BSN 225 Hesi Prep Exam QUESTIONS AND
CORRECT ANSWERS
What is the correct order of actions a nurse should take before entering a room for wound
care?
- wash hands
- apply surgical mask
- don gloves
- put on an isolation gown - CORRECT ANSWER 1. Wash hands
2. Put on an isolation gown
3. Apply surgical mask
4. Don gloves.
Using the SBAR technique, what information should the nurse provide first when notifying
the healthcare provider?
A. Admitted after a motor vehicle accident
B. A 26 year old client
C. Prescription for ?? PO every 12 hours
D. Blood pressure is 80/48mmHG - CORRECT ANSWER A. Admitted after a motor
vehicle accident.
The nurse observed the UAP securing a client's wrist restraints to the bedside rails. Which
action is most important for the nurse to implement?
A. ensure that the restraints are not too tight
B. complete an adverse occurrence/incident report
C. demonstrate proper securing of the restraints
D. initiate the facility's restraint flow sheet - CORRECT ANSWER C. Demonstrate
proper securing of the restraints.
,The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the
radial pulse is no longer palpable at 90mHG, Which action should the nurse take?
A. Document the absence of the radial pulse
B. Inflate the blood pressure cuff to 120mmHG
C. Release the manometer valve immediately
D. record a palpable systolic pressure of 90mmHg - CORRECT ANSWER B. Inflate
the blood pressure cuff to 120 mmHg.
The healthcare provider prescribes Digoxin elixir 125 mcg PO daily. The drug is available in
a 60mL bottle labeled "Digoxin elixir 0.05mg/mL". How many mL should the nurse
administer?
(Enter NUMERIC value only) - CORRECT ANSWER 2.5 mL.
A client with atrial fibrillation receives a prescription for a loading dose of Digoxin 0.5mg
PO. The medication is available in 125 mcg tablets. How many tablets should the nurse
administer?
(Enter NUMERICAL value only). - CORRECT ANSWER 4 tablets.
Which assessment data reflects the need for the nurse to include the problem, "risk for falls"
in a client's plan of care?
Reference range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]
A. expressed feelings of depression
B. Recent serum hemoglobin level of 16 g/dL (160 g/dL)
C. Stooped posture with a steady gait
D. opioid analgesic received one hour ago - CORRECT ANSWER D. Opioid analgesic
received one hour ago.
, What action should the nurse take when preparing to obtain a stool specimen for occult blood
from a client with soft, solid, light brown feces?
A. Wait to obtain the specimen until the observable blood is pre- sent
B. Withhold the specimen collection until tarry black stool is ob- served
C. Obtain the specimen from the client's current bowel movement
D. Contact the healthcare provider before obtaining the specimen - CORRECT
ANSWER C. Obtain the specimen from the client's current bowel movement.
When administering a new medication to a patient, the nurse logs in the electronic medication
administration record (eMAR). Which action should the nurse take next?
A. Reconcile the medication to be administered with the initial client prescription
B. Scan the medication barcode to document administration on the eMAR
C. verify the clients identification by scanning the barcode on the armband
D. remove the mediation from the unit dose packaging while verifying the dose - CORRECT
ANSWER B. Scan the medication barcode to document administration on the eMAR.
The nurse educator is conducting a class for UAP. Which action indicates that a UAP
understands gloving procedures?
A. don sterile gloves when caring for clients with HIV
B. Keeps a pair of gloves in uniform pocket
C. puts on new gloves when entering a client's room
D. Uses sterile gloves when handling bodily fluids - CORRECT ANSWER C. puts on
new gloves when entering a client's room
The nurse is caring for a client with type 2 diabetes who had surgery for a large bowel
resection with a colostomy placement. The client has developed hyperglycemia which
requires self injections of insulin after discharge When designing the postoperative plan of
care, which outcome statement should the nurse use?
CORRECT ANSWERS
What is the correct order of actions a nurse should take before entering a room for wound
care?
- wash hands
- apply surgical mask
- don gloves
- put on an isolation gown - CORRECT ANSWER 1. Wash hands
2. Put on an isolation gown
3. Apply surgical mask
4. Don gloves.
Using the SBAR technique, what information should the nurse provide first when notifying
the healthcare provider?
A. Admitted after a motor vehicle accident
B. A 26 year old client
C. Prescription for ?? PO every 12 hours
D. Blood pressure is 80/48mmHG - CORRECT ANSWER A. Admitted after a motor
vehicle accident.
The nurse observed the UAP securing a client's wrist restraints to the bedside rails. Which
action is most important for the nurse to implement?
A. ensure that the restraints are not too tight
B. complete an adverse occurrence/incident report
C. demonstrate proper securing of the restraints
D. initiate the facility's restraint flow sheet - CORRECT ANSWER C. Demonstrate
proper securing of the restraints.
,The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the
radial pulse is no longer palpable at 90mHG, Which action should the nurse take?
A. Document the absence of the radial pulse
B. Inflate the blood pressure cuff to 120mmHG
C. Release the manometer valve immediately
D. record a palpable systolic pressure of 90mmHg - CORRECT ANSWER B. Inflate
the blood pressure cuff to 120 mmHg.
The healthcare provider prescribes Digoxin elixir 125 mcg PO daily. The drug is available in
a 60mL bottle labeled "Digoxin elixir 0.05mg/mL". How many mL should the nurse
administer?
(Enter NUMERIC value only) - CORRECT ANSWER 2.5 mL.
A client with atrial fibrillation receives a prescription for a loading dose of Digoxin 0.5mg
PO. The medication is available in 125 mcg tablets. How many tablets should the nurse
administer?
(Enter NUMERICAL value only). - CORRECT ANSWER 4 tablets.
Which assessment data reflects the need for the nurse to include the problem, "risk for falls"
in a client's plan of care?
Reference range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]
A. expressed feelings of depression
B. Recent serum hemoglobin level of 16 g/dL (160 g/dL)
C. Stooped posture with a steady gait
D. opioid analgesic received one hour ago - CORRECT ANSWER D. Opioid analgesic
received one hour ago.
, What action should the nurse take when preparing to obtain a stool specimen for occult blood
from a client with soft, solid, light brown feces?
A. Wait to obtain the specimen until the observable blood is pre- sent
B. Withhold the specimen collection until tarry black stool is ob- served
C. Obtain the specimen from the client's current bowel movement
D. Contact the healthcare provider before obtaining the specimen - CORRECT
ANSWER C. Obtain the specimen from the client's current bowel movement.
When administering a new medication to a patient, the nurse logs in the electronic medication
administration record (eMAR). Which action should the nurse take next?
A. Reconcile the medication to be administered with the initial client prescription
B. Scan the medication barcode to document administration on the eMAR
C. verify the clients identification by scanning the barcode on the armband
D. remove the mediation from the unit dose packaging while verifying the dose - CORRECT
ANSWER B. Scan the medication barcode to document administration on the eMAR.
The nurse educator is conducting a class for UAP. Which action indicates that a UAP
understands gloving procedures?
A. don sterile gloves when caring for clients with HIV
B. Keeps a pair of gloves in uniform pocket
C. puts on new gloves when entering a client's room
D. Uses sterile gloves when handling bodily fluids - CORRECT ANSWER C. puts on
new gloves when entering a client's room
The nurse is caring for a client with type 2 diabetes who had surgery for a large bowel
resection with a colostomy placement. The client has developed hyperglycemia which
requires self injections of insulin after discharge When designing the postoperative plan of
care, which outcome statement should the nurse use?
