BSN 366 Exit Hesi (BSN 366 V2) | Questions and
Correct Answers Plus Rationale | New Update
2026/2027 | Graded A+ | Nightingale College
The nurse knows that which statement by the mother indicates that the mother
understands safety precautions with her four month-old infant and her 4 year-old
child?
A) "I have the 4 year-old hold and help feed the four month-old a bottle in the
kitchen while I make supper."
B) "I let the 4 year-old watch the baby while I take a quick shower."
C) "I put the baby in the car seat on the floor while I cook."
D) "I let the 4 year-old carry the baby around the house."
Correct Answer : A) "I have the 4 year-old hold and help feed the four month-
old a bottle in the kitchen while I make supper."
Rationale : This statement indicates understanding of safety. The mother is
supervising the 4-year-old and keeping both children in a safe, controlled
environment (the kitchen) while she is present. The other options involve leaving
the infant unsupervised with a young child or unsafe positioning.
Upon completing the admission documents, the nurse learns that the 87 year-old
client does not have an advance directive. What action should the nurse take?
,A) Give information about advance directives.
B) Ask the family to make a decision.
C) Contact the healthcare provider.
D) Proceed with the admission.
Correct Answer : A) Give information about advance directives.
Rationale : The nurse should provide information about advance directives to
the client. This is a routine part of admission and ensures the client understands
their options for future healthcare decisions. The nurse should not pressure the
client.
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes
after the immunization was given, the client complains of itchy and watery eyes,
increased anxiety, and difficulty breathing. The nurse expects that the first action
in the sequence of care for this client will be to
A) Administer epinephrine 1:1000 as ordered.
B) Call 911.
C) Place the client in a supine position.
D) Administer an antihistamine.
Correct Answer : A) Administer epinephrine 1:1000 as ordered.
,Rationale : The client is showing signs of anaphylaxis (itchy eyes, difficulty
breathing). The first-line treatment is epinephrine. This is a life-threatening
emergency. The nurse should have epinephrine available and administer it
immediately.
Which of these children at the site of a disaster at a child day care center would
the triage nurse put in the "treat last" category?
A) A toddler with severe deep abrasions over 98% of the body.
B) A child with a fractured arm.
C) A child with a head injury.
D) A child with difficulty breathing.
Correct Answer : A) A toddler with severe deep abrasions over 98% of the body.
Rationale : In triage, a client with severe, extensive burns over 98% of the body
would be classified as "treat last" (or expectant) because survival is unlikely. The
nurse would focus resources on clients with a higher chance of survival.
When admitting a client to an acute care facility, an identification bracelet is sent
up with the admission form. In the event these do not match, the nurse's best
action is to
A) Notify the admissions office and wait to apply the bracelet.
B) Apply the bracelet based on the admission form.
C) Apply the bracelet based on the client's verbal identification.
, D) Use a temporary bracelet until corrected.
Correct Answer : A) Notify the admissions office and wait to apply the bracelet.
Rationale : The identification bracelet must be correct to ensure safety. If there
is a discrepancy, the nurse should notify the admissions office and wait for a
corrected bracelet. Applying an incorrect bracelet (B, C) is unsafe. Using a
temporary bracelet (D) is not appropriate.
The nurse is having difficulty reading the health care provider's written order that
was written right before the shift change. What action should be taken?
A) Call the provider for clarification.
B) Ask the pharmacist to interpret the order.
C) Look up the medication in a drug reference.
D) Wait until the next shift to clarify.
Correct Answer : A) Call the provider for clarification.
Rationale : If an order is illegible, the nurse must contact the healthcare
provider for clarification. It is unsafe to interpret the order independently. The
nurse should not delay the order.
An adult client is found to be unresponsive on morning rounds. After checking for
responsiveness and calling for help, the next action that should be taken by the
nurse is to:
Correct Answers Plus Rationale | New Update
2026/2027 | Graded A+ | Nightingale College
The nurse knows that which statement by the mother indicates that the mother
understands safety precautions with her four month-old infant and her 4 year-old
child?
A) "I have the 4 year-old hold and help feed the four month-old a bottle in the
kitchen while I make supper."
B) "I let the 4 year-old watch the baby while I take a quick shower."
C) "I put the baby in the car seat on the floor while I cook."
D) "I let the 4 year-old carry the baby around the house."
Correct Answer : A) "I have the 4 year-old hold and help feed the four month-
old a bottle in the kitchen while I make supper."
Rationale : This statement indicates understanding of safety. The mother is
supervising the 4-year-old and keeping both children in a safe, controlled
environment (the kitchen) while she is present. The other options involve leaving
the infant unsupervised with a young child or unsafe positioning.
Upon completing the admission documents, the nurse learns that the 87 year-old
client does not have an advance directive. What action should the nurse take?
,A) Give information about advance directives.
B) Ask the family to make a decision.
C) Contact the healthcare provider.
D) Proceed with the admission.
Correct Answer : A) Give information about advance directives.
Rationale : The nurse should provide information about advance directives to
the client. This is a routine part of admission and ensures the client understands
their options for future healthcare decisions. The nurse should not pressure the
client.
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes
after the immunization was given, the client complains of itchy and watery eyes,
increased anxiety, and difficulty breathing. The nurse expects that the first action
in the sequence of care for this client will be to
A) Administer epinephrine 1:1000 as ordered.
B) Call 911.
C) Place the client in a supine position.
D) Administer an antihistamine.
Correct Answer : A) Administer epinephrine 1:1000 as ordered.
,Rationale : The client is showing signs of anaphylaxis (itchy eyes, difficulty
breathing). The first-line treatment is epinephrine. This is a life-threatening
emergency. The nurse should have epinephrine available and administer it
immediately.
Which of these children at the site of a disaster at a child day care center would
the triage nurse put in the "treat last" category?
A) A toddler with severe deep abrasions over 98% of the body.
B) A child with a fractured arm.
C) A child with a head injury.
D) A child with difficulty breathing.
Correct Answer : A) A toddler with severe deep abrasions over 98% of the body.
Rationale : In triage, a client with severe, extensive burns over 98% of the body
would be classified as "treat last" (or expectant) because survival is unlikely. The
nurse would focus resources on clients with a higher chance of survival.
When admitting a client to an acute care facility, an identification bracelet is sent
up with the admission form. In the event these do not match, the nurse's best
action is to
A) Notify the admissions office and wait to apply the bracelet.
B) Apply the bracelet based on the admission form.
C) Apply the bracelet based on the client's verbal identification.
, D) Use a temporary bracelet until corrected.
Correct Answer : A) Notify the admissions office and wait to apply the bracelet.
Rationale : The identification bracelet must be correct to ensure safety. If there
is a discrepancy, the nurse should notify the admissions office and wait for a
corrected bracelet. Applying an incorrect bracelet (B, C) is unsafe. Using a
temporary bracelet (D) is not appropriate.
The nurse is having difficulty reading the health care provider's written order that
was written right before the shift change. What action should be taken?
A) Call the provider for clarification.
B) Ask the pharmacist to interpret the order.
C) Look up the medication in a drug reference.
D) Wait until the next shift to clarify.
Correct Answer : A) Call the provider for clarification.
Rationale : If an order is illegible, the nurse must contact the healthcare
provider for clarification. It is unsafe to interpret the order independently. The
nurse should not delay the order.
An adult client is found to be unresponsive on morning rounds. After checking for
responsiveness and calling for help, the next action that should be taken by the
nurse is to:
