BSN366 Exam 4 Actual Exam Style V2 |
BSN 366 HESI RN Exit | Nightingale
1. A nurse is caring for a patient who is 24 hours post-operative after a total hip replacement.
Which of the following findings should the nurse prioritize?
A. Pain level of 5 on a 1-10 scale
B. Sudden onset of shortness of breath and chest pain
C. Serosanguinous drainage on the surgical dressing
D. Decreased appetite and mild nausea
Answer: B
Rationale: The sudden onset of shortness of breath and chest pain in a post-operative
patient suggests a pulmonary embolism, which is a life-threatening emergency. This
requires immediate intervention according to the ABC (Airway, Breathing, Circulation)
priority framework. Other findings like pain or mild drainage are expected post-operative
occurrences.
2. A nurse is preparing to administer digoxin to a client with heart failure. Which of the
following actions should the nurse take first?
A. Monitor the client’s blood pressure
B. Check the client’s serum potassium level
C. Assess the apical pulse for one full minute
,D. Review the client’s last digoxin level
Answer: C
Rationale: The nurse must assess the apical pulse for a full minute before administering
digoxin to ensure the heart rate is at least 60 beats per minute. Digoxin can cause
bradycardia, so withholding the medication based on pulse rate is a standard safety
protocol. While potassium levels and digoxin levels are important, the immediate
assessment of the pulse is the priority action.
3. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which of the following
laboratory results should the nurse expect?
A. pH 7.30, HCO3 15 mEq/L
B. pH 7.45, HCO3 24 mEq/L
C. pH 7.50, HCO3 30 mEq/L
D. pH 7.35, HCO3 22 mEq/L
Answer: A
Rationale: Diabetic ketoacidosis is characterized by metabolic acidosis, which is reflected
by a low pH and low bicarbonate levels. A pH of 7.30 and HCO3 of 15 mEq/L are classic
indicators of this acid-base imbalance. The body attempts to compensate for the excess
ketones by lowering the bicarbonate level.
, 4. Which of the following tasks should a registered nurse (RN) delegate to an unlicensed
assistive personnel (UAP)?
A. Evaluating a client’s response to pain medication
B. Teaching a client how to use an incentive spirometer
C. Assisting a stable client with ambulation
D. Performing a sterile dressing change
Answer: C
Rationale: Assisting a stable client with ambulation is within the scope of practice for a
UAP because it does not require clinical judgment. Evaluation, teaching, and sterile
procedures are nursing responsibilities that must be performed by an RN or LPN.
Delegation must always consider the stability of the patient and the complexity of the task.
5. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which of the
following findings indicates magnesium toxicity?
A. Hyperactive deep tendon reflexes
B. Increased urinary output
C. Respiratory rate of 10 breaths per minute
D. Blood pressure of 150/90 mmHg
Answer: C
BSN 366 HESI RN Exit | Nightingale
1. A nurse is caring for a patient who is 24 hours post-operative after a total hip replacement.
Which of the following findings should the nurse prioritize?
A. Pain level of 5 on a 1-10 scale
B. Sudden onset of shortness of breath and chest pain
C. Serosanguinous drainage on the surgical dressing
D. Decreased appetite and mild nausea
Answer: B
Rationale: The sudden onset of shortness of breath and chest pain in a post-operative
patient suggests a pulmonary embolism, which is a life-threatening emergency. This
requires immediate intervention according to the ABC (Airway, Breathing, Circulation)
priority framework. Other findings like pain or mild drainage are expected post-operative
occurrences.
2. A nurse is preparing to administer digoxin to a client with heart failure. Which of the
following actions should the nurse take first?
A. Monitor the client’s blood pressure
B. Check the client’s serum potassium level
C. Assess the apical pulse for one full minute
,D. Review the client’s last digoxin level
Answer: C
Rationale: The nurse must assess the apical pulse for a full minute before administering
digoxin to ensure the heart rate is at least 60 beats per minute. Digoxin can cause
bradycardia, so withholding the medication based on pulse rate is a standard safety
protocol. While potassium levels and digoxin levels are important, the immediate
assessment of the pulse is the priority action.
3. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which of the following
laboratory results should the nurse expect?
A. pH 7.30, HCO3 15 mEq/L
B. pH 7.45, HCO3 24 mEq/L
C. pH 7.50, HCO3 30 mEq/L
D. pH 7.35, HCO3 22 mEq/L
Answer: A
Rationale: Diabetic ketoacidosis is characterized by metabolic acidosis, which is reflected
by a low pH and low bicarbonate levels. A pH of 7.30 and HCO3 of 15 mEq/L are classic
indicators of this acid-base imbalance. The body attempts to compensate for the excess
ketones by lowering the bicarbonate level.
, 4. Which of the following tasks should a registered nurse (RN) delegate to an unlicensed
assistive personnel (UAP)?
A. Evaluating a client’s response to pain medication
B. Teaching a client how to use an incentive spirometer
C. Assisting a stable client with ambulation
D. Performing a sterile dressing change
Answer: C
Rationale: Assisting a stable client with ambulation is within the scope of practice for a
UAP because it does not require clinical judgment. Evaluation, teaching, and sterile
procedures are nursing responsibilities that must be performed by an RN or LPN.
Delegation must always consider the stability of the patient and the complexity of the task.
5. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which of the
following findings indicates magnesium toxicity?
A. Hyperactive deep tendon reflexes
B. Increased urinary output
C. Respiratory rate of 10 breaths per minute
D. Blood pressure of 150/90 mmHg
Answer: C
