Exit Hesi (BSN 366- V3) || 100% Correct Solutions.
A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of
dentures prior to leaving the unit for the operating room. What would be the most appropriate
intervention by the nurse? correct answers Ask the client if the preference would be to remove
the dentures in the operating room receiving area
The nurse has been teaching adult clients about cardiac risks when they visit the hypertension
clinic. Which form of evaluation would best measure learning? correct answers Reported
behavioral changes
The nurse is planning care for an 18 month-old child. Which action should be included in the
child's care? correct answers Encourage the child to feed himself finger food
A partner is concerned because the client frequently daydreams about moving to Arizona to get
away from the pollution and crowding in southern California. The nurse explains that correct
answers Such fantasies can gratify unconscious wishes or prepare for anticipated future events
An appropriate goal for a client with anxiety would be to correct answers Learn self-help
techniques
While the nurse is administering medications to a client, the client states "I do not want to take
that medicine today." Which of the following responses by the nurse would be best? correct
answers "Is there a reason why you don't want to take your medicine?"
While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area.
Which of the following assessments is appropriate for the nurse to perform? correct answers
Auscultate the mass
A client is admitted to the hospital with a history of confusion. The client has difficulty
remembering recent events and becomes disoriented when away from home. Which statement
would provide the best reality orientation for this client? correct answers "Good morning. You're
in the hospital. I am your nurse Elaine Jones."
The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source
of fluids for an infant until about 12 months of age? correct answers Formula or breast milk
The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be
affected by the injury. Which statement is true concerning long bone fractures in children?
correct answers Epiphyseal fractures often interrupt a child's normal growth pattern
The nurse is assessing a client who states her last menstrual period was March 16, and she has
missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a
urine test. What will the nurse calculate as the estimated date of delivery (EDD)? correct answers
December 23
, When screening children for scoliosis, at what time of development would the nurse expect early
signs to appear? correct answers During the preadolescent growth spurt
A client with congestive heart failure is newly admitted to home health care. The nurse discovers
that the client has not been following the prescribed diet. What would be the most appropriate
nursing action? correct answers Discuss diet with the client to learn the reasons for not following
the diet
A client states, "People think I'm no good, you know what I mean?" Which of these responses
would be most therapeutic? correct answers "I'm not sure what you mean. Tell me a bit more
about that."
A client being treated for hypertension returns to the community clinic for follow up. The client
says, "I know these pills are important, but I just can't take these water pills anymore. I drive a
truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." Which of
these is the best nursing diagnosis? correct answers Noncompliance related to medication side
effects
When teaching effective stress management techniques to a client 1 hour before surgery, which
of the following should the nurse recommend? correct answers Deep breathing
When observing 4 year-old children playing in the hospital playroom, what activity would the
nurse expect to see the children participating in? correct answers Playing cooperatively with
other preschoolers
The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate
finding? correct answers Hold a rattle
When teaching a 10 year-old child about their impending heart surgery, which form of
explanation meets the developmental needs of this age child? correct answers Explain the
surgery using a model of the heart
The parents of a child who has suddenly been hospitalized for an acute illness state that they
should have taken the child to the pediatrician earlier. Which approach by the nurse is best when
dealing with the parents' comments? correct answers Accept their feelings without judgment
When caring for a client who is receiving a thrombolytic agent to open a clot occluded coronary
artery after a myocardial infarction, which finding would be of greatest concern to the nurse?
correct answers Hematemesis
When caring for a client with total parenteral nutrition (TPN), what is the most important action
on the part of the nurse? correct answers Sterile technique for dressing change at IV site
A 52 year-old client is being transfused with one unit of packed cells. A half hour after the
transfusion was initiated, the client complains of chills and headache. Which action should the
nurse implement first? correct answers Stop the transfusion
A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of
dentures prior to leaving the unit for the operating room. What would be the most appropriate
intervention by the nurse? correct answers Ask the client if the preference would be to remove
the dentures in the operating room receiving area
The nurse has been teaching adult clients about cardiac risks when they visit the hypertension
clinic. Which form of evaluation would best measure learning? correct answers Reported
behavioral changes
The nurse is planning care for an 18 month-old child. Which action should be included in the
child's care? correct answers Encourage the child to feed himself finger food
A partner is concerned because the client frequently daydreams about moving to Arizona to get
away from the pollution and crowding in southern California. The nurse explains that correct
answers Such fantasies can gratify unconscious wishes or prepare for anticipated future events
An appropriate goal for a client with anxiety would be to correct answers Learn self-help
techniques
While the nurse is administering medications to a client, the client states "I do not want to take
that medicine today." Which of the following responses by the nurse would be best? correct
answers "Is there a reason why you don't want to take your medicine?"
While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area.
Which of the following assessments is appropriate for the nurse to perform? correct answers
Auscultate the mass
A client is admitted to the hospital with a history of confusion. The client has difficulty
remembering recent events and becomes disoriented when away from home. Which statement
would provide the best reality orientation for this client? correct answers "Good morning. You're
in the hospital. I am your nurse Elaine Jones."
The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source
of fluids for an infant until about 12 months of age? correct answers Formula or breast milk
The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be
affected by the injury. Which statement is true concerning long bone fractures in children?
correct answers Epiphyseal fractures often interrupt a child's normal growth pattern
The nurse is assessing a client who states her last menstrual period was March 16, and she has
missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a
urine test. What will the nurse calculate as the estimated date of delivery (EDD)? correct answers
December 23
, When screening children for scoliosis, at what time of development would the nurse expect early
signs to appear? correct answers During the preadolescent growth spurt
A client with congestive heart failure is newly admitted to home health care. The nurse discovers
that the client has not been following the prescribed diet. What would be the most appropriate
nursing action? correct answers Discuss diet with the client to learn the reasons for not following
the diet
A client states, "People think I'm no good, you know what I mean?" Which of these responses
would be most therapeutic? correct answers "I'm not sure what you mean. Tell me a bit more
about that."
A client being treated for hypertension returns to the community clinic for follow up. The client
says, "I know these pills are important, but I just can't take these water pills anymore. I drive a
truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." Which of
these is the best nursing diagnosis? correct answers Noncompliance related to medication side
effects
When teaching effective stress management techniques to a client 1 hour before surgery, which
of the following should the nurse recommend? correct answers Deep breathing
When observing 4 year-old children playing in the hospital playroom, what activity would the
nurse expect to see the children participating in? correct answers Playing cooperatively with
other preschoolers
The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate
finding? correct answers Hold a rattle
When teaching a 10 year-old child about their impending heart surgery, which form of
explanation meets the developmental needs of this age child? correct answers Explain the
surgery using a model of the heart
The parents of a child who has suddenly been hospitalized for an acute illness state that they
should have taken the child to the pediatrician earlier. Which approach by the nurse is best when
dealing with the parents' comments? correct answers Accept their feelings without judgment
When caring for a client who is receiving a thrombolytic agent to open a clot occluded coronary
artery after a myocardial infarction, which finding would be of greatest concern to the nurse?
correct answers Hematemesis
When caring for a client with total parenteral nutrition (TPN), what is the most important action
on the part of the nurse? correct answers Sterile technique for dressing change at IV site
A 52 year-old client is being transfused with one unit of packed cells. A half hour after the
transfusion was initiated, the client complains of chills and headache. Which action should the
nurse implement first? correct answers Stop the transfusion
