BSN366 EXIT HESI Exam with Verified Answers
1. B) Get an The nurse is providing teaching to a client with type 2
eye exam with DM about important points for disease and symptom
an opthalmolo- management. Which statement by the client indicates
gist annually understanding?
A) Using salt, herbs, and spices will improve the flavor of
foods
B) Get an eye exam with an opthalmologist annually
C) Arrange diet schedule around three regular meals a
day
D) Inspect feet every month for ingrown nails, cuts, and
caluses
2. C) Practice us- The nurse is providing educations to a client who experi-
ing muscle relax- ences recurrent levels of moderate anxiety to situations
ation techniques and perceived stress. In addition to informations about
prescribed medications and administration, which instruc-
tion should the nurse include in the teaching?
A) Center attention on positive upbeat music
B) Find outlets for more social interaction
C) Practice using muscle relaxation techniques
D) Think about reasons the episodes occur
3. C) A 30-year old The charge nurse is planning for the shift and has a RN
depresses client and a PN on the team. Which client should the charge
who admits to nurse assign to the RN?
suicide ideation
A) A 75-year old client with renal calculi who requires
urine straining
B) A 64-year old client who had a total hip replacement
the preious day
C) A 30-year old depresses client who admits to suicide
ideation
D) An adolescent with multiple contusions due to a fall
that occurred 2 days ago
4. Diabetic Find- NGN: (Nurses Notes)
ings: 1800: The client is a female neonate born at 37 weeks of
, BSN366 EXIT HESI Exam with Verified Answers
BG 35 gestation to a G 2 P 1 mother, who was diagnosed with
Axillary temp 96 gestational diabetes. Following a spontaneous vaginal
Ballard score birth, she received Apgar scores of seven at one minute
maturity rating and eight at five minutes. The client weighs 4036.97g
37 (8lbs 9oz) and appears pink with acrocyanosis and a
??????? moderate amount of subcutaneous fat. She is noted to
be slightly jittery at 30min of age. Axillary temperature
Normal Presen- 96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin
tation: seven, fontanelles soft, mongolian spot noted on lower
Soft Fontanelles back, Ballard maturity rating 37 weeks. (For each assess-
Acrocyanosis ment finding, click to indicate whether the findings are
(normal findings associated with an infant of a diabetic mother or normal
include presentation.)
acrocyanosis,
soft fontanelles, Soft Fontanelles
mongolian Blood Glucose 35
spots, and Axillary temp. 96F
Apgar scores 7 Acrocyanosis
to 10) Ballard score maturity rating 37
5. Hyperbilirubine- NGN: (Nurses Notes)
mia , 1800: The client is a female neonate born at 37 weeks of
Resppiratory gestation to a G 2 P 1 mother, who was diagnosed with
Distress gestational diabetes. Following a spontaneous vaginal
Syndrome , and birth, she received Apgar scores of seven at one minute
Cardiomyopathy and eight at five minutes. The client weighs 4036.97g
(8lbs 9oz) and appears pink with acrocyanosis and a
moderate amount of subcutaneous fat. She is noted to
be slightly jittery at 30min of age. Axillary temperature
96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin
seven, fontanelles soft, mongolian spot noted on lower
back, Ballard maturity rating 37 weeks.
The nurse recognizes that the infant of a diabetic moth-
er is at risk for , , and
6. A) Feed Immed- NGN: Orders
icately Breast-feed immediately once stable then on demand.
, BSN366 EXIT HESI Exam with Verified Answers
B) Monitor for If unstable, may feed breastmilk via orogastric tube. If
Respiratory Dis- two feeding attempts failed to increase the glucose levels
tress or if symptoms of hypoglycemia develop, apply dextrose
D) Keep in gel inside the babies cheek. If the above are ineffective,
warmer with bili IV glucose should be administered to maintain glucose
lights levels above 45. Bolus of 2mL/kg glucose 10% IV, hello
E) Monitor temp by a continuous glucose perfusion of 6 to 8mg/kg/min,
q30min maintain glycemic levels over 40.
G) Contact RT for
ABG and O2 ther- Which 6 orders take priority?
apy A) Feed Immediately
J) Blood glucose B) Monitor for respiratory distress
level C) Apply dextrose gell inside the baby's cheek
D) Keep in warmer with bilirubin lights
E) Monitor temp every 30 min
F) Bolus 2 mL/kg glucose 10% IV
G) Contact RT for ABG and oxygen therapy
H) Echo
I) Transfer to NICU
J) Blood glucose level
7. A) Keep infant in NGN Laboratory Results (same case of patient who just
warmer with bili gave birth)
lights to maintain Which actions are appropriate for the nurse to take at this
temp of 97F time? SATA
E) Explain to the
mother that the A) Keep infant in warmer with bili lights to maintain temp
babys RR need of 97.6F
to be below 60 B) Monitor Temp
F) Inform the C) Continue to monitor glucose level
mother that the D) Tell the mother that she will need to discuss this with
baby is sta- the neonatologist
ble enough to E) Explain to the mother that the babys RR needs to be
take out of the below 60
warmer F) Inform the mother that the baby is stable enought to
G) Observe for take out of the warmer
signs of res- G) Observe for signs of respiratory distress and monitor
piratory distress O2 with pulse ox
and monitor
, BSN366 EXIT HESI Exam with Verified Answers
oxygenation by
pulse ox
8. A) NGN: 1800: The client is a female neonate born at 37
B) weeks of gestation to a G 2 P 1 mother, who was di-
C) agnosed with gestational diabetes. Following a sponta-
D) Indicated neous vaginal birth, she received Apgar scores of seven
E) at one minute and eight at five minutes. The client weighs
????????? 4036.97g (8lbs 9oz) and appears pink with acrocyanosis
and a moderate amount of subcutaneous fat. She is noted
to be slightly jittery at 30min of age. Axillary temperature
96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin
seven, fontanelles soft, mongolian spot noted on lower
back, Ballard maturity rating 37 weeks.
(The day shift nurse reviews the nurses notes, labs, and
flow sheet from the night before. The nurse plans on
providing health teaching for the client and her family in
preparation for discharge.)
For each teaching point, click to indicate whether it is
indicated or contraindicated. Only one right option per
row.
A) You will need to se
9. Glucose after NGN: 1800: The client is a female neonate born at 37
feeding was 60 weeks of gestation to a G 2 P 1 mother, who was di-
Direct bili 5 agnosed with gestational diabetes. Following a sponta-
Temp 97.8 neous vaginal birth, she received Apgar scores of seven
Oxygen 98% at one minute and eight at five minutes. The client weighs
Able to tolerate 4036.97g (8lbs 9oz) and appears pink with acrocyanosis
breastmilk and a moderate amount of subcutaneous fat. She is noted
?????????? to be slightly jittery at 30min of age. Axillary temperature
96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin
seven, fontanelles soft, mongolian spot noted on lower
back, Ballard maturity rating 37 weeks.
(Click to highlight notes that demonstrate a positive out-
come)
Day 2, 0630: Vitals have remained stable throughout the
