Nightingale College BSN 366 Exit HESI V1 2026/2027 | 300 Practice
Questions & Correct Answers with Rationales | Graded A+ | New
Update
1. A nurse is caring for a patient who has just returned from surgery. The patient's vital signs are
stable, but they report feeling nauseous. Which action should the nurse take first?
A) Administer the prescribed antiemetic medication.
B) Assess the patient's surgical incision site.
C) Position the patient on their side.
D) Notify the surgeon immediately.
Answer: C
Rationale:
The priority in this situation is patient safety, specifically preventing aspiration. A patient who is nauseous
and has just returned from surgery may be at risk for vomiting and aspiration due to the effects of
anesthesia. Positioning the patient on their side (or in a lateral position) is the immediate, priority action to
maintain a patent airway and prevent aspiration. While administering an antiemetic (A) is an important
intervention, it is not the first action; safety and airway take precedence. Assessing the incision (B) is
relevant but not the priority over airway safety in this acute situation. Notifying the surgeon (D) is not the
first step; the nurse should first perform independent nursing interventions to ensure safety.
2. Which of the following is the most accurate definition of the nursing process?
A) A linear, step-by-step protocol for performing nursing tasks.
B) A systematic, dynamic, and patient-centered method for delivering nursing care.
C) A medical model used to diagnose and treat diseases.
D) A set of rules established by the hospital administration for nurses to follow.
Answer: B
Rationale:
The nursing process is a foundational framework for nursing practice. It is defined as a systematic, dynamic,
and patient-centered method for delivering nursing care. It is not linear (A) because its phases (assessment,
diagnosis, planning, implementation, evaluation) are cyclical and overlapping, and the process often requires
revisiting earlier steps. It is not a medical model (C), which focuses on diagnosing and treating pathology; the
nursing process focuses on the human response to illness. It is also not a set of rigid rules (D) imposed by
administration, but a cognitive framework for critical thinking and clinical judgment.
,3. A patient is admitted with a diagnosis of dehydration. Which of the following assessment findings
would the nurse expect to observe?
A) Bradycardia and hypertension
B) Dry mucous membranes and poor skin turgor
C) Bounding pulses and peripheral edema
D) Increased urine output and weight gain
Answer: B
Rationale:
Dehydration is a state of negative fluid balance. The classic signs and symptoms of dehydration result from a
lack of fluid in the body's tissues and vascular space. Dry mucous membranes and poor skin turgor are direct
results of decreased interstitial fluid. Bradycardia and hypertension (A) are more consistent with fluid
overload, though severe dehydration can eventually lead to tachycardia and hypotension. Bounding pulses
and peripheral edema (C) are classic signs of fluid volume excess. Increased urine output and weight gain (D)
are also signs of fluid retention, not loss.
4. The nurse is preparing to administer a medication via a nasogastric (NG) tube. Which action
demonstrates the correct technique?
A) Flush the tube with 50 mL of water before and after administration.
B) Administer the medication and immediately reposition the patient supine.
C) Mix all prescribed medications together and administer as a single bolus.
D) Verify tube placement by auscultating the epigastric area while injecting air.
Answer: A
Rationale:
Flushing the NG tube with water before and after medication administration is essential to check for patency
and to clear the tube, ensuring the full dose of medication reaches the stomach. Repositioning the patient
supine immediately after (B) is incorrect; the head of the bed should be elevated to at least 30 degrees
during and after feeding/tube medication to prevent aspiration. Mixing all medications together (C) is
unsafe, as it can lead to drug incompatibilities and tube clogging. Auscultating the epigastric area while
injecting air (D) is an unreliable and outdated method for verifying tube placement; the current standard is
to check the pH of gastric aspirate.
5. A nurse is developing a care plan for a patient at risk for developing a pressure ulcer. Which
intervention is the most important to include?
2
,A) Massage reddened areas of the skin every 4 hours.
B) Reposition the patient at least every 2 hours.
C) Apply a heating pad to bony prominences.
D) Keep the patient's skin moisturized with a petroleum-based ointment.
Answer: B
Rationale:
The primary cause of pressure ulcers is unrelieved pressure over a bony prominence, which leads to
ischemia and tissue damage. Therefore, the most critical intervention is to relieve that pressure by
repositioning the patient at least every 2 hours, both in bed and in a chair. Massaging reddened areas (A) is
contraindicated because it can cause further tissue damage to already ischemic skin. Applying a heating pad
(C) increases metabolic demand and the risk of burns in patients with decreased sensation. Keeping skin
moisturized is important, but petroleum-based ointments (D) can clog pores and should be used cautiously;
moisture barriers are often preferred.
6. Which of the following best describes the principle of "beneficence" in nursing ethics?
A) The duty to do no harm.
B) The obligation to act in the best interest of the patient.
C) The right of the patient to make their own decisions.
D) The duty to treat all patients fairly and equally.
Answer: B
Rationale:
Beneficence is one of the core ethical principles in healthcare. It is the obligation to act in the best interest of
the patient, promoting good and preventing harm. The duty to do no harm (A) is the principle of
nonmaleficence. The right of the patient to make their own decisions (C) is the principle of autonomy. The
duty to treat all patients fairly and equally (D) is the principle of justice.
7. A nurse is teaching a patient about a new prescription for a diuretic. Which statement by the
patient indicates a need for further teaching?
A) "I should take this medication in the morning."
B) "I will weigh myself every day at the same time."
C) "I should increase my intake of potassium-rich foods."
D) "If I miss a dose, I should double the next dose."
Answer: D
3
, Rationale:
This statement indicates a need for further teaching because doubling a dose of a diuretic can lead to severe
fluid and electrolyte imbalances, hypotension, and other serious complications. The general rule for missed
doses of most medications is to take it as soon as remembered, but if it is almost time for the next dose, to
skip the missed dose and resume the regular schedule. Taking the medication in the morning (A) is correct to
avoid nocturia. Weighing daily (B) is crucial for monitoring fluid status. Increasing potassium-rich foods (C)
is often recommended for patients on potassium-wasting diuretics, unless they are on a potassium-sparing
diuretic or have renal failure.
8. A patient with a history of chronic obstructive pulmonary disease (COPD) is receiving oxygen
therapy. What is the most appropriate goal for oxygen saturation (SpO2) for this patient?
A) 95% to 100%
B) 88% to 92%
C) 80% to 85%
D) 92% to 98%
Answer: B
Rationale:
For patients with COPD, the target SpO2 is typically 88% to 92%. This is because their respiratory drive is
often dependent on hypoxia (low oxygen levels) rather than hypercapnia (high carbon dioxide levels).
Administering too much oxygen can blunt their hypoxic drive, leading to hypoventilation, carbon dioxide
retention, and potentially respiratory failure. A goal of 95% to 100% (A) or 92% to 98% (D) is too high for a
COPD patient and risks this complication. 80% to 85% (C) is too low and indicates severe hypoxemia.
9. A nurse is caring for a patient with an intravenous (IV) line. The nurse notices swelling, coolness,
and pallor at the IV site. What is the most likely complication?
A) Phlebitis
B) Infection
C) Infiltration
D) Fluid overload
Answer: C
Rationale:
Infiltration occurs when IV fluid or medication leaks into the surrounding tissue instead of entering the vein.
The classic signs are swelling, coolness, and pallor at the site, as the fluid accumulates in the interstitial
space. Phlebitis (A) is inflammation of the vein, characterized by redness, warmth, and pain along the vein.
4
Questions & Correct Answers with Rationales | Graded A+ | New
Update
1. A nurse is caring for a patient who has just returned from surgery. The patient's vital signs are
stable, but they report feeling nauseous. Which action should the nurse take first?
A) Administer the prescribed antiemetic medication.
B) Assess the patient's surgical incision site.
C) Position the patient on their side.
D) Notify the surgeon immediately.
Answer: C
Rationale:
The priority in this situation is patient safety, specifically preventing aspiration. A patient who is nauseous
and has just returned from surgery may be at risk for vomiting and aspiration due to the effects of
anesthesia. Positioning the patient on their side (or in a lateral position) is the immediate, priority action to
maintain a patent airway and prevent aspiration. While administering an antiemetic (A) is an important
intervention, it is not the first action; safety and airway take precedence. Assessing the incision (B) is
relevant but not the priority over airway safety in this acute situation. Notifying the surgeon (D) is not the
first step; the nurse should first perform independent nursing interventions to ensure safety.
2. Which of the following is the most accurate definition of the nursing process?
A) A linear, step-by-step protocol for performing nursing tasks.
B) A systematic, dynamic, and patient-centered method for delivering nursing care.
C) A medical model used to diagnose and treat diseases.
D) A set of rules established by the hospital administration for nurses to follow.
Answer: B
Rationale:
The nursing process is a foundational framework for nursing practice. It is defined as a systematic, dynamic,
and patient-centered method for delivering nursing care. It is not linear (A) because its phases (assessment,
diagnosis, planning, implementation, evaluation) are cyclical and overlapping, and the process often requires
revisiting earlier steps. It is not a medical model (C), which focuses on diagnosing and treating pathology; the
nursing process focuses on the human response to illness. It is also not a set of rigid rules (D) imposed by
administration, but a cognitive framework for critical thinking and clinical judgment.
,3. A patient is admitted with a diagnosis of dehydration. Which of the following assessment findings
would the nurse expect to observe?
A) Bradycardia and hypertension
B) Dry mucous membranes and poor skin turgor
C) Bounding pulses and peripheral edema
D) Increased urine output and weight gain
Answer: B
Rationale:
Dehydration is a state of negative fluid balance. The classic signs and symptoms of dehydration result from a
lack of fluid in the body's tissues and vascular space. Dry mucous membranes and poor skin turgor are direct
results of decreased interstitial fluid. Bradycardia and hypertension (A) are more consistent with fluid
overload, though severe dehydration can eventually lead to tachycardia and hypotension. Bounding pulses
and peripheral edema (C) are classic signs of fluid volume excess. Increased urine output and weight gain (D)
are also signs of fluid retention, not loss.
4. The nurse is preparing to administer a medication via a nasogastric (NG) tube. Which action
demonstrates the correct technique?
A) Flush the tube with 50 mL of water before and after administration.
B) Administer the medication and immediately reposition the patient supine.
C) Mix all prescribed medications together and administer as a single bolus.
D) Verify tube placement by auscultating the epigastric area while injecting air.
Answer: A
Rationale:
Flushing the NG tube with water before and after medication administration is essential to check for patency
and to clear the tube, ensuring the full dose of medication reaches the stomach. Repositioning the patient
supine immediately after (B) is incorrect; the head of the bed should be elevated to at least 30 degrees
during and after feeding/tube medication to prevent aspiration. Mixing all medications together (C) is
unsafe, as it can lead to drug incompatibilities and tube clogging. Auscultating the epigastric area while
injecting air (D) is an unreliable and outdated method for verifying tube placement; the current standard is
to check the pH of gastric aspirate.
5. A nurse is developing a care plan for a patient at risk for developing a pressure ulcer. Which
intervention is the most important to include?
2
,A) Massage reddened areas of the skin every 4 hours.
B) Reposition the patient at least every 2 hours.
C) Apply a heating pad to bony prominences.
D) Keep the patient's skin moisturized with a petroleum-based ointment.
Answer: B
Rationale:
The primary cause of pressure ulcers is unrelieved pressure over a bony prominence, which leads to
ischemia and tissue damage. Therefore, the most critical intervention is to relieve that pressure by
repositioning the patient at least every 2 hours, both in bed and in a chair. Massaging reddened areas (A) is
contraindicated because it can cause further tissue damage to already ischemic skin. Applying a heating pad
(C) increases metabolic demand and the risk of burns in patients with decreased sensation. Keeping skin
moisturized is important, but petroleum-based ointments (D) can clog pores and should be used cautiously;
moisture barriers are often preferred.
6. Which of the following best describes the principle of "beneficence" in nursing ethics?
A) The duty to do no harm.
B) The obligation to act in the best interest of the patient.
C) The right of the patient to make their own decisions.
D) The duty to treat all patients fairly and equally.
Answer: B
Rationale:
Beneficence is one of the core ethical principles in healthcare. It is the obligation to act in the best interest of
the patient, promoting good and preventing harm. The duty to do no harm (A) is the principle of
nonmaleficence. The right of the patient to make their own decisions (C) is the principle of autonomy. The
duty to treat all patients fairly and equally (D) is the principle of justice.
7. A nurse is teaching a patient about a new prescription for a diuretic. Which statement by the
patient indicates a need for further teaching?
A) "I should take this medication in the morning."
B) "I will weigh myself every day at the same time."
C) "I should increase my intake of potassium-rich foods."
D) "If I miss a dose, I should double the next dose."
Answer: D
3
, Rationale:
This statement indicates a need for further teaching because doubling a dose of a diuretic can lead to severe
fluid and electrolyte imbalances, hypotension, and other serious complications. The general rule for missed
doses of most medications is to take it as soon as remembered, but if it is almost time for the next dose, to
skip the missed dose and resume the regular schedule. Taking the medication in the morning (A) is correct to
avoid nocturia. Weighing daily (B) is crucial for monitoring fluid status. Increasing potassium-rich foods (C)
is often recommended for patients on potassium-wasting diuretics, unless they are on a potassium-sparing
diuretic or have renal failure.
8. A patient with a history of chronic obstructive pulmonary disease (COPD) is receiving oxygen
therapy. What is the most appropriate goal for oxygen saturation (SpO2) for this patient?
A) 95% to 100%
B) 88% to 92%
C) 80% to 85%
D) 92% to 98%
Answer: B
Rationale:
For patients with COPD, the target SpO2 is typically 88% to 92%. This is because their respiratory drive is
often dependent on hypoxia (low oxygen levels) rather than hypercapnia (high carbon dioxide levels).
Administering too much oxygen can blunt their hypoxic drive, leading to hypoventilation, carbon dioxide
retention, and potentially respiratory failure. A goal of 95% to 100% (A) or 92% to 98% (D) is too high for a
COPD patient and risks this complication. 80% to 85% (C) is too low and indicates severe hypoxemia.
9. A nurse is caring for a patient with an intravenous (IV) line. The nurse notices swelling, coolness,
and pallor at the IV site. What is the most likely complication?
A) Phlebitis
B) Infection
C) Infiltration
D) Fluid overload
Answer: C
Rationale:
Infiltration occurs when IV fluid or medication leaks into the surrounding tissue instead of entering the vein.
The classic signs are swelling, coolness, and pallor at the site, as the fluid accumulates in the interstitial
space. Phlebitis (A) is inflammation of the vein, characterized by redness, warmth, and pain along the vein.
4
