BSN366 EXIT HESI || 100% NO ERROR.
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. correct answers 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). correct answers 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."
3. "I have known many clients with depression who have felt better after several weeks of
treatment."
4. "You are feeling very pessimistic, but that is part of your illness. It should go away as you
recover." correct answers 3. "I have known many clients with depression who have felt better
after several weeks of treatment."
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. correct
answers 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. correct answers 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. correct answers 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. correct answers 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. correct answers 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. correct answers 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. correct answers 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. correct answers 3.
Dispose of soiled dressings in plastic bags that are securely closed.
When assessing a client's interior eye structures with an ophthalmoscope, which action
should the nurse use?
1. Use a red-free filter.
2. Adjust the diopters.
3. Direct a wide-beam light.
4. Dilate the client's pupils. correct answers 2. Adjust the diopters.
The nurse administers dopamine (Intropin) IV infusion at 3 mcg/kg/min to a critically ill,
hypotensive client. What is the intended effect of this treatment? To increase
1. blood pressure to 140/80.
2. urine output to 55 ml/hr.
3. pulse to 132 beats/min.
4. respirations to 24 breaths/min. correct answers 2. urine output to 55 ml/hr.
During an admission assessment interview, a client states, "I do not use many drugs."
How should the nurse respond?
1. "Tell me about the drugs you use now."
2. "Explain what you mean by many drugs."
3. "Do you mean legal drugs or illegal ones?"
4. "What kind of drugs are you talking about?" correct answers 1. "Tell me about the drugs you
use now."
The nurse begins a physical assessment of an 8-month-old. The child is sitting
contentedly on the mother's lap, chewing on a toy. Which action should the nurse
implement first?
1. Elicit reflexes.
2. Auscultate heart and lungs.
3. Examine eyes, ears, and mouth.
4. Take an axillary temperature. correct answers 2. Auscultate heart and lungs.
Which client is at highest risk for chronic kidney disease (CKD) secondary to diabetes
mellitus (DM)?
1. Type 1 DM and a serum hemoglobin-A1c of 3.5%.
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. correct answers 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). correct answers 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."
3. "I have known many clients with depression who have felt better after several weeks of
treatment."
4. "You are feeling very pessimistic, but that is part of your illness. It should go away as you
recover." correct answers 3. "I have known many clients with depression who have felt better
after several weeks of treatment."
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. correct
answers 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. correct answers 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. correct answers 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. correct answers 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. correct answers 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. correct answers 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. correct answers 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. correct answers 3.
Dispose of soiled dressings in plastic bags that are securely closed.
When assessing a client's interior eye structures with an ophthalmoscope, which action
should the nurse use?
1. Use a red-free filter.
2. Adjust the diopters.
3. Direct a wide-beam light.
4. Dilate the client's pupils. correct answers 2. Adjust the diopters.
The nurse administers dopamine (Intropin) IV infusion at 3 mcg/kg/min to a critically ill,
hypotensive client. What is the intended effect of this treatment? To increase
1. blood pressure to 140/80.
2. urine output to 55 ml/hr.
3. pulse to 132 beats/min.
4. respirations to 24 breaths/min. correct answers 2. urine output to 55 ml/hr.
During an admission assessment interview, a client states, "I do not use many drugs."
How should the nurse respond?
1. "Tell me about the drugs you use now."
2. "Explain what you mean by many drugs."
3. "Do you mean legal drugs or illegal ones?"
4. "What kind of drugs are you talking about?" correct answers 1. "Tell me about the drugs you
use now."
The nurse begins a physical assessment of an 8-month-old. The child is sitting
contentedly on the mother's lap, chewing on a toy. Which action should the nurse
implement first?
1. Elicit reflexes.
2. Auscultate heart and lungs.
3. Examine eyes, ears, and mouth.
4. Take an axillary temperature. correct answers 2. Auscultate heart and lungs.
Which client is at highest risk for chronic kidney disease (CKD) secondary to diabetes
mellitus (DM)?
1. Type 1 DM and a serum hemoglobin-A1c of 3.5%.
