BSN366 Exam 3 Actual Exam Style V2 |
BSN 366 HESI RN Exit | Nightingale
1. A nurse is caring for a client who is taking digoxin 0.25 mg daily. Which of the following
findings should the nurse identify as a manifestation of digoxin toxicity?
A. Constipation
B. Increased appetite
C. Yellow-tinged vision
D. Hypertension
Answer: C
Rationale: Visual changes such as yellow-green halos or tinged vision are classic signs of
digoxin toxicity. The nurse should also monitor for gastrointestinal effects like nausea and
vomiting which often occur early. Immediate reporting to the provider is necessary to
prevent cardiac arrhythmias.
2. A nurse is reviewing the arterial blood gas (ABG) results for a client: pH 7.30, PaCO2 50
mmHg, and HCO3 24 mEq/L. The nurse should identify these results as which of the
following?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
,D. Respiratory acidosis
Answer: D
Rationale: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg indicates a
respiratory cause. Since the bicarbonate level is within the normal range, this represents
uncompensated respiratory acidosis. The nurse should assess the client’s respiratory status
and airway patency immediately.
3. A nurse is planning care for a client who has a prescription for a magnesium sulfate
infusion for preeclampsia. Which of the following items should the nurse have at the
bedside?
A. Protamine sulfate
B. Calcium gluconate
C. Naloxone
D. Atropine
Answer: B
Rationale: Calcium gluconate is the specific antidote for magnesium sulfate toxicity and
must be readily available. Toxicity is characterized by loss of deep tendon reflexes and
respiratory depression. The nurse should perform frequent neurovascular and respiratory
assessments during the infusion.
, 4. A nurse is teaching a client who has a new prescription for warfarin. Which of the following
statements should the nurse include in the teaching?
A. Increase your intake of dark green leafy vegetables.
B. You will need a PT/INR test once a year.
C. Take aspirin if you experience a headache.
D. Use a soft-bristled toothbrush to prevent gum bleeding.
Answer: D
Rationale: Warfarin increases the risk of bleeding, so clients should use soft-bristled
toothbrushes and electric razors. Consistent Vitamin K intake is required rather than
increasing it, as Vitamin K is the antidote. Aspirin should be avoided because it further
increases the risk of hemorrhage.
5. A nurse is assessing a client who is 2 hours postoperative following a total hip arthroplasty.
Which of the following assessments is the priority?
A. Pain level at the surgical site
B. Pedal pulses of the affected extremity
C. Bowel sounds in all four quadrants
D. Urinary output for the last 2 hours
Answer: B
BSN 366 HESI RN Exit | Nightingale
1. A nurse is caring for a client who is taking digoxin 0.25 mg daily. Which of the following
findings should the nurse identify as a manifestation of digoxin toxicity?
A. Constipation
B. Increased appetite
C. Yellow-tinged vision
D. Hypertension
Answer: C
Rationale: Visual changes such as yellow-green halos or tinged vision are classic signs of
digoxin toxicity. The nurse should also monitor for gastrointestinal effects like nausea and
vomiting which often occur early. Immediate reporting to the provider is necessary to
prevent cardiac arrhythmias.
2. A nurse is reviewing the arterial blood gas (ABG) results for a client: pH 7.30, PaCO2 50
mmHg, and HCO3 24 mEq/L. The nurse should identify these results as which of the
following?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
,D. Respiratory acidosis
Answer: D
Rationale: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg indicates a
respiratory cause. Since the bicarbonate level is within the normal range, this represents
uncompensated respiratory acidosis. The nurse should assess the client’s respiratory status
and airway patency immediately.
3. A nurse is planning care for a client who has a prescription for a magnesium sulfate
infusion for preeclampsia. Which of the following items should the nurse have at the
bedside?
A. Protamine sulfate
B. Calcium gluconate
C. Naloxone
D. Atropine
Answer: B
Rationale: Calcium gluconate is the specific antidote for magnesium sulfate toxicity and
must be readily available. Toxicity is characterized by loss of deep tendon reflexes and
respiratory depression. The nurse should perform frequent neurovascular and respiratory
assessments during the infusion.
, 4. A nurse is teaching a client who has a new prescription for warfarin. Which of the following
statements should the nurse include in the teaching?
A. Increase your intake of dark green leafy vegetables.
B. You will need a PT/INR test once a year.
C. Take aspirin if you experience a headache.
D. Use a soft-bristled toothbrush to prevent gum bleeding.
Answer: D
Rationale: Warfarin increases the risk of bleeding, so clients should use soft-bristled
toothbrushes and electric razors. Consistent Vitamin K intake is required rather than
increasing it, as Vitamin K is the antidote. Aspirin should be avoided because it further
increases the risk of hemorrhage.
5. A nurse is assessing a client who is 2 hours postoperative following a total hip arthroplasty.
Which of the following assessments is the priority?
A. Pain level at the surgical site
B. Pedal pulses of the affected extremity
C. Bowel sounds in all four quadrants
D. Urinary output for the last 2 hours
Answer: B
