HESI PRACTICE EXAM BSN AND
CORRECT ANSWERS/
NIGHTINGALE BSN 225 HESI
LATEST MOCK PRACTICE SET
225 Questions with Answers and Detailed Rationales
100 PERCENT GUARANTEED PASS
INSTANT DOWNLOAD ANSWERS INCLUDED
IMPORTANCE OF THIS DOCUMENT
This comprehensive examination preparation guide has been meticulously developed to help you succeed in the
HESI PRACTICE EXAM BSN AND CORRECT ANSWERS/ NIGHTINGALE BSN 225 HESI PRACTICE TEST. It
contains 225 carefully selected questions that reflect the most current exam content and testing strategies. Each
question is accompanied by a correct answer and a detailed rationale that explains the underlying concepts and
reasoning required to master the material.
Self-Assessment – Test your knowledge and Exam Preparation – Familiarize yourself with the
identify areas requiring further question format and content
study areas
Concept Reinforcement – Deepen your Confidence Building – Develop test-taking
understanding through strategies and reduce
evidence-based exam anxiety
rationales
Time Management – Practice answering questions
under simulated exam
conditions
Review Summary 225 Questions
Foundations - Application - HESI BSN AND Correct / Nightingale BSN 225 HESI Nursing Comprehensive
HESI Undergraduate YEAR 4 BSN
All answers with rationales
,Table of Contents
Section A - Fundamentals OF Nursing Section B - Medical-surgical Nursing
Questions 1 to 57 Questions 58 to 114
Section C - Pharmacology Section D - Pediatrics
Questions 115 to 171 Questions 172 to 225
,Section A - Fundamentals OF Nursing
Q1.
A client receiving IV vancomycin develops sudden onset of flushing, hypotension, and a
maculopapular rash on the face and upper trunk. Which intervention should the nurse
prioritize?
A. Administer diphenhydramine and B. Stop the infusion, maintain IV access,
continue the infusion at a slower rate and notify the provider immediately
C. Slow the infusion rate to 10 mL/hr and D. Increase IV fluids and administer
document the reaction epinephrine 0.3 mg IM
Correct: B - Stop the infusion, maintain IV access, and notify the provider immediately
Rationale:
This describes vancomycin flushing reaction (red man syndrome) from rapid infusion. The
priority is to stop the infusion immediately to prevent worsening anaphylactoid reaction.
Slowing or continuing can exacerbate hypotension. Epinephrine is reserved for anaphylaxis
with airway compromise.
Q2.
A nurse is caring for four clients. Which client should the nurse assess first after receiving
shift report?
A. Client with chronic kidney disease who B. Client with heart failure who has 2+
has a serum potassium of 5.8 mEq/L and is pitting edema and reports mild dyspnea on
receiving a potassium-sparing diuretic exertion
C. Client with type 1 diabetes whose blood D. Client with a fractured femur who is in
glucose is 320 mg/dL and urine ketones are balanced skeletal traction and reports leg
small pain of 4/10
Correct: A - Client with chronic kidney disease who has a serum potassium of 5.8 mEq/L
and is receiving a potassium-sparing diuretic
Rationale:
A potassium of 5.8 mEq/L with a potassium-sparing diuretic poses imminent risk for
life-threatening dysrhythmias. Hyperkalemia requires immediate intervention. The other
clients are stable: edema and mild dyspnea are chronic, hyperglycemia with small ketones is
concerning but not emergent, and pain controlled.
Q3.
The nurse is planning care for a client with a chest tube connected to a drainage system at
-20 cm H2O suction. Which observation indicates a system leak?
Page 3
, Section A - Fundamentals OF Nursing
A. Intermittent bubbling in the water seal B. Continuous bubbling in the water seal
chamber during exhalation chamber
C. Fluctuations in the water seal chamber D. No bubbling in the suction control
with respirations chamber
Correct: B - Continuous bubbling in the water seal chamber
Rationale:
Continuous bubbling in the water seal chamber indicates an air leak in the system.
Intermittent bubbling during exhalation is normal as air is expelled. Fluctuations (tidaling) are
normal. Suction control chamber bubbling is expected if suction is applied.
Q4.
A client with an indwelling urinary catheter has a urine output of 20 mL over the past hour.
The nurse assesses the bladder by palpation and finds no distention. Which action should
the nurse take next?
A. Irrigate the catheter with 30 mL sterile B. Reposition the catheter and check for
saline kinks
C. Notify the provider of possible acute D. Increase IV fluid rate to 150 mL/hr
kidney injury
Correct: B - Reposition the catheter and check for kinks
Rationale:
Low output without bladder distention suggests obstruction or mechanical issue. First step is
to check for kinks, reposition, and ensure patency. Irrigation is not first line. Notifying provider
is premature. Increasing IV fluids may be appropriate after mechanical issues ruled out.
Q5.
A nurse is administering an IV vesicant chemotherapy agent. The client reports burning at
the IV site, and the nurse notes erythema without swelling. Which action should the nurse
take?
A. Apply a warm compress and continue the B. Stop the infusion, keep the IV in place,
infusion at a slower rate and prepare for antidote administration
C. Flush the line with normal saline and D. Remove the IV and apply pressure to the
apply cold compress site for 5 minutes
Correct: B - Stop the infusion, keep the IV in place, and prepare for antidote administration
Page 4
CORRECT ANSWERS/
NIGHTINGALE BSN 225 HESI
LATEST MOCK PRACTICE SET
225 Questions with Answers and Detailed Rationales
100 PERCENT GUARANTEED PASS
INSTANT DOWNLOAD ANSWERS INCLUDED
IMPORTANCE OF THIS DOCUMENT
This comprehensive examination preparation guide has been meticulously developed to help you succeed in the
HESI PRACTICE EXAM BSN AND CORRECT ANSWERS/ NIGHTINGALE BSN 225 HESI PRACTICE TEST. It
contains 225 carefully selected questions that reflect the most current exam content and testing strategies. Each
question is accompanied by a correct answer and a detailed rationale that explains the underlying concepts and
reasoning required to master the material.
Self-Assessment – Test your knowledge and Exam Preparation – Familiarize yourself with the
identify areas requiring further question format and content
study areas
Concept Reinforcement – Deepen your Confidence Building – Develop test-taking
understanding through strategies and reduce
evidence-based exam anxiety
rationales
Time Management – Practice answering questions
under simulated exam
conditions
Review Summary 225 Questions
Foundations - Application - HESI BSN AND Correct / Nightingale BSN 225 HESI Nursing Comprehensive
HESI Undergraduate YEAR 4 BSN
All answers with rationales
,Table of Contents
Section A - Fundamentals OF Nursing Section B - Medical-surgical Nursing
Questions 1 to 57 Questions 58 to 114
Section C - Pharmacology Section D - Pediatrics
Questions 115 to 171 Questions 172 to 225
,Section A - Fundamentals OF Nursing
Q1.
A client receiving IV vancomycin develops sudden onset of flushing, hypotension, and a
maculopapular rash on the face and upper trunk. Which intervention should the nurse
prioritize?
A. Administer diphenhydramine and B. Stop the infusion, maintain IV access,
continue the infusion at a slower rate and notify the provider immediately
C. Slow the infusion rate to 10 mL/hr and D. Increase IV fluids and administer
document the reaction epinephrine 0.3 mg IM
Correct: B - Stop the infusion, maintain IV access, and notify the provider immediately
Rationale:
This describes vancomycin flushing reaction (red man syndrome) from rapid infusion. The
priority is to stop the infusion immediately to prevent worsening anaphylactoid reaction.
Slowing or continuing can exacerbate hypotension. Epinephrine is reserved for anaphylaxis
with airway compromise.
Q2.
A nurse is caring for four clients. Which client should the nurse assess first after receiving
shift report?
A. Client with chronic kidney disease who B. Client with heart failure who has 2+
has a serum potassium of 5.8 mEq/L and is pitting edema and reports mild dyspnea on
receiving a potassium-sparing diuretic exertion
C. Client with type 1 diabetes whose blood D. Client with a fractured femur who is in
glucose is 320 mg/dL and urine ketones are balanced skeletal traction and reports leg
small pain of 4/10
Correct: A - Client with chronic kidney disease who has a serum potassium of 5.8 mEq/L
and is receiving a potassium-sparing diuretic
Rationale:
A potassium of 5.8 mEq/L with a potassium-sparing diuretic poses imminent risk for
life-threatening dysrhythmias. Hyperkalemia requires immediate intervention. The other
clients are stable: edema and mild dyspnea are chronic, hyperglycemia with small ketones is
concerning but not emergent, and pain controlled.
Q3.
The nurse is planning care for a client with a chest tube connected to a drainage system at
-20 cm H2O suction. Which observation indicates a system leak?
Page 3
, Section A - Fundamentals OF Nursing
A. Intermittent bubbling in the water seal B. Continuous bubbling in the water seal
chamber during exhalation chamber
C. Fluctuations in the water seal chamber D. No bubbling in the suction control
with respirations chamber
Correct: B - Continuous bubbling in the water seal chamber
Rationale:
Continuous bubbling in the water seal chamber indicates an air leak in the system.
Intermittent bubbling during exhalation is normal as air is expelled. Fluctuations (tidaling) are
normal. Suction control chamber bubbling is expected if suction is applied.
Q4.
A client with an indwelling urinary catheter has a urine output of 20 mL over the past hour.
The nurse assesses the bladder by palpation and finds no distention. Which action should
the nurse take next?
A. Irrigate the catheter with 30 mL sterile B. Reposition the catheter and check for
saline kinks
C. Notify the provider of possible acute D. Increase IV fluid rate to 150 mL/hr
kidney injury
Correct: B - Reposition the catheter and check for kinks
Rationale:
Low output without bladder distention suggests obstruction or mechanical issue. First step is
to check for kinks, reposition, and ensure patency. Irrigation is not first line. Notifying provider
is premature. Increasing IV fluids may be appropriate after mechanical issues ruled out.
Q5.
A nurse is administering an IV vesicant chemotherapy agent. The client reports burning at
the IV site, and the nurse notes erythema without swelling. Which action should the nurse
take?
A. Apply a warm compress and continue the B. Stop the infusion, keep the IV in place,
infusion at a slower rate and prepare for antidote administration
C. Flush the line with normal saline and D. Remove the IV and apply pressure to the
apply cold compress site for 5 minutes
Correct: B - Stop the infusion, keep the IV in place, and prepare for antidote administration
Page 4
