BSN 366 HESI RN EXIT EXAM V1 (PDF) | 2026 EXAM
QUESTIONS AND ANSWERS + RATIONALES | STUDY GUIDE |
100% CORRECT
1. Which action best prevents hospital-acquired infections in a clinical setting?
A) Wearing sterile gloves for all patient contact
B) Performing hand hygiene before and after patient care
C) Using antibiotics prophylactically for all admissions
D) Wearing a mask at all times while on duty
Correct Answer: B) Performing hand hygiene before and after patient care
Rationale: Hand hygiene is the single most effective infection control measure to prevent the
transmission of pathogens in healthcare settings. Alcohol-based hand rubs are preferred unless
hands are visibly soiled, in which case soap and water should be used.
2. A nurse is triaging multiple clients in an emergency department. Which client should be
seen first?
A) Client with mild abdominal pain rated 4/10
B) Client with an oxygen saturation of 86% on room air
C) Client requesting discharge instructions for a sprained ankle
D) Client with chronic back pain requesting medication refill
Correct Answer: B) Client with an oxygen saturation of 86% on room air
Rationale: An oxygen saturation of 86% indicates significant hypoxia and is a life-threatening
airway and breathing priority . According to the ABCs (Airway, Breathing, Circulation), this
client requires immediate intervention before any other concerns.
3. Which laboratory value is most concerning and requires immediate nursing action?
A) Sodium 140 mEq/L
B) Potassium 6.5 mEq/L
C) Hemoglobin 13 g/dL
D) Calcium 9.2 mg/dL
Correct Answer: B) Potassium 6.5 mEq/L
Rationale: This potassium level represents severe hyperkalemia, which can cause lethal cardiac
dysrhythmias . Normal potassium range is 3.5–5.0 mEq/L, and a value of 6.5 requires immediate
intervention such as cardiac monitoring and medication administration.
4. A 68-year-old client with heart failure reports sudden weight gain of 2.3 kg (5 lb) over 3
days. Which finding should the nurse anticipate?
A) Decreased jugular venous distension
B) Bilateral crackles in the lung bases
C) Hypertension with supine positioning
D) Bradycardia with premature ventricular contractions
,Correct Answer: B) Bilateral crackles in the lung bases
Rationale: Rapid weight gain in heart failure indicates fluid retention and worsening volume
overload, which commonly presents as bilateral basilar crackles due to pulmonary venous
congestion . Jugular venous distension would increase, not decrease, with fluid overload.
5. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial
assessment, the nurse would anticipate which finding?
A) Lethargy
B) Heat intolerance
C) Diarrhea
D) Skin eruptions
Correct Answer: A) Lethargy
Rationale: Low T3/T4 with elevated TSH indicates primary hypothyroidism . Classic
manifestations include lethargy, fatigue, cold intolerance, constipation, and dry skin. Heat
intolerance and diarrhea are associated with hyperthyroidism.
6. Which medication requires monitoring of the INR level?
A) Heparin
B) Warfarin
C) Insulin
D) Digoxin
Correct Answer: B) Warfarin
Rationale: Warfarin is an anticoagulant that affects the vitamin K-dependent clotting factors, and
its therapeutic range is monitored using the International Normalized Ratio (INR) . The target
INR is typically 2.0–3.0 for most indications. Heparin is monitored using aPTT.
7. In a client with a hypertensive crisis, which assessment is the priority during the first hour
of care?
A) Heart rate
B) Pedal pulses
C) Lung sounds
D) Pupil responses
Correct Answer: D) Pupil responses
Rationale: In severe hypertension, neurological complications such as stroke or hypertensive
encephalopathy can present quickly . Changes in pupillary response may indicate rising
intracranial pressure or other neurological compromise requiring immediate intervention.
8. A client receiving atorvastatin develops an increased serum creatine phosphokinase (CK)
level. The nurse should assess the client for which problem?
A) Muscle pain or weakness
B) Excessive bruising
, C) Peripheral edema
D) Jaundice
Correct Answer: A) Muscle pain or weakness
Rationale: Elevated CK with statin therapy suggests myopathy or rhabdomyolysis, a serious
adverse effect . The nurse should assess for muscle pain, tenderness, or weakness, especially in
the proximal muscle groups, and report findings to the healthcare provider.
9. The nurse is performing preoperative care for a client scheduled for open reduction and
internal fixation (ORIF) of a fractured right tibia. Which action should the nurse
prioritize?
A) Verify the client's signed informed consent
B) Administer preoperative antibiotics
C) Insert a Foley catheter
D) Apply antiembolism stockings
Correct Answer: A) Verify the client's signed informed consent
Rationale: Verifying that the client has signed the informed consent form and that all questions
have been answered is a legal and ethical priority before any invasive procedure . This ensures
patient autonomy and proper documentation.
10. Which finding would the nurse most closely associate with anemia in a 10-month-old
infant?
A) Hemoglobin level of 12 g/dL
B) Pale mucosa of the eyelids and lips
C) Hypoactivity
D) Heart rate between 140 and 160 beats per minute
Correct Answer: B) Pale mucosa of the eyelids and lips
Rationale: Pallor, especially of the mucosal membranes, is a hallmark sign of anemia in infants
and children . A hemoglobin of 12 g/dL is within normal range for this age, while hypoactivity
and elevated heart rate are less specific early indicators.
11. What is the most important consideration when teaching parents how to reduce injury
risks in the home?
A) Age and knowledge level of the parents
B) Proximity to emergency services
C) Number of children in the home
D) Age and developmental level of the children
Correct Answer: D) Age and developmental level of the children
Rationale: The child's developmental level drives risk assessment and injury prevention
strategies . Toddlers require toddler-proofing (cabinets, stair gates), while older children need
education on different hazards. Safety teaching must be tailored to the child's age and abilities.
QUESTIONS AND ANSWERS + RATIONALES | STUDY GUIDE |
100% CORRECT
1. Which action best prevents hospital-acquired infections in a clinical setting?
A) Wearing sterile gloves for all patient contact
B) Performing hand hygiene before and after patient care
C) Using antibiotics prophylactically for all admissions
D) Wearing a mask at all times while on duty
Correct Answer: B) Performing hand hygiene before and after patient care
Rationale: Hand hygiene is the single most effective infection control measure to prevent the
transmission of pathogens in healthcare settings. Alcohol-based hand rubs are preferred unless
hands are visibly soiled, in which case soap and water should be used.
2. A nurse is triaging multiple clients in an emergency department. Which client should be
seen first?
A) Client with mild abdominal pain rated 4/10
B) Client with an oxygen saturation of 86% on room air
C) Client requesting discharge instructions for a sprained ankle
D) Client with chronic back pain requesting medication refill
Correct Answer: B) Client with an oxygen saturation of 86% on room air
Rationale: An oxygen saturation of 86% indicates significant hypoxia and is a life-threatening
airway and breathing priority . According to the ABCs (Airway, Breathing, Circulation), this
client requires immediate intervention before any other concerns.
3. Which laboratory value is most concerning and requires immediate nursing action?
A) Sodium 140 mEq/L
B) Potassium 6.5 mEq/L
C) Hemoglobin 13 g/dL
D) Calcium 9.2 mg/dL
Correct Answer: B) Potassium 6.5 mEq/L
Rationale: This potassium level represents severe hyperkalemia, which can cause lethal cardiac
dysrhythmias . Normal potassium range is 3.5–5.0 mEq/L, and a value of 6.5 requires immediate
intervention such as cardiac monitoring and medication administration.
4. A 68-year-old client with heart failure reports sudden weight gain of 2.3 kg (5 lb) over 3
days. Which finding should the nurse anticipate?
A) Decreased jugular venous distension
B) Bilateral crackles in the lung bases
C) Hypertension with supine positioning
D) Bradycardia with premature ventricular contractions
,Correct Answer: B) Bilateral crackles in the lung bases
Rationale: Rapid weight gain in heart failure indicates fluid retention and worsening volume
overload, which commonly presents as bilateral basilar crackles due to pulmonary venous
congestion . Jugular venous distension would increase, not decrease, with fluid overload.
5. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial
assessment, the nurse would anticipate which finding?
A) Lethargy
B) Heat intolerance
C) Diarrhea
D) Skin eruptions
Correct Answer: A) Lethargy
Rationale: Low T3/T4 with elevated TSH indicates primary hypothyroidism . Classic
manifestations include lethargy, fatigue, cold intolerance, constipation, and dry skin. Heat
intolerance and diarrhea are associated with hyperthyroidism.
6. Which medication requires monitoring of the INR level?
A) Heparin
B) Warfarin
C) Insulin
D) Digoxin
Correct Answer: B) Warfarin
Rationale: Warfarin is an anticoagulant that affects the vitamin K-dependent clotting factors, and
its therapeutic range is monitored using the International Normalized Ratio (INR) . The target
INR is typically 2.0–3.0 for most indications. Heparin is monitored using aPTT.
7. In a client with a hypertensive crisis, which assessment is the priority during the first hour
of care?
A) Heart rate
B) Pedal pulses
C) Lung sounds
D) Pupil responses
Correct Answer: D) Pupil responses
Rationale: In severe hypertension, neurological complications such as stroke or hypertensive
encephalopathy can present quickly . Changes in pupillary response may indicate rising
intracranial pressure or other neurological compromise requiring immediate intervention.
8. A client receiving atorvastatin develops an increased serum creatine phosphokinase (CK)
level. The nurse should assess the client for which problem?
A) Muscle pain or weakness
B) Excessive bruising
, C) Peripheral edema
D) Jaundice
Correct Answer: A) Muscle pain or weakness
Rationale: Elevated CK with statin therapy suggests myopathy or rhabdomyolysis, a serious
adverse effect . The nurse should assess for muscle pain, tenderness, or weakness, especially in
the proximal muscle groups, and report findings to the healthcare provider.
9. The nurse is performing preoperative care for a client scheduled for open reduction and
internal fixation (ORIF) of a fractured right tibia. Which action should the nurse
prioritize?
A) Verify the client's signed informed consent
B) Administer preoperative antibiotics
C) Insert a Foley catheter
D) Apply antiembolism stockings
Correct Answer: A) Verify the client's signed informed consent
Rationale: Verifying that the client has signed the informed consent form and that all questions
have been answered is a legal and ethical priority before any invasive procedure . This ensures
patient autonomy and proper documentation.
10. Which finding would the nurse most closely associate with anemia in a 10-month-old
infant?
A) Hemoglobin level of 12 g/dL
B) Pale mucosa of the eyelids and lips
C) Hypoactivity
D) Heart rate between 140 and 160 beats per minute
Correct Answer: B) Pale mucosa of the eyelids and lips
Rationale: Pallor, especially of the mucosal membranes, is a hallmark sign of anemia in infants
and children . A hemoglobin of 12 g/dL is within normal range for this age, while hypoactivity
and elevated heart rate are less specific early indicators.
11. What is the most important consideration when teaching parents how to reduce injury
risks in the home?
A) Age and knowledge level of the parents
B) Proximity to emergency services
C) Number of children in the home
D) Age and developmental level of the children
Correct Answer: D) Age and developmental level of the children
Rationale: The child's developmental level drives risk assessment and injury prevention
strategies . Toddlers require toddler-proofing (cabinets, stair gates), while older children need
education on different hazards. Safety teaching must be tailored to the child's age and abilities.
