BSN 366 Exit HESI || 100% Accurate Answers.
The nurse is planning discharge instructions for a client with type 2 diabetes who will be starting
Exenatide. Which information should be included in the discharge instructions?
A. Exenatide acts in the same way as insulin in lowering blood glucose.
B. Inject exenatide within 30 minutes before or after a meal.
C. There are no precautions when taking Exenatide with other medications.
D. Notify your healthcare provider if you start having abdominal pain. correct answers D. Notify
your healthcare provider if you start having abdominal pain.
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
1. Click to highlight the aspects of the assessment that require urgent attention:
The client's pain is 2/10. The client requests sleeping medication for the night. She states she has
horrible thoughts and memories about the house collapsing all the time, and that it is keeping her
from falling asleep. She states "I used to be so happy before all of this happened. Now I can;t
seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the
unit as she is currently by the nurses station and hears talking and alarms constantly. correct
answers -She states she has horrible thoughts and memories about the house collapsing all the
time.
- it is keeping her from falling asleep.
-prefers to be in a quieter area of the unit.
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
2. Drag from the options to complete the sentence:
After listening to the clients symptoms, the nurse realizes that she likely has______________
related to _______________ correct answers Acute Stress Disorder, Traumatic Stress exposure
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
3. Click to specify which client statement of behaviors is most likely associated with each of the
listed defense mechanism. Some statements or behaviors may be consistent with more than one
mechanism. Each column must have at least one but may have more than one answer selected.
correct answers
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
,4. What nursing reviews the physicians orders for Clonazepam and gives the medication as
ordered. (SATA)
a. monitor calcium levels
b. assist the client to the bathroom
c. screen for orthostatic hypotension
d. assess mental status regularly
e. provide oral care at least twice a day
f. have an opioid agonist at the bedside correct answers b. assist the client to the bathroom
d. assess mental status regularly
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
5. What other treatment might be helpful for this client? SATA
a. animal therapy
b. administration of lithium
c. consciousness-raising
d. phototherapy
e. electroconvulsive therapy
f. cognitive behavioral therapy correct answers a. animal therapy
c. consciousness-raising
f. cognitive behavioral therapy
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
6. For each client statement, click to highlight the statement(s) below that require follow up
teaching by the nurse.
a. "this diagnosis means that I am crazy"
b. " I can learn to manage my thoughts better through therapy"
c. "I can use holistic approaches like medication to help my symptoms"
d. "Many people have the same response to a stressful situation as I am having right"
e. "I am at high risk for post-traumatic-stress disorder because I have acute stress disorder"
f. " I will probably need to be on medication for the rest of my life" correct answers a. "this
diagnosis means that I am crazy"
b. " I can learn to manage my thoughts better through therapy"
f. " I will probably need to be on medication for the rest of my life"
A client with foul-smelling drainage from an incision on the upper left arm is admitted with a
suspected methicillin-resistant Staphylococcus aureus (MRSA). What nursing interventions
should the nurse include in the plan of care? Select all that apply
a. Explain the purpose of a low-bacteria diet
,b. Send wound drainage for culture and sensitivity
c. Institute contact precautions for staff and visitors
d. Use standard precautions and wear a mask
e. Monitor the clients white blood cell count correct answers b. Send wound drainage for culture
and sensitivity
c. Institute contact precautions for staff and visitors
e. Monitor the clients white blood cell count
An older adult client who has difficulty hearing is being discharged form surgery following
cataract extraction and lens implantation. Which intervention is most important for the nurse to
implement to ensure the clients compliance with self-care.
a. Provide written instructions for eye drop administration
b. Speak clearly and face the client for lip reading
c. Have the client vocalize the instructions provided
d. Ensure that someone will stay with the client for 24 hours correct answers a. Provide written
instructions for eye drop administration
When assessing a client with an ionized calcium level of 15 mg/dL (4.25 mmol/L), which
intervention is most important for the nurse to implement Reference Range Ionized calcium
[ adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)
a. Compare muscle strength bilaterally b. Assess strength of deep tendon reflexes
c. Determine apical pulse rate and rhythm
d. Observe color and amount of urine correct answers c. Determine apical pulse rate and rhythm
While changing a client postoperative dressing, the nurse observes purulent drainage at the
wound. Before reporting this to the healthcare provider, the nurse should note which of the
client's laboratory results
a. Creatinine level
b. Platelet count
c. Hematocrit
d. White blood cell (WBC) count correct answers d. White blood cell (WBC) count
A client receiving "Heparin sodium 25,000 units in 250 mL 5% dextrose" IV at 7 ml/hour. The
healthcare provider changes the prescription to 900 units/hour. The nurse should program the
infusion pump to deliver at how many mL/hour? correct answers Answer: 9
The nurse is caring for a client with pneumonia who now develops initial signs of septic shock
and multi-organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention
is most important for the nurse to include in the plan of care?
a. Maintain a strict intake and output
b. Keep head of bed raised to 45 degrees
c. Assess warmth in extremities
, d. Monitor blood glucose levels correct answers a. Maintain a strict intake and output
A client is receiving Mesalamine 800 mg PO three times a day. Which assessment should the
nurse perform to assess the effectiveness of the medication?
A. Bowel patterns
B. Pupillary response
C. Peripheral pulses
D. Oxygen saturation correct answers A. Bowel patterns
The nurse if providing teaching to a client with type 2 diabetes (DM) about managing care at
home. Which information provided by the client indicates an understanding of the teaching?
a. Ensure carbohydrate intake to be 35 % of total calories
b. Get an eye examination with an ophthalmologist annually.
c. Using salt, herbs, and spices will improve the flavor of foods
d. Check blood sugar levels every 4 to 6 hours every day. correct answers b. Get an eye
examination with an ophthalmologist annually.
Which is the best approach for the nurse to use when interviewing the client for sexual abuse?
a. Ask the question in a vague, non-specific format
b. Get the most difficult questions over with first
c. Begin with questions that are less sensitive in nature
d. Share personal values to put the client at ease correct answers c. Begin with questions that are
less sensitive in nature.
A client is admitted with an exacerbation of heart failure secondary to COPD. Which
observations by the nurse require immediate intervention to reduce the likelihood of harm to this
client? Select all that apply
A. A bedside commode is positioned near the bed.
B. A saline lock is present in the right forearm
C. A full pitcher of water is on the bedside table.
D. The client is lying in a supine position in bed.
E. A low sodium diet tray was brought to the room. correct answers C. A full pitcher of water at
the bedside
D. the client is lying in a supine position in bed
The nurse is managing the care of a client with Cushing syndrome. Which intervention(s) should
the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
a. Weigh the client and report any weight gain
b. Note and report the client's food and liquid intake during meals and snacks? c. Assess the
client for weakness and fatigue
d. Evaluate the client for sleep disturbances
The nurse is planning discharge instructions for a client with type 2 diabetes who will be starting
Exenatide. Which information should be included in the discharge instructions?
A. Exenatide acts in the same way as insulin in lowering blood glucose.
B. Inject exenatide within 30 minutes before or after a meal.
C. There are no precautions when taking Exenatide with other medications.
D. Notify your healthcare provider if you start having abdominal pain. correct answers D. Notify
your healthcare provider if you start having abdominal pain.
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
1. Click to highlight the aspects of the assessment that require urgent attention:
The client's pain is 2/10. The client requests sleeping medication for the night. She states she has
horrible thoughts and memories about the house collapsing all the time, and that it is keeping her
from falling asleep. She states "I used to be so happy before all of this happened. Now I can;t
seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the
unit as she is currently by the nurses station and hears talking and alarms constantly. correct
answers -She states she has horrible thoughts and memories about the house collapsing all the
time.
- it is keeping her from falling asleep.
-prefers to be in a quieter area of the unit.
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
2. Drag from the options to complete the sentence:
After listening to the clients symptoms, the nurse realizes that she likely has______________
related to _______________ correct answers Acute Stress Disorder, Traumatic Stress exposure
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
3. Click to specify which client statement of behaviors is most likely associated with each of the
listed defense mechanism. Some statements or behaviors may be consistent with more than one
mechanism. Each column must have at least one but may have more than one answer selected.
correct answers
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
,4. What nursing reviews the physicians orders for Clonazepam and gives the medication as
ordered. (SATA)
a. monitor calcium levels
b. assist the client to the bathroom
c. screen for orthostatic hypotension
d. assess mental status regularly
e. provide oral care at least twice a day
f. have an opioid agonist at the bedside correct answers b. assist the client to the bathroom
d. assess mental status regularly
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
5. What other treatment might be helpful for this client? SATA
a. animal therapy
b. administration of lithium
c. consciousness-raising
d. phototherapy
e. electroconvulsive therapy
f. cognitive behavioral therapy correct answers a. animal therapy
c. consciousness-raising
f. cognitive behavioral therapy
Case Study: The client is in the hospital after her house collapsed during a hurricane. She has
been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue
monitoring her respiratory function and to complete intravenous antibiotic administration.
6. For each client statement, click to highlight the statement(s) below that require follow up
teaching by the nurse.
a. "this diagnosis means that I am crazy"
b. " I can learn to manage my thoughts better through therapy"
c. "I can use holistic approaches like medication to help my symptoms"
d. "Many people have the same response to a stressful situation as I am having right"
e. "I am at high risk for post-traumatic-stress disorder because I have acute stress disorder"
f. " I will probably need to be on medication for the rest of my life" correct answers a. "this
diagnosis means that I am crazy"
b. " I can learn to manage my thoughts better through therapy"
f. " I will probably need to be on medication for the rest of my life"
A client with foul-smelling drainage from an incision on the upper left arm is admitted with a
suspected methicillin-resistant Staphylococcus aureus (MRSA). What nursing interventions
should the nurse include in the plan of care? Select all that apply
a. Explain the purpose of a low-bacteria diet
,b. Send wound drainage for culture and sensitivity
c. Institute contact precautions for staff and visitors
d. Use standard precautions and wear a mask
e. Monitor the clients white blood cell count correct answers b. Send wound drainage for culture
and sensitivity
c. Institute contact precautions for staff and visitors
e. Monitor the clients white blood cell count
An older adult client who has difficulty hearing is being discharged form surgery following
cataract extraction and lens implantation. Which intervention is most important for the nurse to
implement to ensure the clients compliance with self-care.
a. Provide written instructions for eye drop administration
b. Speak clearly and face the client for lip reading
c. Have the client vocalize the instructions provided
d. Ensure that someone will stay with the client for 24 hours correct answers a. Provide written
instructions for eye drop administration
When assessing a client with an ionized calcium level of 15 mg/dL (4.25 mmol/L), which
intervention is most important for the nurse to implement Reference Range Ionized calcium
[ adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)
a. Compare muscle strength bilaterally b. Assess strength of deep tendon reflexes
c. Determine apical pulse rate and rhythm
d. Observe color and amount of urine correct answers c. Determine apical pulse rate and rhythm
While changing a client postoperative dressing, the nurse observes purulent drainage at the
wound. Before reporting this to the healthcare provider, the nurse should note which of the
client's laboratory results
a. Creatinine level
b. Platelet count
c. Hematocrit
d. White blood cell (WBC) count correct answers d. White blood cell (WBC) count
A client receiving "Heparin sodium 25,000 units in 250 mL 5% dextrose" IV at 7 ml/hour. The
healthcare provider changes the prescription to 900 units/hour. The nurse should program the
infusion pump to deliver at how many mL/hour? correct answers Answer: 9
The nurse is caring for a client with pneumonia who now develops initial signs of septic shock
and multi-organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention
is most important for the nurse to include in the plan of care?
a. Maintain a strict intake and output
b. Keep head of bed raised to 45 degrees
c. Assess warmth in extremities
, d. Monitor blood glucose levels correct answers a. Maintain a strict intake and output
A client is receiving Mesalamine 800 mg PO three times a day. Which assessment should the
nurse perform to assess the effectiveness of the medication?
A. Bowel patterns
B. Pupillary response
C. Peripheral pulses
D. Oxygen saturation correct answers A. Bowel patterns
The nurse if providing teaching to a client with type 2 diabetes (DM) about managing care at
home. Which information provided by the client indicates an understanding of the teaching?
a. Ensure carbohydrate intake to be 35 % of total calories
b. Get an eye examination with an ophthalmologist annually.
c. Using salt, herbs, and spices will improve the flavor of foods
d. Check blood sugar levels every 4 to 6 hours every day. correct answers b. Get an eye
examination with an ophthalmologist annually.
Which is the best approach for the nurse to use when interviewing the client for sexual abuse?
a. Ask the question in a vague, non-specific format
b. Get the most difficult questions over with first
c. Begin with questions that are less sensitive in nature
d. Share personal values to put the client at ease correct answers c. Begin with questions that are
less sensitive in nature.
A client is admitted with an exacerbation of heart failure secondary to COPD. Which
observations by the nurse require immediate intervention to reduce the likelihood of harm to this
client? Select all that apply
A. A bedside commode is positioned near the bed.
B. A saline lock is present in the right forearm
C. A full pitcher of water is on the bedside table.
D. The client is lying in a supine position in bed.
E. A low sodium diet tray was brought to the room. correct answers C. A full pitcher of water at
the bedside
D. the client is lying in a supine position in bed
The nurse is managing the care of a client with Cushing syndrome. Which intervention(s) should
the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
a. Weigh the client and report any weight gain
b. Note and report the client's food and liquid intake during meals and snacks? c. Assess the
client for weakness and fatigue
d. Evaluate the client for sleep disturbances
