BSN366 Final Exam Actual Exam Style V3
| BSN 366 HESI RN Exit | Nightingale
1. A nurse manager is evaluating the time management skills of a newly licensed nurse.
Which of the following actions by the new nurse indicates an understanding of effective time
management?
A. Completing the most difficult tasks at the end of the shift
B. Charting patient assessments immediately after performing them
C. Waiting to gather all necessary supplies until entering the client’s room
D. Delegating all medication administration to an unlicensed assistive personnel
Answer: B
Rationale: Charting immediately after an assessment ensures accuracy and prevents the
loss of critical information. It also prevents a large accumulation of paperwork at the end of
the shift, which can lead to errors. Effective time management involves prioritizing tasks
and organizing the day to maximize efficiency.
2. A nurse is preparing to delegate tasks to an unlicensed assistive personnel (UAP). Which of
the following tasks is appropriate for the nurse to delegate?
A. Evaluating a client’s response to pain medication
B. Measuring and recording a client’s intake and output
C. Teaching a client how to use an incentive spirometer
,D. Assessing a client’s surgical incision site
Answer: B
Rationale: The measurement of intake and output is a routine task that does not require
clinical judgment or assessment. The nurse is responsible for the nursing process, which
includes assessment, teaching, and evaluation. Delegating clinical judgment tasks to a UAP
is a violation of the scope of practice.
3. A nurse is caring for a group of clients on a medical-surgical unit. Which client should the
nurse assess first?
A. A client who had a hip replacement 2 days ago and reports a pain level of 6 on a 1-10
scale
B. A client with pneumonia who has a new onset of confusion and restlessness
C. A client with diabetes whose blood glucose was 150 mg/dL before breakfast
D. A client receiving IV antibiotics for a urinary tract infection who needs a dressing change
Answer: B
Rationale: Confusion and restlessness in a client with pneumonia can be early signs of
hypoxia. This indicates a potential respiratory emergency that requires immediate
intervention following the ABC (Airway, Breathing, Circulation) priority framework. The
other clients are stable or have expected findings that can be addressed after the
emergency is handled.
, 4. A nurse is participating in a root cause analysis (RCA) following a medication error. What is
the primary purpose of an RCA?
A. To identify systemic factors that contributed to the error
B. To discipline the individuals involved in the incident
C. To identify which staff member is responsible for the error
D. To provide a report to the hospital’s legal counsel
Answer: A
Rationale: A root cause analysis is a process used to identify the underlying causes of a
sentinel event or error. It focuses on systems and processes rather than individual
performance to prevent future occurrences. By understanding ‘why’ an event happened,
organizations can implement changes to improve patient safety.
5. A nurse is caring for a client who is scheduled for surgery. The client tells the nurse, ‘I am
not sure I want to go through with this.’ Which of the following is the nurse’s priority action?
A. Tell the client that the surgery is necessary for their health
B. Notify the surgeon that the client has concerns about the procedure
C. Administer the preoperative sedative as ordered
D. Ask the client to explain their concerns and feelings
Answer: D
| BSN 366 HESI RN Exit | Nightingale
1. A nurse manager is evaluating the time management skills of a newly licensed nurse.
Which of the following actions by the new nurse indicates an understanding of effective time
management?
A. Completing the most difficult tasks at the end of the shift
B. Charting patient assessments immediately after performing them
C. Waiting to gather all necessary supplies until entering the client’s room
D. Delegating all medication administration to an unlicensed assistive personnel
Answer: B
Rationale: Charting immediately after an assessment ensures accuracy and prevents the
loss of critical information. It also prevents a large accumulation of paperwork at the end of
the shift, which can lead to errors. Effective time management involves prioritizing tasks
and organizing the day to maximize efficiency.
2. A nurse is preparing to delegate tasks to an unlicensed assistive personnel (UAP). Which of
the following tasks is appropriate for the nurse to delegate?
A. Evaluating a client’s response to pain medication
B. Measuring and recording a client’s intake and output
C. Teaching a client how to use an incentive spirometer
,D. Assessing a client’s surgical incision site
Answer: B
Rationale: The measurement of intake and output is a routine task that does not require
clinical judgment or assessment. The nurse is responsible for the nursing process, which
includes assessment, teaching, and evaluation. Delegating clinical judgment tasks to a UAP
is a violation of the scope of practice.
3. A nurse is caring for a group of clients on a medical-surgical unit. Which client should the
nurse assess first?
A. A client who had a hip replacement 2 days ago and reports a pain level of 6 on a 1-10
scale
B. A client with pneumonia who has a new onset of confusion and restlessness
C. A client with diabetes whose blood glucose was 150 mg/dL before breakfast
D. A client receiving IV antibiotics for a urinary tract infection who needs a dressing change
Answer: B
Rationale: Confusion and restlessness in a client with pneumonia can be early signs of
hypoxia. This indicates a potential respiratory emergency that requires immediate
intervention following the ABC (Airway, Breathing, Circulation) priority framework. The
other clients are stable or have expected findings that can be addressed after the
emergency is handled.
, 4. A nurse is participating in a root cause analysis (RCA) following a medication error. What is
the primary purpose of an RCA?
A. To identify systemic factors that contributed to the error
B. To discipline the individuals involved in the incident
C. To identify which staff member is responsible for the error
D. To provide a report to the hospital’s legal counsel
Answer: A
Rationale: A root cause analysis is a process used to identify the underlying causes of a
sentinel event or error. It focuses on systems and processes rather than individual
performance to prevent future occurrences. By understanding ‘why’ an event happened,
organizations can implement changes to improve patient safety.
5. A nurse is caring for a client who is scheduled for surgery. The client tells the nurse, ‘I am
not sure I want to go through with this.’ Which of the following is the nurse’s priority action?
A. Tell the client that the surgery is necessary for their health
B. Notify the surgeon that the client has concerns about the procedure
C. Administer the preoperative sedative as ordered
D. Ask the client to explain their concerns and feelings
Answer: D
