BSN 366 Exam 4 Actual Style V3 | BSN366 HESI
RN Exit Practice Bank | Nightingale
QUESTION 1
A patient arrives at the emergency department with chest pain, diaphoresis, and nausea.
What is the nurse's first action?
A. Obtain a 12-lead ECG
B. Give an antacid for suspected indigestion
C. Offer the patient food
D. Document the patient's history
Answer: A. Obtain a 12-lead ECG
Rationale: Chest pain with diaphoresis and nausea are classic signs of an acute myocardial
infarction (MI). The priority is to obtain an ECG to identify ischemic changes and guide
immediate treatment. This is a life-threatening situation that requires rapid assessment .
QUESTION 2
A post-operative patient becomes tachycardic and hypotensive. The nurse suspects
which complication first?
A. Hemorrhage
B. Anxiety
C. Constipation
D. Fluid overload
Answer: A. Hemorrhage
Rationale: Tachycardia and hypotension in a post-operative patient are classic signs of
hypovolemic shock, most commonly caused by internal or external hemorrhage. This
requires immediate intervention to identify and stop the bleeding and restore circulating
volume .
,QUESTION 3
A patient with a history of asthma is having an exacerbation. Which medication should
the nurse administer first?
A. Albuterol
B. Insulin
C. Morphine
D. Furosemide (Lasix)
Answer: A. Albuterol
Rationale: Albuterol is a short-acting beta-agonist (SABA) bronchodilator that provides
rapid relief of bronchospasm during an acute asthma attack. It is the first-line medication
for acute symptoms .
QUESTION 4
The nurse is providing discharge teaching to a client with COPD. Which statement
indicates a need for further education?
A. "I will stop smoking to slow the progression of my disease."
B. "I should eat more canned vegetables to reduce my sodium intake."
C. "I should use a salt substitute."
D. "I will eat more oatmeal for breakfast."
Answer: B. "I should eat more canned vegetables to reduce my sodium intake."
Rationale: Canned vegetables are often high in sodium, which can lead to fluid retention
and worsen symptoms in clients with COPD. Fresh or frozen vegetables are better choices.
Smoking cessation is the most important intervention, and a diet high in fiber (like
oatmeal) and low in sodium is encouraged .
QUESTION 5
A patient with a brain tumor has a tonic-clonic seizure that lasts 50 seconds. Following
the seizure, the patient is lethargic and confused. What should the nurse do?
A. Notify the emergency response team
B. Ask the wife to leave the room
,C. Explain the postictal state to the family
D. Restrain the patient to prevent further injury
Answer: C. Explain the postictal state to the family
Rationale: The period following a seizure (postictal state) is characterized by confusion,
lethargy, and disorientation. This is a normal and expected phase. Reassuring the family
and providing education is the most appropriate nursing intervention .
QUESTION 6
The healthcare provider prescribes acarbose, an alpha-glucosidase inhibitor, for a client
with type 2 diabetes. Which information provides the best indicator of the drug's
effectiveness?
A. Body mass index between 20 and 24
B. Blood pressure readings less than 120/80
C. Self-reported glucose levels 120 to 150
D. Hemoglobin A1c readings less than 7%
Answer: D. Hemoglobin A1c readings less than 7%
Rationale: Hemoglobin A1c reflects average blood glucose levels over the past 2-3 months.
An A1c of less than 7% is the target goal for most adults with diabetes and is the best
indicator of long-term glycemic control and medication effectiveness .
QUESTION 7
A patient receiving IV vesicant chemotherapy develops pain and erythema at the
infusion site, but no swelling. What is the initial management?
A. Stop the infusion and apply a cold compress
B. Apply warm compresses and continue the infusion
C. Administer an antihistamine
D. Slow the infusion rate
Answer: A. Stop the infusion and apply a cold compress
, Rationale: This presentation suggests possible extravasation. The infusion should be
stopped immediately. For many vesicants, cold compresses are used to reduce
inflammation and limit tissue damage. Warm compresses may be used for specific agents;
assessment is needed .
QUESTION 8
A patient on rivaroxaban develops a life-threatening gastrointestinal bleed. Which agent
reverses the anticoagulant effect of rivaroxaban?
A. Vitamin K
B. Protamine sulfate
C. Andexanet alfa
D. Fresh frozen plasma
Answer: C. Andexanet alfa
Rationale: Andexanet alfa is the specific reversal agent for direct factor Xa inhibitors like
rivaroxaban and apixaban. Vitamin K reverses warfarin, protamine reverses heparin, and
fresh frozen plasma contains clotting factors but is not the first-line for DOACs .
QUESTION 9
The charge nurse is making assignments for the shift. Which client should the charge
nurse assign to the registered nurse (RN) rather than the licensed practical nurse (LPN)?
A. A 75-year-old client with renal calculi who requires urine straining
B. A 64-year-old client who had a total hip replacement the previous day
C. A 30-year-old depressed client who admits to suicide ideation
D. An adolescent with multiple contusions due to a fall that occurred 2 days ago
Answer: C. A 30-year-old depressed client who admits to suicide ideation
Rationale: A client with active suicidal ideation requires a comprehensive psychiatric
nursing assessment, which is outside the LPN's scope of practice. The LPN can care for
stable post-operative clients and those with routine monitoring needs .
RN Exit Practice Bank | Nightingale
QUESTION 1
A patient arrives at the emergency department with chest pain, diaphoresis, and nausea.
What is the nurse's first action?
A. Obtain a 12-lead ECG
B. Give an antacid for suspected indigestion
C. Offer the patient food
D. Document the patient's history
Answer: A. Obtain a 12-lead ECG
Rationale: Chest pain with diaphoresis and nausea are classic signs of an acute myocardial
infarction (MI). The priority is to obtain an ECG to identify ischemic changes and guide
immediate treatment. This is a life-threatening situation that requires rapid assessment .
QUESTION 2
A post-operative patient becomes tachycardic and hypotensive. The nurse suspects
which complication first?
A. Hemorrhage
B. Anxiety
C. Constipation
D. Fluid overload
Answer: A. Hemorrhage
Rationale: Tachycardia and hypotension in a post-operative patient are classic signs of
hypovolemic shock, most commonly caused by internal or external hemorrhage. This
requires immediate intervention to identify and stop the bleeding and restore circulating
volume .
,QUESTION 3
A patient with a history of asthma is having an exacerbation. Which medication should
the nurse administer first?
A. Albuterol
B. Insulin
C. Morphine
D. Furosemide (Lasix)
Answer: A. Albuterol
Rationale: Albuterol is a short-acting beta-agonist (SABA) bronchodilator that provides
rapid relief of bronchospasm during an acute asthma attack. It is the first-line medication
for acute symptoms .
QUESTION 4
The nurse is providing discharge teaching to a client with COPD. Which statement
indicates a need for further education?
A. "I will stop smoking to slow the progression of my disease."
B. "I should eat more canned vegetables to reduce my sodium intake."
C. "I should use a salt substitute."
D. "I will eat more oatmeal for breakfast."
Answer: B. "I should eat more canned vegetables to reduce my sodium intake."
Rationale: Canned vegetables are often high in sodium, which can lead to fluid retention
and worsen symptoms in clients with COPD. Fresh or frozen vegetables are better choices.
Smoking cessation is the most important intervention, and a diet high in fiber (like
oatmeal) and low in sodium is encouraged .
QUESTION 5
A patient with a brain tumor has a tonic-clonic seizure that lasts 50 seconds. Following
the seizure, the patient is lethargic and confused. What should the nurse do?
A. Notify the emergency response team
B. Ask the wife to leave the room
,C. Explain the postictal state to the family
D. Restrain the patient to prevent further injury
Answer: C. Explain the postictal state to the family
Rationale: The period following a seizure (postictal state) is characterized by confusion,
lethargy, and disorientation. This is a normal and expected phase. Reassuring the family
and providing education is the most appropriate nursing intervention .
QUESTION 6
The healthcare provider prescribes acarbose, an alpha-glucosidase inhibitor, for a client
with type 2 diabetes. Which information provides the best indicator of the drug's
effectiveness?
A. Body mass index between 20 and 24
B. Blood pressure readings less than 120/80
C. Self-reported glucose levels 120 to 150
D. Hemoglobin A1c readings less than 7%
Answer: D. Hemoglobin A1c readings less than 7%
Rationale: Hemoglobin A1c reflects average blood glucose levels over the past 2-3 months.
An A1c of less than 7% is the target goal for most adults with diabetes and is the best
indicator of long-term glycemic control and medication effectiveness .
QUESTION 7
A patient receiving IV vesicant chemotherapy develops pain and erythema at the
infusion site, but no swelling. What is the initial management?
A. Stop the infusion and apply a cold compress
B. Apply warm compresses and continue the infusion
C. Administer an antihistamine
D. Slow the infusion rate
Answer: A. Stop the infusion and apply a cold compress
, Rationale: This presentation suggests possible extravasation. The infusion should be
stopped immediately. For many vesicants, cold compresses are used to reduce
inflammation and limit tissue damage. Warm compresses may be used for specific agents;
assessment is needed .
QUESTION 8
A patient on rivaroxaban develops a life-threatening gastrointestinal bleed. Which agent
reverses the anticoagulant effect of rivaroxaban?
A. Vitamin K
B. Protamine sulfate
C. Andexanet alfa
D. Fresh frozen plasma
Answer: C. Andexanet alfa
Rationale: Andexanet alfa is the specific reversal agent for direct factor Xa inhibitors like
rivaroxaban and apixaban. Vitamin K reverses warfarin, protamine reverses heparin, and
fresh frozen plasma contains clotting factors but is not the first-line for DOACs .
QUESTION 9
The charge nurse is making assignments for the shift. Which client should the charge
nurse assign to the registered nurse (RN) rather than the licensed practical nurse (LPN)?
A. A 75-year-old client with renal calculi who requires urine straining
B. A 64-year-old client who had a total hip replacement the previous day
C. A 30-year-old depressed client who admits to suicide ideation
D. An adolescent with multiple contusions due to a fall that occurred 2 days ago
Answer: C. A 30-year-old depressed client who admits to suicide ideation
Rationale: A client with active suicidal ideation requires a comprehensive psychiatric
nursing assessment, which is outside the LPN's scope of practice. The LPN can care for
stable post-operative clients and those with routine monitoring needs .
