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BSN 366 EXIT HESI QUESTIONS AND ANSWERS
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BSN 366 EXIT HESI QUESTIONS AND ANSWERS
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BSN 366 EXIT HESI QUESTIONS AND ANSWERSA newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has
not been sleeping well lately and is experiencing labored breathing. List the client's
problems in order of priority for the nurse. (Rank in the priority order from highest to
lowest.)
1.
Airway and breathing.
2.
Pain management.
3.
Definitive therapy.
4.
Sleep and rest. - answer- Correct Answer:
1.Airway and breathing. 2.Pain management. 3.Sleep and rest. 4.Definitive therapy.
Rationale
First-level problems are immediate priorities (airway, breathing, and circulation). In this
scenario, airway and breathing are the first priority, followed by pain management,
Maslow's hierarchy of basic needs for rest and sleep, and then definitive drug therapies.
Which biological practices are federally regulated for healthcare workers? (Select all
that apply.)
Select all that apply
1.Standard precautions.
2. N-95 tuberculosis standard.
3. Blood-borne pathogen standard.
4. Biological product exposure limit (BPEL).
5. Resource Conservation and Recovery Act (RCRA).
6. As Low as Reasonably Allowable standard (ALARA). - answer- 3. Blood-borne
pathogen standard.
5. Resource Conservation and Recovery Act (RCRA)
Basic standards for healthcare workers, as delineated by Occupational Safety and
Health Administration (OSHA), include standard precautions, droplet precautions using
N-95 respiratory particulate masks when caring for a client who is positive for
tuberculosis, and required annual updates for healthcare workers about blood-borne
pathogen transmission, methods of minimizing exposure, and employee rights. Other
options [BPEL and ALARA ] are not federally regulated.
A client with severe depression tells the nurse, "I do not know why you bother with me
or give me pills. I am never going to get well." What is the most therapeutic response?
1. "You need to stop thinking negative thoughts. They get in the way of your recovery."
2. "You are no bother to me or to the staff. We want you to get well and not feel sad
anymore."
,3. "I have known many clients with depression who have felt better after several weeks
of treatment."
4. "You are feeling very pessimistic, but that is part of your illness. It should go away as
you recover." - answer- 3. "I have known many clients with depression who have felt
better after several weeks of treatment."
Stating the observation that others have recovered can give a client hope. Telling a
person to stop negtive thinking is ineffective because the client must be taught cognitive
strategies to stop negative thinking. Stating the person is "no bother" is arguing with the
client's beliefs and attempting to tell him how to feel, both of which are not therapeutic
responses. Bring up pessimistic feelings interprets the client's feelings and does not
provide the same degree of hope.
The nurse is caring for a client with a nursing problem of, "Infection, risk for, related to
inadequate primary defenses as evidenced by surgical incision and IV access." What
nursing intervention should the nurse implement?
1. Limit visitors to immediate family to decrease exposure to infection.
2. Maintain "clean" technique in the change of wound dressing and IV site.
3. Assess and document skin condition around the incision and IV site at each shift.
4. Require the use of a face mask by staff when providing care requiring close contact. -
answer- 3. Assess and document skin condition around the incision and IV site at each
shift.
Early identification of infection leads to prompt treatment and decreased nosocomial
transmission to others, so the condition of any invasive lines or breaks in the skin
should be assessed and documented during each shift.
A client with ulcerative colitis is scheduled for surgical creation of an ileoanal reservoir
(J pouch). As part of preoperative teaching, what information should the nurse provide?
1. The transverse loop ostomy is permanent.
2. Easily removable appliances allow independence in self-care.
3. Daily irrigation is started after the J pouch heals.
4. Stool is eventually expelled through the rectum. - answer- 4. Stool is eventually
expelled through the rectum.
An ileal pouch-anal anastomosis (also known as the J pouch) is a surgically created
ileoanal reservoir in the anal canal that preserves the rectal sphincter muscle, so that
passage of stool through the rectum is the eventual result. To promote healing of the
anastomosed parts of the colon, a temporary loop ostomy is created, not a permanent
one. Although appliances that are easy to use are advantageous, the ostomy is
reversed after healing takes place. Stool drains into the reservoir, so daily irrigation is
not usually indicated.
The nurse inflates the cuff on a tracheostomy tube to minimal occlusion pressure for a
client who is breathing spontaneously. Which action should the nurse follow?
,1. Check the pilot balloon to ensure that it is firm.
2. Verify the healthcare provider's prescription for the required cuff pressure.
3. Use a manometer to maintain cuff pressure between 25 and 30 mmHg.
4. Inject air until no air is auscultated over the larynx during a deep breath. - answer- 4.
Inject air until no air is auscultated over the larynx during a deep breath.
To achieve minimal pressure (minimal occlusion volume technique) against the tracheal
wall, inject air into the tracheostomy tube cuff while auscultating with a stethoscope
placed over the larynx (over the cuff) during inhalation. At the point when sounds of air
movement cease, inflation is stopped, indicating that the cuff is sealed against the
tracheal wall.
A 60-year-old homeless man who complains of a cough, late-afternoon fever, and night
sweats has a 10 mm induration after receiving a purified protein derivative (PPD) skin
test. Which action should the nurse implement?
1. Refer for further diagnostic evaluation.
2. Determine exposure of others to the tuberculosis.
3. Begin anti-tubercular drug therapy.
4. Quarantine or isolate to control communicability. - answer- 1. Refer for further
diagnostic evaluation.
The PPD skin test results is indicative of exposure or latent Mycobacterium tuberculosis
infection (LTBI), which this client is in a high-risk category for exposure in a homeless
environment. Although productive prolonged cough, fever, and night sweats are
common early symptoms, persons suspected of LTBI should not begin treatment until
active TB disease has been excluded. Further diagnostic evaluation should be
implemented. A dormant form that neither causes disease nor is communicable.
Which contextual factors are considered external environmental influences in the
framework for occupational health programs and services? (Select all that apply.)
Select all that apply
1. Economics.
2. Workforce.
3. Technology.
4. Interventions.
5. Socio-economic status.
6. Legislation/regulation. - answer- 1. Economics.
3. Technology.
6. Legislation/regulation.
Economics affects the health of the company and its workforce productivity, in termsof
profitability, growth, and expansion. Technology adds to an industry's capacity to
develop and implement new or improved work processes. Legislation/regulation in the
workplace, such as the blood-borne pathogen standard, affects the workforce in terms
of requirements, administration, and control strategies. Occupational safety programs
are built around the workforce to strive for maximum internal productivity. Interventions
, are internal environmental influences of an occupational health and safety program.
Socio-economic status is a demographic variable commonly used in epidemiology.
The nurse is analyzing the waveforms of a client's electrocardiogram. What finding
indicates a disturbance in electrical conduction in the ventricles?
1. T wave of 0.16 second.
2. PR interval of 0.18 second.
3. QT interval of 0.34 second.
4. QRS interval of 0.14 second. - answer- 4. QRS interval of 0.14 second.
The normal duration of the QRS is 0.04 to 0.12 second, so a prolonged QRS indicates
an electrical anomaly in the ventricles. The T wave is normally 0.16 seconds. The PR
interval range is 0.12 to 0.20 second. The QT interval should be 0.31 to 0.38 second.
The nurse is assigned a client with numerous treatments and decides it is not possible
to complete all the needed treatments in the time scheduled for this shift. Which process
should the nurse use?
1. Delegate tasks to competent team members.
2. Prioritize tasks with the most crucial needs first.
3. Report the incomplete treatments to next shift nurse.
4. Start with the easiest treatment first. - answer- 2. Prioritize tasks with the most crucial
needs first.
Planning care for a client with numerous treatments should be prioritized with the most
crucial client needs first to the least. Delegating to others or reporting displace the
nurse's responsibility to provide care. Starting with easiest is an inefficient utilization of
time in meeting critical client needs.
A male client is on contact precautions due to an infected draining wound and is being
discharged home. The client lives at home with his wife and their adolescent daughter.
What discharge instruction should the nurse include for the client?
1. Use disposable plates and utensils.
2. Stay in a room with the door closed.
3. Dispose of soiled dressings in plastic bags that are securely closed.
4. Others who are in the same room with the client should wear a mask. - answer- 3.
Dispose of soiled dressings in plastic bags that are securely closed.
Contact precautions require the use of a barrier that prevents contact with wound
secretions on soiled dressings, which are best disposed of in tightly closed plastic bags.
Disposable dishes is not necessary with contact precautions. Isolating themself to one
room or wearing masks should be implemented for airborne, droplet precautions, or
protective environments.
When assessing a client's interior eye structures with an ophthalmoscope, which action
should the nurse use?
1. Use a red-free filter.
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