BSN 366 HESI RN Exit Exam Questions and
Answers Plus Rationale | New Update 2026/2027 |
Graded A+ | Nightingale College
Question 1
The nurse is performing preoperative care of a client for an open reduction and
internal fixation (ORIF) of a fractured right tibia before the procedure, which
action should the nurse prioritize?
• □
A. Verify the client is NPO
• □
B. Check the client's vital signs
• □
C. Ensure the surgical site is marked
• ☑
D. Verify the client's signed consent
Correct Answer : D. Verify the client's signed consent
Expert Rationale : The priority action before any surgical procedure is to verify
that the client has signed an informed consent. This is a legal and ethical requirement
that ensures the client understands the procedure, risks, benefits, and alternatives. While
other actions (NPO status, vital signs, site marking) are important components of
preoperative care, consent verification is the nurse's legal responsibility and priority.
Without a valid signed consent, the procedure cannot proceed legally.
,Question 2
A client receives a prescription for acetaminophen 1,000 mg by mouth every 8
hours as needed for pain. The bottle is labeled "Acetaminophen for Oral
Suspension, USP 500 mg per 15 mL." How many tablespoons should the nurse
instruct the client to take with each dose? (Enter numerical value only.)
Answer: 2
Expert Rationale :
• Medication concentration: 500 mg per 15 mL
• Prescribed dose: 1,000 mg
• Calculation: 1,000 mg ÷ 500 mg = 2 (meaning 2 doses of 15 mL each)
• 15 mL × 2 = 30 mL total
• 1 tablespoon = 15 mL
• 30 mL ÷ 15 mL = 2 tablespoons
Question 3
The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility
prior to discharge. Which behaviors indicate the client understands how to
maintain balance safely?
Select all that apply
• ☑
A. Brings a heavy can close to body before lifting
• □
B. Locks knees while preparing food on the counter
• ☑
C. Widens stance while working near the sink
• □
D. Bends from the waist to pick trash off the floor
, • □
E. Leans forward to pull a pan from a high shelf
Correct Answer s: A and C
Expert Rationale :
• A (Correct): Bringing a heavy object close to the body before lifting maintains
the center of gravity and reduces strain on the back, promoting balance and
safety.
• C (Correct): Widening the stance provides a broader base of support, which
enhances stability and balance during activities.
• B (Incorrect): Locking knees can reduce circulation and may cause dizziness or
fainting; knees should remain slightly flexed.
• D (Incorrect): Bending from the waist to pick up objects places excessive strain
on the lumbar spine; clients should bend at the knees and hips.
• E (Incorrect): Leaning forward to reach high objects shifts the center of gravity
forward and increases fall risk; clients should use a step stool or reacher.
Question 4
The RN is assigned to care for four surgical clients. After receiving the report,
which client should the nurse see first?
• □
A. Two days postoperative bladder surgery with continuous bladder irrigation
infusing
• □
B. One-day postoperative laparoscopic cholecystectomy requesting pain
medication
• ☑
C. Three days postoperative colon resection receiving a transfusion of packed
RBCs
• □
, D. Preoperative, in Buck's traction, and scheduled for hip arthroplasty within the
next 12 hours
Correct Answer : C. Three days postoperative colon resection receiving a
transfusion of packed RBCs
Expert Rationale : The client receiving a blood transfusion requires the highest
priority assessment. Transfusions carry the risk of transfusion reactions, which can be
life-threatening. The nurse must assess this client first to monitor for signs of transfusion
reaction (fever, chills, rash, dyspnea, hypotension). The other clients, while important, do
not present with immediate life-threatening risks requiring urgent assessment.
Question 5
A client is receiving a continuous infusion of the anticoagulant, heparin, for
treatment of a deep vein thrombosis of the right calf. Which goal should the nurse
include in this client's plan of care?
• ☑
A. No further thrombus will form
• □
B. The client's INR (international normalized ratio) will be 2
• □
C. The existing thrombosis will dissolve
• □
D. The circumference of the client's right calf will decrease
Correct Answer : A. No further thrombus will form
Expert Rationale : Heparin prevents the extension of existing thrombi and the
formation of new thrombi, but it does not dissolve existing clots. The body's
endogenous fibrinolytic system gradually dissolves the clot over time. INR is monitored
for warfarin therapy, not heparin (which is monitored by aPTT). While decreased calf
Answers Plus Rationale | New Update 2026/2027 |
Graded A+ | Nightingale College
Question 1
The nurse is performing preoperative care of a client for an open reduction and
internal fixation (ORIF) of a fractured right tibia before the procedure, which
action should the nurse prioritize?
• □
A. Verify the client is NPO
• □
B. Check the client's vital signs
• □
C. Ensure the surgical site is marked
• ☑
D. Verify the client's signed consent
Correct Answer : D. Verify the client's signed consent
Expert Rationale : The priority action before any surgical procedure is to verify
that the client has signed an informed consent. This is a legal and ethical requirement
that ensures the client understands the procedure, risks, benefits, and alternatives. While
other actions (NPO status, vital signs, site marking) are important components of
preoperative care, consent verification is the nurse's legal responsibility and priority.
Without a valid signed consent, the procedure cannot proceed legally.
,Question 2
A client receives a prescription for acetaminophen 1,000 mg by mouth every 8
hours as needed for pain. The bottle is labeled "Acetaminophen for Oral
Suspension, USP 500 mg per 15 mL." How many tablespoons should the nurse
instruct the client to take with each dose? (Enter numerical value only.)
Answer: 2
Expert Rationale :
• Medication concentration: 500 mg per 15 mL
• Prescribed dose: 1,000 mg
• Calculation: 1,000 mg ÷ 500 mg = 2 (meaning 2 doses of 15 mL each)
• 15 mL × 2 = 30 mL total
• 1 tablespoon = 15 mL
• 30 mL ÷ 15 mL = 2 tablespoons
Question 3
The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility
prior to discharge. Which behaviors indicate the client understands how to
maintain balance safely?
Select all that apply
• ☑
A. Brings a heavy can close to body before lifting
• □
B. Locks knees while preparing food on the counter
• ☑
C. Widens stance while working near the sink
• □
D. Bends from the waist to pick trash off the floor
, • □
E. Leans forward to pull a pan from a high shelf
Correct Answer s: A and C
Expert Rationale :
• A (Correct): Bringing a heavy object close to the body before lifting maintains
the center of gravity and reduces strain on the back, promoting balance and
safety.
• C (Correct): Widening the stance provides a broader base of support, which
enhances stability and balance during activities.
• B (Incorrect): Locking knees can reduce circulation and may cause dizziness or
fainting; knees should remain slightly flexed.
• D (Incorrect): Bending from the waist to pick up objects places excessive strain
on the lumbar spine; clients should bend at the knees and hips.
• E (Incorrect): Leaning forward to reach high objects shifts the center of gravity
forward and increases fall risk; clients should use a step stool or reacher.
Question 4
The RN is assigned to care for four surgical clients. After receiving the report,
which client should the nurse see first?
• □
A. Two days postoperative bladder surgery with continuous bladder irrigation
infusing
• □
B. One-day postoperative laparoscopic cholecystectomy requesting pain
medication
• ☑
C. Three days postoperative colon resection receiving a transfusion of packed
RBCs
• □
, D. Preoperative, in Buck's traction, and scheduled for hip arthroplasty within the
next 12 hours
Correct Answer : C. Three days postoperative colon resection receiving a
transfusion of packed RBCs
Expert Rationale : The client receiving a blood transfusion requires the highest
priority assessment. Transfusions carry the risk of transfusion reactions, which can be
life-threatening. The nurse must assess this client first to monitor for signs of transfusion
reaction (fever, chills, rash, dyspnea, hypotension). The other clients, while important, do
not present with immediate life-threatening risks requiring urgent assessment.
Question 5
A client is receiving a continuous infusion of the anticoagulant, heparin, for
treatment of a deep vein thrombosis of the right calf. Which goal should the nurse
include in this client's plan of care?
• ☑
A. No further thrombus will form
• □
B. The client's INR (international normalized ratio) will be 2
• □
C. The existing thrombosis will dissolve
• □
D. The circumference of the client's right calf will decrease
Correct Answer : A. No further thrombus will form
Expert Rationale : Heparin prevents the extension of existing thrombi and the
formation of new thrombi, but it does not dissolve existing clots. The body's
endogenous fibrinolytic system gradually dissolves the clot over time. INR is monitored
for warfarin therapy, not heparin (which is monitored by aPTT). While decreased calf
