BSN 366 exit HESI
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1. Four hours following surgical repair of a compound Elevate the client's right
fracture of the right ulna, the nurse is unable to hand on one or two pil-
palpate the client's right radial pulse. Which action lows
should the nurse take first
2. After placing a 36- week- gestation newborn in an Remove the wet blankets
isolette and drying the infant with several blankets, and linen from the isolette
what should the nurse implement next?
3. A client in the third trimester of pregnancy complains Record the respiratory
of frequent nasal stiffness and occasional nosebleeds. finding in the clients chart
Her chest circumference has increased by 5 cm dur- as normal
ing the pregnancy, and she uses thoracic breathing.
Her diaphragm is elevated and she has an increased
costal angle. Which intervention should the nurse im-
plement?
4. A terminally ill male hospice client who is at home Instruct family to offer
is showing decreased awareness of his surroundings. client only soft bland
His appetite is poor and he often refuses oral intake foods
of solids and liquids. For the past several days he has
been unable to get out of bed. Which action should
the hospice nurse implement?
5. A woman was admitted yesterday afternoon with se- Verify correct placement of
vere abdominal pain. Her pregnancy test and ultra- the nasogastric tube
sound were negative, so an exploratory laparotomy
was completed during the night. When coffee ground
materials is observed in the drainage from the na-
sogastric tube (NGT), which intervention should the
nurse implement?
6. Lipase
, BSN 366 exit HESI
Study online at https://quizlet.com/_di1l9t
The nurse is reviewing the laboratory values for a
client with acute pancreatitis who reports of the ab-
dominal pain is not as severe as it was on admission.
Which laboratory test should the nurse review to eval-
uate the clients clinical recovery?
7. While assessing a client who had a laparotomy the take vital signs
previous day, the nurse notices that 300 mL of dark
red fluid has drained from the nasogastric tube in the
last hour. Which action should the nurse take first?
8. The nurse is reviewing the recommended preventa- Avoid large crowded areas
tive care for clients with asthma, chronic bronchi- during the colder months
tis, and emphysema. Which health care measure is of the year
most important for the nurse to recommend to these
clients?
9. The mother of a one-moth-old infant calls the clinic to Position the infant on
report that the back of her infant's head is flat. How the stomach occasionally
should the nurse respond? when awake and active
10. A woman is brought to the labor and delivery unti Perform a fundal massage
after delivering a term infant and the placenta in the
hospital parking lot 10 minutes ago. Which action
should the nurse perform first?
11. A client has a new prescription for the maximum Decrease serum creatine
recommended dosage of pipercillin/tazobactam for
nosocomial pneumonia. The nurse should report
which laboratory finding to the healthcare provider
before administering the prescribed dose?
12. Fruity breath
, BSN 366 exit HESI
Study online at https://quizlet.com/_di1l9t
A client who is admitted with diabetic ketoacidosis
(DKA) is demonstrating Kussmaul breathing and has
a severe headache along with nausea. Her arterial
blood gases (ABG) are: pH 7.50; PaCO2 30 mmHg;
HCO3 24 mEq/L (24mmol/L). Which assessment find-
ing warrants immediate intervention by the nurse?
13. When performing postural drainage on a client with Explain that the client may
Chronic Obstructive Pulmonary disease (COPD), which be placed in five positions
approach should the nurse use?
14. A young male client with testicular cancer has a living Initiate an ethics commit-
will that describes his desire that no extraordinary tee review
measures be taken to save his life. The healthcare
provider knows the client has a good prognosis and
refuses to write a "do not resuscitate" (DNR) prescrip-
tion. Which action should the nurse take?
15. In observing a clients face, which assessment find- Oral mucosa is cyanotic
ing requires the most immediate intervention by the Blue lips
nurse?
16. The nurse is assessing a client with cirrhosis and notes Complete a thorough
that the client has a positive Babinski reflex. Which ac- neurological assessment
tion should the nurse take in response to the finding?
17. Which action should the nurse take first after obtain- Ensure continued sterility
ing a urine specimen for culture and sensitivity from of the specimen container
an indwelling urinary catheter?
18. The home health nurse observes an older client with Hold the walker securely
unilateral weakness place the walker in front of the to prevent slipping while
the client raises
, BSN 366 exit HESI
Study online at https://quizlet.com/_di1l9t
chair for support while rising to a standing position.
Which action should the nurse take?
19. A client with cancer complains of fever, chills, Monitor lab values for an
malaise, and headache following administration of a increase in WBCs
colony-stimulating factor. Which nursing intervention
is most beneficial in helping to reduce the flu like
symptoms?
20. Which laboratory value should the nurse review prior Serum liver enzymes
to administering the initial dose of a statin medica-
tion?
21. Following a lumbar puncture, a client voices several I have a headache that
concerns. Which concern indicates to the nurse that gets worse when I sit up
the client is experiencing a complication of the proce-
dure?
22. The nurse is caring for a client withdrawing from a Advise to sit up slowly from
fentanyl citrate addiction. The client receives a pre- a reclining position
scription for clonidine 0.2 mg PO taken twice daily.
Which action should the nurse take?
23. A 7-year-old child is admitted to the hospital with a di- Sore throat
agnosis of acute rheumatic fever. In obtaining a health
history form the child's mother, the recent occurrence
of what illness is most significant?
24. Following discharge teaching, a client with a duodenal Review with the client the
ulcer tells the nurse of plans to eat plenty of dairy need to avoid foods that
products, such as milk, to help coat and protect their are rich in milk and cream
ulcer. Which is the best follow-up action by the nurse?
Study online at https://quizlet.com/_di1l9t
1. Four hours following surgical repair of a compound Elevate the client's right
fracture of the right ulna, the nurse is unable to hand on one or two pil-
palpate the client's right radial pulse. Which action lows
should the nurse take first
2. After placing a 36- week- gestation newborn in an Remove the wet blankets
isolette and drying the infant with several blankets, and linen from the isolette
what should the nurse implement next?
3. A client in the third trimester of pregnancy complains Record the respiratory
of frequent nasal stiffness and occasional nosebleeds. finding in the clients chart
Her chest circumference has increased by 5 cm dur- as normal
ing the pregnancy, and she uses thoracic breathing.
Her diaphragm is elevated and she has an increased
costal angle. Which intervention should the nurse im-
plement?
4. A terminally ill male hospice client who is at home Instruct family to offer
is showing decreased awareness of his surroundings. client only soft bland
His appetite is poor and he often refuses oral intake foods
of solids and liquids. For the past several days he has
been unable to get out of bed. Which action should
the hospice nurse implement?
5. A woman was admitted yesterday afternoon with se- Verify correct placement of
vere abdominal pain. Her pregnancy test and ultra- the nasogastric tube
sound were negative, so an exploratory laparotomy
was completed during the night. When coffee ground
materials is observed in the drainage from the na-
sogastric tube (NGT), which intervention should the
nurse implement?
6. Lipase
, BSN 366 exit HESI
Study online at https://quizlet.com/_di1l9t
The nurse is reviewing the laboratory values for a
client with acute pancreatitis who reports of the ab-
dominal pain is not as severe as it was on admission.
Which laboratory test should the nurse review to eval-
uate the clients clinical recovery?
7. While assessing a client who had a laparotomy the take vital signs
previous day, the nurse notices that 300 mL of dark
red fluid has drained from the nasogastric tube in the
last hour. Which action should the nurse take first?
8. The nurse is reviewing the recommended preventa- Avoid large crowded areas
tive care for clients with asthma, chronic bronchi- during the colder months
tis, and emphysema. Which health care measure is of the year
most important for the nurse to recommend to these
clients?
9. The mother of a one-moth-old infant calls the clinic to Position the infant on
report that the back of her infant's head is flat. How the stomach occasionally
should the nurse respond? when awake and active
10. A woman is brought to the labor and delivery unti Perform a fundal massage
after delivering a term infant and the placenta in the
hospital parking lot 10 minutes ago. Which action
should the nurse perform first?
11. A client has a new prescription for the maximum Decrease serum creatine
recommended dosage of pipercillin/tazobactam for
nosocomial pneumonia. The nurse should report
which laboratory finding to the healthcare provider
before administering the prescribed dose?
12. Fruity breath
, BSN 366 exit HESI
Study online at https://quizlet.com/_di1l9t
A client who is admitted with diabetic ketoacidosis
(DKA) is demonstrating Kussmaul breathing and has
a severe headache along with nausea. Her arterial
blood gases (ABG) are: pH 7.50; PaCO2 30 mmHg;
HCO3 24 mEq/L (24mmol/L). Which assessment find-
ing warrants immediate intervention by the nurse?
13. When performing postural drainage on a client with Explain that the client may
Chronic Obstructive Pulmonary disease (COPD), which be placed in five positions
approach should the nurse use?
14. A young male client with testicular cancer has a living Initiate an ethics commit-
will that describes his desire that no extraordinary tee review
measures be taken to save his life. The healthcare
provider knows the client has a good prognosis and
refuses to write a "do not resuscitate" (DNR) prescrip-
tion. Which action should the nurse take?
15. In observing a clients face, which assessment find- Oral mucosa is cyanotic
ing requires the most immediate intervention by the Blue lips
nurse?
16. The nurse is assessing a client with cirrhosis and notes Complete a thorough
that the client has a positive Babinski reflex. Which ac- neurological assessment
tion should the nurse take in response to the finding?
17. Which action should the nurse take first after obtain- Ensure continued sterility
ing a urine specimen for culture and sensitivity from of the specimen container
an indwelling urinary catheter?
18. The home health nurse observes an older client with Hold the walker securely
unilateral weakness place the walker in front of the to prevent slipping while
the client raises
, BSN 366 exit HESI
Study online at https://quizlet.com/_di1l9t
chair for support while rising to a standing position.
Which action should the nurse take?
19. A client with cancer complains of fever, chills, Monitor lab values for an
malaise, and headache following administration of a increase in WBCs
colony-stimulating factor. Which nursing intervention
is most beneficial in helping to reduce the flu like
symptoms?
20. Which laboratory value should the nurse review prior Serum liver enzymes
to administering the initial dose of a statin medica-
tion?
21. Following a lumbar puncture, a client voices several I have a headache that
concerns. Which concern indicates to the nurse that gets worse when I sit up
the client is experiencing a complication of the proce-
dure?
22. The nurse is caring for a client withdrawing from a Advise to sit up slowly from
fentanyl citrate addiction. The client receives a pre- a reclining position
scription for clonidine 0.2 mg PO taken twice daily.
Which action should the nurse take?
23. A 7-year-old child is admitted to the hospital with a di- Sore throat
agnosis of acute rheumatic fever. In obtaining a health
history form the child's mother, the recent occurrence
of what illness is most significant?
24. Following discharge teaching, a client with a duodenal Review with the client the
ulcer tells the nurse of plans to eat plenty of dairy need to avoid foods that
products, such as milk, to help coat and protect their are rich in milk and cream
ulcer. Which is the best follow-up action by the nurse?
