BSN366 Exam 4 Actual Exam Style V1 |
BSN 366 HESI RN Exit | Nightingale
1. A patient with a potassium level of 3.2 mEq/L is scheduled for surgery. Which action should
the nurse take first?
A. Notify the healthcare provider immediately.
B. Document the finding in the medical record.
C. Encourage the patient to eat a banana.
D. Administer an IV bolus of potassium.
Answer: A
Rationale: Hypokalemia increases the risk of cardiac arrhythmias during anesthesia and
must be addressed before surgery. The nurse must notify the provider to obtain orders for
replacement or potential postponement. Potassium is never given as a bolus and
documented findings alone do not ensure patient safety.
2. The nurse is assessing a patient receiving Digoxin. Which symptom most likely indicates
toxicity?
A. Increased appetite
B. Occasional heart palpitations
C. Visual disturbances such as yellow halos
,D. Hyperactive bowel sounds
Answer: C
Rationale: Visual changes, particularly yellow-green halos, are a classic sign of digoxin
toxicity. The nurse should also monitor for nausea, vomiting, and bradycardia. Digoxin
levels must be checked frequently to ensure they remain within the therapeutic range of
0.5 to 2.0 ng/mL.
3. Which task is most appropriate for the nurse to delegate to an Unlicensed Assistive
Personnel (UAP)?
A. Assisting a stable patient with a bed bath.
B. Assessing the lung sounds of a post-op patient.
C. Teaching a patient how to use an incentive spirometer.
D. Evaluating the effectiveness of pain medication.
Answer: A
Rationale: UAPs can perform basic tasks such as hygiene and ADLs for stable patients.
Assessment, teaching, and evaluation are core nursing responsibilities that cannot be
delegated. The RN is always responsible for clinical judgment and complex patient care.
4. A child is suspected of having epiglottitis. Which nursing action is contraindicated?
A. Preparing for emergency intubation.
B. Applying humidified oxygen.
, C. Examining the throat with a tongue depressor.
D. Keeping the child in a tripod position.
Answer: C
Rationale: Inserting a tongue depressor can trigger a laryngospasm and completely
obstruct the airway in a child with epiglottitis. The nurse should keep the child calm and in
a position of comfort while preparing for emergency airway management. This is a medical
emergency that requires immediate intervention by a skilled provider.
5. A patient on Lithium therapy reports polyuria and fine hand tremors. What is the nurse’s
best interpretation?
A. The lithium dose is likely too low.
B. The patient is experiencing severe toxicity.
C. The patient is having an allergic reaction.
D. These are expected side effects of lithium.
Answer: D
Rationale: Fine tremors, polyuria, and mild thirst are common side effects that occur when
starting lithium. Severe toxicity is characterized by ataxia, blurred vision, and coarse
tremors. The nurse should monitor serum levels and hydration status to prevent
complications.
BSN 366 HESI RN Exit | Nightingale
1. A patient with a potassium level of 3.2 mEq/L is scheduled for surgery. Which action should
the nurse take first?
A. Notify the healthcare provider immediately.
B. Document the finding in the medical record.
C. Encourage the patient to eat a banana.
D. Administer an IV bolus of potassium.
Answer: A
Rationale: Hypokalemia increases the risk of cardiac arrhythmias during anesthesia and
must be addressed before surgery. The nurse must notify the provider to obtain orders for
replacement or potential postponement. Potassium is never given as a bolus and
documented findings alone do not ensure patient safety.
2. The nurse is assessing a patient receiving Digoxin. Which symptom most likely indicates
toxicity?
A. Increased appetite
B. Occasional heart palpitations
C. Visual disturbances such as yellow halos
,D. Hyperactive bowel sounds
Answer: C
Rationale: Visual changes, particularly yellow-green halos, are a classic sign of digoxin
toxicity. The nurse should also monitor for nausea, vomiting, and bradycardia. Digoxin
levels must be checked frequently to ensure they remain within the therapeutic range of
0.5 to 2.0 ng/mL.
3. Which task is most appropriate for the nurse to delegate to an Unlicensed Assistive
Personnel (UAP)?
A. Assisting a stable patient with a bed bath.
B. Assessing the lung sounds of a post-op patient.
C. Teaching a patient how to use an incentive spirometer.
D. Evaluating the effectiveness of pain medication.
Answer: A
Rationale: UAPs can perform basic tasks such as hygiene and ADLs for stable patients.
Assessment, teaching, and evaluation are core nursing responsibilities that cannot be
delegated. The RN is always responsible for clinical judgment and complex patient care.
4. A child is suspected of having epiglottitis. Which nursing action is contraindicated?
A. Preparing for emergency intubation.
B. Applying humidified oxygen.
, C. Examining the throat with a tongue depressor.
D. Keeping the child in a tripod position.
Answer: C
Rationale: Inserting a tongue depressor can trigger a laryngospasm and completely
obstruct the airway in a child with epiglottitis. The nurse should keep the child calm and in
a position of comfort while preparing for emergency airway management. This is a medical
emergency that requires immediate intervention by a skilled provider.
5. A patient on Lithium therapy reports polyuria and fine hand tremors. What is the nurse’s
best interpretation?
A. The lithium dose is likely too low.
B. The patient is experiencing severe toxicity.
C. The patient is having an allergic reaction.
D. These are expected side effects of lithium.
Answer: D
Rationale: Fine tremors, polyuria, and mild thirst are common side effects that occur when
starting lithium. Severe toxicity is characterized by ataxia, blurred vision, and coarse
tremors. The nurse should monitor serum levels and hydration status to prevent
complications.
