BSN HESI V2 150 QUESTIONS
AND CORRECT ANSWERS LATEST
UPDATE 2025
As the nurse prepares the equipment to be used to start an IV on a 4-year-
old boy in the treatment room, he cries continuously. What intervention
should the nurse implement?
Take the child back to his room.
Recruit others to restrain the child.
Ask the mother to be present to soothe the child.
Show the child how to manipulate the equipment.
Ask the mother to be present to soothe the child.
Rationale
A 4-year-old typically has a vivid imagination and lacks concrete thinking
abilities. The mother's assistance (C) can provide a stabilizing presence to
help soothe the preschooler, who may perceive the invasive procedure as
mutilating. To preserve the child's sense of security associated with the
hospital room, it is best to perform difficult or painful procedures in another
area (A). (B) may be necessary to prevent injury if the child is unable to
cooperate with the mother's coaxing. (D) is best done before going to the
treatment room when the child feels less threatened.
,In evaluating client care, which action should the nurse take first?
Determine if the expected outcomes of care were achieved.
Review the rationales used as the basis of nursing actions.
Document the care plan goals that were successfully met.
Prioritize interventions to be added to the client's plan of care.
Submit
Determine if the expected outcomes of care were achieved.
Rationale
In evaluating care, the nurse should first determine if the expected outcomes
of the plan of care were achieved.
What action should the nurse implement when adding sterile liquids to a
sterile field?
Use an outdated sterile liquid if the bottle is sealed and has not been
opened.
,Consider the sterile field contaminated if it becomes wet during the
procedure.
Remove the container cap and lay it with the inside facing down on the
sterile field.
Hold the container high and pour the solution into a receptacle at the back of
the sterile field.
Consider the sterile field contaminated if it becomes wet during the
procedure.
Rationale
, Wet or damp areas on a sterile field allow organisms to “wick” from the table
surface and permeate into the sterile area, so the field is considered
contaminated if it becomes wet (B). Outdated liquids may be contaminated
and should be discarded, not used (A). The container’s cap should be
removed, placed facing up, and off the sterile field, not (C). To prevent
contamination of the sterile field, liquids should be held close (6 inches) to
the receptacle when pouring to prevent splashing, and the receptacle should
be placed near the front edge to avoid reaching over or across the sterile
field (D).
The nurse formulates the nursing diagnosis of, “Ineffective health
maintenance related to lack of motivation” for a client with Type 2 diabetes.
Which finding supports this nursing diagnosis?
Does not check capillary blood glucose as directed.
Occasionally forgets to take daily prescribed medication.
AND CORRECT ANSWERS LATEST
UPDATE 2025
As the nurse prepares the equipment to be used to start an IV on a 4-year-
old boy in the treatment room, he cries continuously. What intervention
should the nurse implement?
Take the child back to his room.
Recruit others to restrain the child.
Ask the mother to be present to soothe the child.
Show the child how to manipulate the equipment.
Ask the mother to be present to soothe the child.
Rationale
A 4-year-old typically has a vivid imagination and lacks concrete thinking
abilities. The mother's assistance (C) can provide a stabilizing presence to
help soothe the preschooler, who may perceive the invasive procedure as
mutilating. To preserve the child's sense of security associated with the
hospital room, it is best to perform difficult or painful procedures in another
area (A). (B) may be necessary to prevent injury if the child is unable to
cooperate with the mother's coaxing. (D) is best done before going to the
treatment room when the child feels less threatened.
,In evaluating client care, which action should the nurse take first?
Determine if the expected outcomes of care were achieved.
Review the rationales used as the basis of nursing actions.
Document the care plan goals that were successfully met.
Prioritize interventions to be added to the client's plan of care.
Submit
Determine if the expected outcomes of care were achieved.
Rationale
In evaluating care, the nurse should first determine if the expected outcomes
of the plan of care were achieved.
What action should the nurse implement when adding sterile liquids to a
sterile field?
Use an outdated sterile liquid if the bottle is sealed and has not been
opened.
,Consider the sterile field contaminated if it becomes wet during the
procedure.
Remove the container cap and lay it with the inside facing down on the
sterile field.
Hold the container high and pour the solution into a receptacle at the back of
the sterile field.
Consider the sterile field contaminated if it becomes wet during the
procedure.
Rationale
, Wet or damp areas on a sterile field allow organisms to “wick” from the table
surface and permeate into the sterile area, so the field is considered
contaminated if it becomes wet (B). Outdated liquids may be contaminated
and should be discarded, not used (A). The container’s cap should be
removed, placed facing up, and off the sterile field, not (C). To prevent
contamination of the sterile field, liquids should be held close (6 inches) to
the receptacle when pouring to prevent splashing, and the receptacle should
be placed near the front edge to avoid reaching over or across the sterile
field (D).
The nurse formulates the nursing diagnosis of, “Ineffective health
maintenance related to lack of motivation” for a client with Type 2 diabetes.
Which finding supports this nursing diagnosis?
Does not check capillary blood glucose as directed.
Occasionally forgets to take daily prescribed medication.
