BSN 366 HESI Comprehensive TEST BANK FINAL EXAM 2026
\NEWEST EXAM WITH COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS (RATIONALES) GRADED A+ \Nightingale
College \BEST DOCUMENT FOR EXAM PRACTICE \DOWNLOAD PDF
FOR 2026-2027
The night nurse is caring for a client who just had a craniotomy. The nurse is
monitoring the client's Jackson-Pratt drain that is being maintained on suction.
The nurse notes that a total of 200 mL of red drainage has drained from the
Jackson-Pratt (J-P) tube in the last 8 hours. What action should the nurse take?
Document the amount in the client's record.
Discontinue the Jackson-Pratt drain from suction.
Continue to monitor the amount and color of the drainage.
Notify the primary health care provider immediately of the amount of drainage.
Notify the primary health care provider immediately of the amount of drainage.
Rationale: The nurse must immediately notify the primary health care provider of
this excessive amount of drainage. The primary health care
provider must also be immediately notified of any saturated head dressings.
The normal amount of drainage from a Jackson-Pratt drain is 30 to 50 mL
per shift. Discontinuing the suction from the J-P drain is not an option and is not
done. Also, just documenting the amount in the client's record is not
correct even though the nurse would document that the primary health care
provider was notified of the total drain amount. Just continuing to monitor the
amount of drainage is also not an option.
,Lorazepam 1 mg by way of intravenous (IV) injection (IV push) is
prescribed for a client for the management of anxiety. The nurse
prepares the
medication as prescribed. Over what period of time should the
nurse administer this medication?
3 minutes
10 seconds
15 seconds
30 minutes
3 minutes
Rationale: Lorazepam is a benzodiazepine. When administered
by IV injection, each 2 mg or fraction thereof is administered over a
period of 1 to 5 minutes. Ten seconds and 30 seconds are brief
periods. Thirty minutes is a lengthy period.
,A nurse, conducting an assessment of a client being seen in the clinic for
signs/symptoms of a sinus infection, asks the client about medications that he
is taking. The client tells the nurse that he is taking nefazodone
hydrochloride. On the basis of this information, the nurse determines that the
client most likely has a history of what problem?
Depression
Diabetes mellitus
Hyperthyroidism
Coronary artery disease
Depression
Rationale: The client is most likely suffering from depression. Nefazodone
hydrochloride is an antidepressant used as maintenance therapy to prevent
relapse of an acute depression. Diabetes mellitus, hypethyroidism, and
coronary artery disease are not treated with this medication.
, Phenelzine sulfate is prescribed for a client with depression. The nurse provides
information to the client about the adverse effects of the
medication and tells the client to contact the primary health care provider immediately
if he/she experiences what sign/symptom?
Dry mouth
Restlessness
Feelings of depression
Neck stiffness or soreness
Neck stiffness or soreness
Rationale: The client is taught to immediately contact the primary health care
provider if the client experiences any occipital headache radiating
frontally and neck stiffness or soreness, which could be the first sign of a hypertensive
crisis. Phenelzine sulfate, a monoamine oxidase inhibitor
(MAOI), is an antidepressant and is used to treat depression. Hypertensive
crisis, an adverse effect of this medication, is characterized by hypertension,
frontally radiating occipital headache, neck stiffness and soreness, nausea,
vomiting, sweating, fever and chills, clammy skin, dilated pupils, and
palpitations. Tachycardia, bradycardia, and constricting chest pain may also be
present. Dry mouth and restlessness are common side effects of the
medication.
\NEWEST EXAM WITH COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS (RATIONALES) GRADED A+ \Nightingale
College \BEST DOCUMENT FOR EXAM PRACTICE \DOWNLOAD PDF
FOR 2026-2027
The night nurse is caring for a client who just had a craniotomy. The nurse is
monitoring the client's Jackson-Pratt drain that is being maintained on suction.
The nurse notes that a total of 200 mL of red drainage has drained from the
Jackson-Pratt (J-P) tube in the last 8 hours. What action should the nurse take?
Document the amount in the client's record.
Discontinue the Jackson-Pratt drain from suction.
Continue to monitor the amount and color of the drainage.
Notify the primary health care provider immediately of the amount of drainage.
Notify the primary health care provider immediately of the amount of drainage.
Rationale: The nurse must immediately notify the primary health care provider of
this excessive amount of drainage. The primary health care
provider must also be immediately notified of any saturated head dressings.
The normal amount of drainage from a Jackson-Pratt drain is 30 to 50 mL
per shift. Discontinuing the suction from the J-P drain is not an option and is not
done. Also, just documenting the amount in the client's record is not
correct even though the nurse would document that the primary health care
provider was notified of the total drain amount. Just continuing to monitor the
amount of drainage is also not an option.
,Lorazepam 1 mg by way of intravenous (IV) injection (IV push) is
prescribed for a client for the management of anxiety. The nurse
prepares the
medication as prescribed. Over what period of time should the
nurse administer this medication?
3 minutes
10 seconds
15 seconds
30 minutes
3 minutes
Rationale: Lorazepam is a benzodiazepine. When administered
by IV injection, each 2 mg or fraction thereof is administered over a
period of 1 to 5 minutes. Ten seconds and 30 seconds are brief
periods. Thirty minutes is a lengthy period.
,A nurse, conducting an assessment of a client being seen in the clinic for
signs/symptoms of a sinus infection, asks the client about medications that he
is taking. The client tells the nurse that he is taking nefazodone
hydrochloride. On the basis of this information, the nurse determines that the
client most likely has a history of what problem?
Depression
Diabetes mellitus
Hyperthyroidism
Coronary artery disease
Depression
Rationale: The client is most likely suffering from depression. Nefazodone
hydrochloride is an antidepressant used as maintenance therapy to prevent
relapse of an acute depression. Diabetes mellitus, hypethyroidism, and
coronary artery disease are not treated with this medication.
, Phenelzine sulfate is prescribed for a client with depression. The nurse provides
information to the client about the adverse effects of the
medication and tells the client to contact the primary health care provider immediately
if he/she experiences what sign/symptom?
Dry mouth
Restlessness
Feelings of depression
Neck stiffness or soreness
Neck stiffness or soreness
Rationale: The client is taught to immediately contact the primary health care
provider if the client experiences any occipital headache radiating
frontally and neck stiffness or soreness, which could be the first sign of a hypertensive
crisis. Phenelzine sulfate, a monoamine oxidase inhibitor
(MAOI), is an antidepressant and is used to treat depression. Hypertensive
crisis, an adverse effect of this medication, is characterized by hypertension,
frontally radiating occipital headache, neck stiffness and soreness, nausea,
vomiting, sweating, fever and chills, clammy skin, dilated pupils, and
palpitations. Tachycardia, bradycardia, and constricting chest pain may also be
present. Dry mouth and restlessness are common side effects of the
medication.
