BSN366 Exam 3 Actual Exam Style V1 |
BSN 366 HESI RN Exit | Nightingale
1. A client is admitted with suspected increased intracranial pressure (ICP). Which clinical
manifestation should the nurse prioritize for immediate assessment?
A. Narrowing pulse pressure
B. Increased heart rate
C. Bilateral pupil constriction
D. Decreased level of consciousness
Answer: D
Rationale: A decrease in the level of consciousness is often the earliest sign of increased
intracranial pressure. The nurse must monitor for subtle changes in orientation or
alertness to prevent brain herniation. Other late signs include Cushing’s triad, which
features a widening pulse pressure rather than a narrowing one.
2. The nurse is caring for a client with Chronic Obstructive Pulmonary Disease (COPD)
receiving oxygen via nasal cannula. Which observation requires the most immediate
intervention?
A. Oxygen saturation of 89% on 2L/min
B. Presence of a productive cough
C. Respiratory rate of 10 breaths/min
,D. Use of pursed-lip breathing
Answer: C
Rationale: A respiratory rate of 10 breaths/min in a COPD client receiving oxygen may
indicate CO2 narcosis and respiratory depression. Patients with COPD often rely on a
hypoxic drive to breathe, and excessive oxygen can blunt this stimulus. The nurse should
immediately assess the client’s ventilatory status and notify the healthcare provider.
3. A patient with Type 1 Diabetes Mellitus is admitted in Diabetic Ketoacidosis (DKA). Which
IV fluid should the nurse expect to administer first?
A. 0.45% Normal Saline
B. Dextrose 5% in Water
C. 0.9% Normal Saline
D. Dextrose 5% in 0.9% Normal Saline
Answer: C
Rationale: Initial management of DKA focuses on rehydrating the extracellular fluid
volume to treat hypotension and tachycardia. Isotonic solutions like 0.9% Normal Saline
are used first to stabilize the circulatory system. Once blood glucose levels drop to around
250 mg/dL, dextrose is added to prevent hypoglycemia and cerebral edema.
4. A toddler with Tetralogy of Fallot begins to cry and becomes cyanotic with rapid
respirations. What is the nurse’s priority action?
A. Administer high-flow oxygen via mask
, B. Obtain a set of vital signs
C. Place the child in a knee-chest position
D. Prepare for immediate intubation
Answer: C
Rationale: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt in a ‘Tet spell.’ This maneuver forced more blood into the
pulmonary artery to improve oxygenation of the blood. After positioning, the nurse can
then proceed with oxygen administration and calming the child.
5. A laboring client is receiving an intravenous infusion of Magnesium Sulfate for
preeclampsia. Which finding would indicate magnesium toxicity?
A. Respiratory rate of 14 breaths/min
B. Blood pressure of 150/90 mmHg
C. Urine output of 40 mL/hr
D. Absence of deep tendon reflexes
Answer: D
Rationale: The loss of deep tendon reflexes is a primary sign of magnesium toxicity as the
mineral acts as a central nervous system depressant. If this occurs, the infusion must be
stopped immediately to prevent respiratory arrest. The nurse should also have the
antidote, calcium gluconate, readily available at the bedside.
BSN 366 HESI RN Exit | Nightingale
1. A client is admitted with suspected increased intracranial pressure (ICP). Which clinical
manifestation should the nurse prioritize for immediate assessment?
A. Narrowing pulse pressure
B. Increased heart rate
C. Bilateral pupil constriction
D. Decreased level of consciousness
Answer: D
Rationale: A decrease in the level of consciousness is often the earliest sign of increased
intracranial pressure. The nurse must monitor for subtle changes in orientation or
alertness to prevent brain herniation. Other late signs include Cushing’s triad, which
features a widening pulse pressure rather than a narrowing one.
2. The nurse is caring for a client with Chronic Obstructive Pulmonary Disease (COPD)
receiving oxygen via nasal cannula. Which observation requires the most immediate
intervention?
A. Oxygen saturation of 89% on 2L/min
B. Presence of a productive cough
C. Respiratory rate of 10 breaths/min
,D. Use of pursed-lip breathing
Answer: C
Rationale: A respiratory rate of 10 breaths/min in a COPD client receiving oxygen may
indicate CO2 narcosis and respiratory depression. Patients with COPD often rely on a
hypoxic drive to breathe, and excessive oxygen can blunt this stimulus. The nurse should
immediately assess the client’s ventilatory status and notify the healthcare provider.
3. A patient with Type 1 Diabetes Mellitus is admitted in Diabetic Ketoacidosis (DKA). Which
IV fluid should the nurse expect to administer first?
A. 0.45% Normal Saline
B. Dextrose 5% in Water
C. 0.9% Normal Saline
D. Dextrose 5% in 0.9% Normal Saline
Answer: C
Rationale: Initial management of DKA focuses on rehydrating the extracellular fluid
volume to treat hypotension and tachycardia. Isotonic solutions like 0.9% Normal Saline
are used first to stabilize the circulatory system. Once blood glucose levels drop to around
250 mg/dL, dextrose is added to prevent hypoglycemia and cerebral edema.
4. A toddler with Tetralogy of Fallot begins to cry and becomes cyanotic with rapid
respirations. What is the nurse’s priority action?
A. Administer high-flow oxygen via mask
, B. Obtain a set of vital signs
C. Place the child in a knee-chest position
D. Prepare for immediate intubation
Answer: C
Rationale: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt in a ‘Tet spell.’ This maneuver forced more blood into the
pulmonary artery to improve oxygenation of the blood. After positioning, the nurse can
then proceed with oxygen administration and calming the child.
5. A laboring client is receiving an intravenous infusion of Magnesium Sulfate for
preeclampsia. Which finding would indicate magnesium toxicity?
A. Respiratory rate of 14 breaths/min
B. Blood pressure of 150/90 mmHg
C. Urine output of 40 mL/hr
D. Absence of deep tendon reflexes
Answer: D
Rationale: The loss of deep tendon reflexes is a primary sign of magnesium toxicity as the
mineral acts as a central nervous system depressant. If this occurs, the infusion must be
stopped immediately to prevent respiratory arrest. The nurse should also have the
antidote, calcium gluconate, readily available at the bedside.
