BSN366 Final Exam Actual Exam Style V1
| BSN 366 HESI RN Exit | Nightingale
1. A nurse is caring for a client who is 4 hours postoperative following a subtotal
thyroidectomy. Which of the following findings should the nurse report to the provider first?
A. Laryngeal stridor and hoarseness
B. Occasional coughing when swallowing liquids
C. Pain level of 5 on a scale of 0 to 10
D. Soreness at the incision site
Answer: A
Rationale: Laryngeal stridor indicates an acute airway obstruction, which is a medical
emergency. The nurse must prioritize airway, breathing, and circulation (ABCs) when
assessing postoperative patients. Reporting this finding immediately allows for rapid
intervention such as tracheostomy if necessary.
2. A nurse is preparing to administer digoxin to a client with heart failure. Which of the
following laboratory results should the nurse review before administration?
A. Serum potassium level
B. Serum sodium level
C. Serum calcium level
,D. Serum glucose level
Answer: A
Rationale: Hypokalemia increases the risk of digoxin toxicity, so monitoring potassium
levels is critical. If the potassium level is low, the nurse should hold the medication and
notify the provider. Maintaining a therapeutic potassium balance is essential for the safety
of patients on cardiac glycosides.
3. Which assessment finding in a patient receiving magnesium sulfate for preeclampsia
indicates magnesium toxicity?
A. Respiratory rate of 10 breaths per minute
B. Presence of deep tendon reflexes
C. Increased urinary output
D. Blood pressure of 140/90 mmHg
Answer: A
Rationale: A respiratory rate below 12 breaths per minute is a classic sign of magnesium
toxicity. Other signs include absent deep tendon reflexes and decreased urinary output.
The nurse should immediately stop the infusion and prepare calcium gluconate as the
antidote.
4. A nurse is assessing a client with a history of chronic venous insufficiency. Which of the
following skin changes should the nurse expect to find?
A. Pale, cool, and shiny skin
, B. Dependent rubor and thick toenails
C. Presence of a painful, punched-out ulcer
D. Brownish discoloration of the lower legs
Answer: D
Rationale: Brownish discoloration, or stasis dermatitis, occurs due to the breakdown of
red blood cells in the tissues of clients with venous insufficiency. This condition is caused
by high venous pressure forcing fluids and cells into the surrounding skin. Unlike arterial
disease, venous insufficiency typically involves edema and warm skin temperatures.
5. The nurse is assigned to four clients. Which client should the nurse assess first?
A. A client with a new onset of confusion and restlessness
B. A client with a chest tube who has 50 mL of drainage in the last hour
C. A client with pneumonia who has a pulse oximetry of 91% on room air
D. A client scheduled for a dressing change in 30 minutes
Answer: A
Rationale: New onset confusion and restlessness are early signs of hypoxia or neurological
distress. These symptoms require immediate assessment to determine the underlying
cause and prevent further deterioration. Prioritization is based on the acute change in
mental status over stable respiratory or surgical findings.
| BSN 366 HESI RN Exit | Nightingale
1. A nurse is caring for a client who is 4 hours postoperative following a subtotal
thyroidectomy. Which of the following findings should the nurse report to the provider first?
A. Laryngeal stridor and hoarseness
B. Occasional coughing when swallowing liquids
C. Pain level of 5 on a scale of 0 to 10
D. Soreness at the incision site
Answer: A
Rationale: Laryngeal stridor indicates an acute airway obstruction, which is a medical
emergency. The nurse must prioritize airway, breathing, and circulation (ABCs) when
assessing postoperative patients. Reporting this finding immediately allows for rapid
intervention such as tracheostomy if necessary.
2. A nurse is preparing to administer digoxin to a client with heart failure. Which of the
following laboratory results should the nurse review before administration?
A. Serum potassium level
B. Serum sodium level
C. Serum calcium level
,D. Serum glucose level
Answer: A
Rationale: Hypokalemia increases the risk of digoxin toxicity, so monitoring potassium
levels is critical. If the potassium level is low, the nurse should hold the medication and
notify the provider. Maintaining a therapeutic potassium balance is essential for the safety
of patients on cardiac glycosides.
3. Which assessment finding in a patient receiving magnesium sulfate for preeclampsia
indicates magnesium toxicity?
A. Respiratory rate of 10 breaths per minute
B. Presence of deep tendon reflexes
C. Increased urinary output
D. Blood pressure of 140/90 mmHg
Answer: A
Rationale: A respiratory rate below 12 breaths per minute is a classic sign of magnesium
toxicity. Other signs include absent deep tendon reflexes and decreased urinary output.
The nurse should immediately stop the infusion and prepare calcium gluconate as the
antidote.
4. A nurse is assessing a client with a history of chronic venous insufficiency. Which of the
following skin changes should the nurse expect to find?
A. Pale, cool, and shiny skin
, B. Dependent rubor and thick toenails
C. Presence of a painful, punched-out ulcer
D. Brownish discoloration of the lower legs
Answer: D
Rationale: Brownish discoloration, or stasis dermatitis, occurs due to the breakdown of
red blood cells in the tissues of clients with venous insufficiency. This condition is caused
by high venous pressure forcing fluids and cells into the surrounding skin. Unlike arterial
disease, venous insufficiency typically involves edema and warm skin temperatures.
5. The nurse is assigned to four clients. Which client should the nurse assess first?
A. A client with a new onset of confusion and restlessness
B. A client with a chest tube who has 50 mL of drainage in the last hour
C. A client with pneumonia who has a pulse oximetry of 91% on room air
D. A client scheduled for a dressing change in 30 minutes
Answer: A
Rationale: New onset confusion and restlessness are early signs of hypoxia or neurological
distress. These symptoms require immediate assessment to determine the underlying
cause and prevent further deterioration. Prioritization is based on the acute change in
mental status over stable respiratory or surgical findings.
