.
3 multiple choice options
, An older client is taken to the clinic by the spouse, who appears extremely worried. The
spouse reports to the nurse that the client started to not make any sense and asked to
visit a brother who has been dead for many years. Which action{s) should the nurse
take? (Select all that apply.)
A. Obtain the client's tympanic temperature measurement.
B. Review the client's current food and medication allergies.
C. Ask if the client is experiencing any pain with urination.
D. Encourage increasing the intake of high-protein foods
E. Determine if the client has recently experienced a fall.
A. Obtain the client's tympanic temperature measurement.
C. Ask if the client is experiencing any pain with urination.
E. Determine if the client has recently experienced a fall.
The nurse is triaging several children as they present to the emergency room after a
school bus accident. Which child requires the most immediate intervention by the
nurse?
An 11-year-old with a headache, nausea, and projectile vomiting.
3 multiple choice options
When the parents of a 6-year-old boy with a brain tumor are told that his condition is
terminal, the mother shouts at the father, "This is your fault! It never would have
happened if we had sought treatment sooner!" Which intervention is best for the nurse
to implement?
Explain to the parents that anger is a common response to grief.
3 multiple choice options
When the nurse enters the room of a male client who was admitted for a fractured
femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no
spontaneous respirations and his carotid pulse is not palpable. Which intervention
should the nurse implement?
Begin chest compressions at 100/minute.
3 multiple choice options
