BSN 366 Exit HESI Exam Actual 2026 Update with Bank &
Correct Answers | Nightingale College | NGN-Style Case
Scenarios & Detailed Rationales | 100% Pass Guarantee - 215
Questions
This culminating exam assesses comprehensive mastery of general nursing principles, evidence-based practice,
professional standards, and clinical reasoning required for entry into professional practice. It integrates
advanced concepts from pharmacology, pathophysiology, ethics, leadership, and safety, reflecting current
standards for US licensure and practice. It contains 215 multiple-choice questions, each with four distractors and
a fully worked rationale that explains why the keyed answer is correct. Content is organized into 1 focused
section: General. Targeted learning outcomes include: Synthesize evidence-based interventions for complex
patient scenarios across diverse settings.; Apply ethical and legal frameworks to clinical decision-making with
attention to patient autonomy and advocacy.; Integrate principles of safety, quality improvement, and
interprofessional collaboration to optimize patient outcomes.; Utilize advanced pharmacological knowledge to
evaluate medication therapy and prevent adverse events.. Every item has been reviewed for clinical accuracy,
current guidelines, and clarity so that students can study with confidence and self-correct as they work through
the bank. Use it as a high-yield review immediately before the exam, or as a structured practice tool during the
unit - the rationales double as concise teaching notes. The recommended writing time is 3 hours and 30 minutes,
with a passing score of 85% (750/900) Scaled. Aligned with This exam is designed in accordance with the
standards of the Commission on Collegiate Nursing Education (CCNE) and the National Council of State Boards
Section 1: General (Questions 1-215)
1 In a patient with acute pancreatitis receiving total parenteral nutrition, which
addition is most critical to prevent a life-threatening metabolic complication?
A) Regular insulin sliding scale to prevent hyperglycemia
B) Intravenous lipids to provide essential fatty acids
C) Daily electrolyte panel monitoring for refeeding syndrome
D) Trace element supplementation including zinc and copper
Answer: C
Rationale: Refeeding syndrome can occur when nutrition is rapidly
reintroduced in malnourished patients, leading to dangerous shifts in
phosphorus, potassium, and magnesium. Acute pancreatitis patients are often
malnourished, making monitoring essential. While insulin and lipids are
important, preventing refeeding syndrome takes priority as it can cause
arrhythmias and respiratory failure.
2 A patient receiving vancomycin develops red man syndrome. Which
intervention should the nurse implement first?
A) Stop the infusion immediately and administer diphenhydramine
,B) Slow the infusion rate and monitor vital signs
C) Flush the IV line with normal saline and apply a warm compress
D) Change the IV site and administer an antipyretic
Answer: B
Rationale: Red man syndrome is often infusion-rate related and not a true
allergic reaction. Slowing the infusion and monitoring are first-line responses.
Stopping the infusion is reserved for severe reactions; diphenhydramine may
be given but after slowing. The other options do not address the cause.
3 A patient with diabetic ketoacidosis has a serum potassium of 5.8 mEq/L.
The nurse reviews the provider's prescriptions. Which prescription should
the nurse question?
A) Administer regular insulin 0.1 units/kg/hour IV
B) Infuse 0.9% sodium chloride at 500 mL/hour
C) Add 20 mEq potassium chloride to the IV fluid
D) Monitor cardiac rhythm continuously
Answer: C
Rationale: In DKA, initial potassium is often elevated due to acidosis shifting
potassium out of cells. However, total body potassium is depleted. Once
insulin therapy begins and acidosis corrects, potassium moves intracellularly,
leading to hypokalemia. The potassium level of 5.8 mEq/L indicates
hyperkalemia; adding potassium would be dangerous. The other orders are
appropriate for DKA management.
4 During a home visit, a patient with a new colostomy expresses concern about
odor and leakage. The stoma appears dusky and edematous. What should the
nurse do first?
A) Teach the patient to use a pouch with a charcoal filter
B) Apply a topical antifungal powder to the peristomal skin
C) Notify the healthcare provider of the stoma's appearance
D) Counsel the patient about dietary modifications to reduce odor
Answer: C
Rationale: A dusky stoma indicates compromised blood flow, potentially
ischemia or necrosis, requiring immediate medical evaluation. Edema can also
impair perfusion. Addressing odor and leakage is secondary to ensuring stoma
viability. The nurse must prioritize the physiologic problem over comfort
,issues.
5 A nurse is providing discharge teaching to a patient after a kidney transplant.
Which statement by the patient indicates a need for further instruction?
A) I will avoid crowds and people who are sick.
B) I should take my immunosuppressants at the same time each day.
C) If I have a fever, I will wait 24 hours before calling the doctor.
D) I will monitor my urine output daily and report decreases.
Answer: C
Rationale: Fever in an immunosuppressed transplant recipient may signal
infection or rejection; waiting 24 hours is dangerous. Patients must report fever
immediately. The other statements reflect correct understanding: infection
precautions, adherence to immunosuppressants, and monitoring urine output.
6 A nurse is caring for a patient with a pulmonary artery catheter. The
waveform shows a sudden appearance of a large V wave. The nurse suspects
which complication?
A) Pulmonary artery rupture
B) Tricuspid regurgitation
C) Mitral regurgitation
D) Right ventricular infarction
Answer: C
Rationale: A large V wave on the pulmonary capillary wedge pressure tracing
indicates mitral regurgitation; the V wave represents atrial pressure during
ventricular systole when blood regurgitates into the left atrium. Pulmonary
artery rupture would show a different clinical picture. Tricuspid regurgitation
affects right-sided pressures. Right ventricular infarction manifests differently.
7 A nurse is evaluating the laboratory results of a patient receiving heparin
therapy for a pulmonary embolism. The aPTT is 45 seconds (control 30
seconds). What should the nurse do?
A) Increase the heparin infusion rate as per protocol
B) Administer a bolus of heparin 5000 units IV
C) Continue the current heparin infusion rate
D) Hold the infusion and notify the healthcare provider
Answer: C
, Rationale: The goal aPTT for heparin therapy is typically 1.5-2.5 times the
control, i.e., 45-75 seconds. 45 seconds is at the lower therapeutic range;
continuing is appropriate. Increasing or bolusing may cause supratherapeutic
levels. Holding is not indicated unless significantly elevated.
8 A patient with chronic kidney disease (GFR 20 mL/min) is prescribed
spironolactone for heart failure. Which assessment finding should the nurse
report to the healthcare provider immediately?
A) Serum potassium 5.0 mEq/L
B) Serum sodium 138 mEq/L
C) Blood pressure 128/78 mm Hg
D) Weight increase of 0.5 kg over 2 days
Answer: A
Rationale: Spironolactone is a potassium-sparing diuretic. In CKD, the risk of
hyperkalemia is high. A potassium of 5.0 mEq/L is near the upper limit (5.2)
and may increase further, leading to life-threatening arrhythmias. The nurse
should report and possibly hold the medication. Other values are within or near
normal and less critical.
9 A nurse is assisting with a thoracentesis. During the procedure, the patient
coughs and becomes dyspneic. What should the nurse do first?
A) Increase oxygen flow rate and monitor pulse oximetry
B) Stop the procedure and reposition the patient upright
C) Prepare to administer a bronchodilator via nebulizer
D) Check the insertion site for bleeding or hematoma
Answer: B
Rationale: Coughing and dyspnea during thoracentesis may indicate
pneumothorax or pleural reaction. The immediate action is to stop the
procedure and reposition the patient upright to optimize breathing.
Administering oxygen may follow but is not first. The priority is to prevent
further complications and assess.
10 A patient with cirrhosis and ascites is receiving furosemide 40 mg IV. The
nurse notes a urine output of 30 mL over the last 2 hours. The patient's
blood pressure is 98/58 mm Hg. What should the nurse do first?
A) Administer a second dose of furosemide as prescribed
Correct Answers | Nightingale College | NGN-Style Case
Scenarios & Detailed Rationales | 100% Pass Guarantee - 215
Questions
This culminating exam assesses comprehensive mastery of general nursing principles, evidence-based practice,
professional standards, and clinical reasoning required for entry into professional practice. It integrates
advanced concepts from pharmacology, pathophysiology, ethics, leadership, and safety, reflecting current
standards for US licensure and practice. It contains 215 multiple-choice questions, each with four distractors and
a fully worked rationale that explains why the keyed answer is correct. Content is organized into 1 focused
section: General. Targeted learning outcomes include: Synthesize evidence-based interventions for complex
patient scenarios across diverse settings.; Apply ethical and legal frameworks to clinical decision-making with
attention to patient autonomy and advocacy.; Integrate principles of safety, quality improvement, and
interprofessional collaboration to optimize patient outcomes.; Utilize advanced pharmacological knowledge to
evaluate medication therapy and prevent adverse events.. Every item has been reviewed for clinical accuracy,
current guidelines, and clarity so that students can study with confidence and self-correct as they work through
the bank. Use it as a high-yield review immediately before the exam, or as a structured practice tool during the
unit - the rationales double as concise teaching notes. The recommended writing time is 3 hours and 30 minutes,
with a passing score of 85% (750/900) Scaled. Aligned with This exam is designed in accordance with the
standards of the Commission on Collegiate Nursing Education (CCNE) and the National Council of State Boards
Section 1: General (Questions 1-215)
1 In a patient with acute pancreatitis receiving total parenteral nutrition, which
addition is most critical to prevent a life-threatening metabolic complication?
A) Regular insulin sliding scale to prevent hyperglycemia
B) Intravenous lipids to provide essential fatty acids
C) Daily electrolyte panel monitoring for refeeding syndrome
D) Trace element supplementation including zinc and copper
Answer: C
Rationale: Refeeding syndrome can occur when nutrition is rapidly
reintroduced in malnourished patients, leading to dangerous shifts in
phosphorus, potassium, and magnesium. Acute pancreatitis patients are often
malnourished, making monitoring essential. While insulin and lipids are
important, preventing refeeding syndrome takes priority as it can cause
arrhythmias and respiratory failure.
2 A patient receiving vancomycin develops red man syndrome. Which
intervention should the nurse implement first?
A) Stop the infusion immediately and administer diphenhydramine
,B) Slow the infusion rate and monitor vital signs
C) Flush the IV line with normal saline and apply a warm compress
D) Change the IV site and administer an antipyretic
Answer: B
Rationale: Red man syndrome is often infusion-rate related and not a true
allergic reaction. Slowing the infusion and monitoring are first-line responses.
Stopping the infusion is reserved for severe reactions; diphenhydramine may
be given but after slowing. The other options do not address the cause.
3 A patient with diabetic ketoacidosis has a serum potassium of 5.8 mEq/L.
The nurse reviews the provider's prescriptions. Which prescription should
the nurse question?
A) Administer regular insulin 0.1 units/kg/hour IV
B) Infuse 0.9% sodium chloride at 500 mL/hour
C) Add 20 mEq potassium chloride to the IV fluid
D) Monitor cardiac rhythm continuously
Answer: C
Rationale: In DKA, initial potassium is often elevated due to acidosis shifting
potassium out of cells. However, total body potassium is depleted. Once
insulin therapy begins and acidosis corrects, potassium moves intracellularly,
leading to hypokalemia. The potassium level of 5.8 mEq/L indicates
hyperkalemia; adding potassium would be dangerous. The other orders are
appropriate for DKA management.
4 During a home visit, a patient with a new colostomy expresses concern about
odor and leakage. The stoma appears dusky and edematous. What should the
nurse do first?
A) Teach the patient to use a pouch with a charcoal filter
B) Apply a topical antifungal powder to the peristomal skin
C) Notify the healthcare provider of the stoma's appearance
D) Counsel the patient about dietary modifications to reduce odor
Answer: C
Rationale: A dusky stoma indicates compromised blood flow, potentially
ischemia or necrosis, requiring immediate medical evaluation. Edema can also
impair perfusion. Addressing odor and leakage is secondary to ensuring stoma
viability. The nurse must prioritize the physiologic problem over comfort
,issues.
5 A nurse is providing discharge teaching to a patient after a kidney transplant.
Which statement by the patient indicates a need for further instruction?
A) I will avoid crowds and people who are sick.
B) I should take my immunosuppressants at the same time each day.
C) If I have a fever, I will wait 24 hours before calling the doctor.
D) I will monitor my urine output daily and report decreases.
Answer: C
Rationale: Fever in an immunosuppressed transplant recipient may signal
infection or rejection; waiting 24 hours is dangerous. Patients must report fever
immediately. The other statements reflect correct understanding: infection
precautions, adherence to immunosuppressants, and monitoring urine output.
6 A nurse is caring for a patient with a pulmonary artery catheter. The
waveform shows a sudden appearance of a large V wave. The nurse suspects
which complication?
A) Pulmonary artery rupture
B) Tricuspid regurgitation
C) Mitral regurgitation
D) Right ventricular infarction
Answer: C
Rationale: A large V wave on the pulmonary capillary wedge pressure tracing
indicates mitral regurgitation; the V wave represents atrial pressure during
ventricular systole when blood regurgitates into the left atrium. Pulmonary
artery rupture would show a different clinical picture. Tricuspid regurgitation
affects right-sided pressures. Right ventricular infarction manifests differently.
7 A nurse is evaluating the laboratory results of a patient receiving heparin
therapy for a pulmonary embolism. The aPTT is 45 seconds (control 30
seconds). What should the nurse do?
A) Increase the heparin infusion rate as per protocol
B) Administer a bolus of heparin 5000 units IV
C) Continue the current heparin infusion rate
D) Hold the infusion and notify the healthcare provider
Answer: C
, Rationale: The goal aPTT for heparin therapy is typically 1.5-2.5 times the
control, i.e., 45-75 seconds. 45 seconds is at the lower therapeutic range;
continuing is appropriate. Increasing or bolusing may cause supratherapeutic
levels. Holding is not indicated unless significantly elevated.
8 A patient with chronic kidney disease (GFR 20 mL/min) is prescribed
spironolactone for heart failure. Which assessment finding should the nurse
report to the healthcare provider immediately?
A) Serum potassium 5.0 mEq/L
B) Serum sodium 138 mEq/L
C) Blood pressure 128/78 mm Hg
D) Weight increase of 0.5 kg over 2 days
Answer: A
Rationale: Spironolactone is a potassium-sparing diuretic. In CKD, the risk of
hyperkalemia is high. A potassium of 5.0 mEq/L is near the upper limit (5.2)
and may increase further, leading to life-threatening arrhythmias. The nurse
should report and possibly hold the medication. Other values are within or near
normal and less critical.
9 A nurse is assisting with a thoracentesis. During the procedure, the patient
coughs and becomes dyspneic. What should the nurse do first?
A) Increase oxygen flow rate and monitor pulse oximetry
B) Stop the procedure and reposition the patient upright
C) Prepare to administer a bronchodilator via nebulizer
D) Check the insertion site for bleeding or hematoma
Answer: B
Rationale: Coughing and dyspnea during thoracentesis may indicate
pneumothorax or pleural reaction. The immediate action is to stop the
procedure and reposition the patient upright to optimize breathing.
Administering oxygen may follow but is not first. The priority is to prevent
further complications and assess.
10 A patient with cirrhosis and ascites is receiving furosemide 40 mg IV. The
nurse notes a urine output of 30 mL over the last 2 hours. The patient's
blood pressure is 98/58 mm Hg. What should the nurse do first?
A) Administer a second dose of furosemide as prescribed
