BSN 266 HESI V1] PRACTICE TEST QUESTIONS AND CORRECT ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES 2026 Q&A | INSTANT DOWNLOAD PDF.
*Core Domains
Medical-Surgical Nursing
Pediatric Nursing
Maternity and Infant Care
Psychiatric-Mental Health Nursing
Pharmacological Therapeutics
Nursing Leadership and Management
Community Health Nursing
Legal and Ethical Responsibilities*
Introduction
The purpose of this examination is to evaluate critical thinking, clinical judgment, and the application of
core nursing concepts required for safe, effective client care. The skills and knowledge assessed span
diverse clinical areas, focusing on health promotion, physiological integrity, and psychosocial
adaptations. Utilizing a multiple-choice and scenario-based structure, this test challenges candidates to
synthesize theoretical principles and apply them to complex clinical situations. A heavy emphasis is
placed on real-world application, prioritization, and rapid clinical decision-making to mirror the demands
of modern professional nursing practice and validate preparation for licensure and clinical competency.
Q1. A client with a history of heart failure is admitted with a brain natriuretic peptide (BNP) level of 850
pg/mL, shortness of breath, and bilateral 3+ pitting edema. Which provider order should the nurse
implement first?
,A. Administer furosemide 40 mg intravenously.
B. Obtain a 12-lead electrocardiogram.
C. Insert an indwelling urinary catheter.
D. Draw a complete blood count and metabolic panel.
🟢 Correct answer: A. Administer furosemide 40 mg intravenously.
🔴 RATIONALE: The client is exhibiting signs of acute decompensated heart failure with severe fluid
volume overload, as evidenced by the significantly elevated BNP level (normal is less than 100 pg/mL),
dyspnea, and peripheral edema. Administering a loop diuretic intravenously works quickly to reduce
preload and alleviate respiratory distress, making it the highest priority action to ensure ABC (airway,
breathing, circulation) stability. The other interventions are appropriate but secondary to relieving the
immediate fluid overload.
Q2. A nurse is caring for a client who is 24 hours postoperative following a total hip arthroplasty. Which
assessment finding requires immediate notification of the healthcare provider?
A. Pain level of 5 out of 10 at the surgical site after receiving oral analgesics.
B. Sudden onset of shortness of breath and chest pain during deep breathing.
C. Serosanguineous drainage on the surgical dressing measuring 3 cm in diameter.
D. Erythema and minor localized swelling around the Jackson-Pratt drain insertion site.
🟢 Correct answer: B. Sudden onset of shortness of breath and chest pain during deep breathing.
🔴 RATIONALE: Sudden onset of dyspnea and chest pain in a postoperative orthopedic client is highly
suggestive of a pulmonary embolism (PE), which is a life-threatening complication resulting from deep
vein thrombosis (DVT). Immediate medical intervention is required. Mild to moderate pain, small amounts
of serosanguineous drainage, and localized inflammation are expected postoperative findings that do not
take priority over an acute respiratory or circulatory emergency.
Q3. A nurse is preparing to administer digoxin 0.125 mg orally to a client with atrial fibrillation. The client's
vital signs are: temperature 98.6°F (37°C), pulse 54 beats/minute, respirations 18 breaths/minute, and
blood pressure 118/74 mmHg. Which action should the nurse take?
,A. Administer the medication as scheduled.
B. Withhold the medication and notify the healthcare provider.
C. Recheck the pulse in 30 minutes and give if above 50 beats/minute.
D. Administer half of the prescribed dose.
🟢 Correct answer: B. Withhold the medication and notify the healthcare provider.
🔴 RATIONALE: Digoxin is a cardiac glycoside that exerts a negative chronotropic effect, slowing the
heart rate. The nurse must assess the apical pulse for one full minute prior to administration. If the pulse
is less than 60 beats/minute in an adult, the dose should be withheld and the provider notified due to the
risk of worsening bradycardia and digoxin toxicity. The nurse cannot independently alter a medication
dose.
Q4. A client diagnosed with schizophrenia is admitted to the psychiatric unit. The client stands in the
corner of the dayroom, avoids eye contact, and states, "The government has placed microchips in the
light fixtures to read my thoughts." Which response by the nurse is therapeutic?
A. "The light fixtures only contain lightbulbs; no one can read your thoughts."
B. "I know you believe that is happening, but I do not see any microchips there."
C. "Why do you think the government is targeted at you specifically?"
D. "Let's go to your room so we can look for the microchips together."
🟢 Correct answer: B. "I know you believe that is happening, but I do not see any microchips there."
🔴 RATIONALE: This response validates the client's feelings and experience of the delusion without
reinforcing or validating the false belief itself. It presents reality gently without challenging, arguing, or
mocking the client. Arguing with a delusional client can increase anxiety and damage the therapeutic
relationship, while looking for microchips reinforces the delusion. "Why" questions can make the client
defensive.
Q5. A nurse in the emergency department is assessing an 8-month-old infant brought in by a parent.
Which finding is the most reliable indicator of severe dehydration?
A. Sunken fontanels and dry mucous membranes.
B. Capillary refill time of 4 seconds and mottled skin.
, C. Absence of tears when crying.
D. Decreased wet diapers reported by the caregiver.
🟢 Correct answer: B. Capillary refill time of 4 seconds and mottled skin.
🔴 RATIONALE: While sunken fontanels, dry mucous membranes, and lack of tears indicate
dehydration, a prolonged capillary refill time (greater than 3 seconds) combined with cool, mottled skin
indicates poor peripheral perfusion and systemic hemodynamic compromise, signaling severe
dehydration and impending hypovolemic shock. This requires urgent fluid resuscitation.
Q6. A client at 34 weeks gestation presents to the labor and delivery unit reporting sudden, severe
abdominal pain and dark red vaginal bleeding. The nurse notes that the client's abdomen is rigid and
tender to touch. Which complication should the nurse suspect?
A. Placenta previa.
B. Abruptio placentae.
C. Uterine rupture.
D. Preterm labor.
🟢 Correct answer: B. Abruptio placentae.
🔴 RATIONALE: Abruptio placentae is the premature separation of a normally implanted placenta from
the uterine wall. Classic signs include sudden onset of severe abdominal pain, a rigid or board-like
abdomen, uterine tenderness, and dark red vaginal bleeding. Placenta previa typically presents with
painless, bright red vaginal bleeding. Preterm labor involves rhythmic uterine contractions, and uterine
rupture is usually associated with a history of a previous cesarean section and sudden loss of fetal
station.
Q7. A nurse is caring for a client who is receiving a continuous intravenous infusion of heparin for a deep
vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 110 seconds. Which action
should the nurse anticipate taking?
A. Increase the heparin infusion rate.
B. Stop the infusion and prepare to administer protamine sulfate.
ANSWERS) PLUS RATIONALES 2026 Q&A | INSTANT DOWNLOAD PDF.
*Core Domains
Medical-Surgical Nursing
Pediatric Nursing
Maternity and Infant Care
Psychiatric-Mental Health Nursing
Pharmacological Therapeutics
Nursing Leadership and Management
Community Health Nursing
Legal and Ethical Responsibilities*
Introduction
The purpose of this examination is to evaluate critical thinking, clinical judgment, and the application of
core nursing concepts required for safe, effective client care. The skills and knowledge assessed span
diverse clinical areas, focusing on health promotion, physiological integrity, and psychosocial
adaptations. Utilizing a multiple-choice and scenario-based structure, this test challenges candidates to
synthesize theoretical principles and apply them to complex clinical situations. A heavy emphasis is
placed on real-world application, prioritization, and rapid clinical decision-making to mirror the demands
of modern professional nursing practice and validate preparation for licensure and clinical competency.
Q1. A client with a history of heart failure is admitted with a brain natriuretic peptide (BNP) level of 850
pg/mL, shortness of breath, and bilateral 3+ pitting edema. Which provider order should the nurse
implement first?
,A. Administer furosemide 40 mg intravenously.
B. Obtain a 12-lead electrocardiogram.
C. Insert an indwelling urinary catheter.
D. Draw a complete blood count and metabolic panel.
🟢 Correct answer: A. Administer furosemide 40 mg intravenously.
🔴 RATIONALE: The client is exhibiting signs of acute decompensated heart failure with severe fluid
volume overload, as evidenced by the significantly elevated BNP level (normal is less than 100 pg/mL),
dyspnea, and peripheral edema. Administering a loop diuretic intravenously works quickly to reduce
preload and alleviate respiratory distress, making it the highest priority action to ensure ABC (airway,
breathing, circulation) stability. The other interventions are appropriate but secondary to relieving the
immediate fluid overload.
Q2. A nurse is caring for a client who is 24 hours postoperative following a total hip arthroplasty. Which
assessment finding requires immediate notification of the healthcare provider?
A. Pain level of 5 out of 10 at the surgical site after receiving oral analgesics.
B. Sudden onset of shortness of breath and chest pain during deep breathing.
C. Serosanguineous drainage on the surgical dressing measuring 3 cm in diameter.
D. Erythema and minor localized swelling around the Jackson-Pratt drain insertion site.
🟢 Correct answer: B. Sudden onset of shortness of breath and chest pain during deep breathing.
🔴 RATIONALE: Sudden onset of dyspnea and chest pain in a postoperative orthopedic client is highly
suggestive of a pulmonary embolism (PE), which is a life-threatening complication resulting from deep
vein thrombosis (DVT). Immediate medical intervention is required. Mild to moderate pain, small amounts
of serosanguineous drainage, and localized inflammation are expected postoperative findings that do not
take priority over an acute respiratory or circulatory emergency.
Q3. A nurse is preparing to administer digoxin 0.125 mg orally to a client with atrial fibrillation. The client's
vital signs are: temperature 98.6°F (37°C), pulse 54 beats/minute, respirations 18 breaths/minute, and
blood pressure 118/74 mmHg. Which action should the nurse take?
,A. Administer the medication as scheduled.
B. Withhold the medication and notify the healthcare provider.
C. Recheck the pulse in 30 minutes and give if above 50 beats/minute.
D. Administer half of the prescribed dose.
🟢 Correct answer: B. Withhold the medication and notify the healthcare provider.
🔴 RATIONALE: Digoxin is a cardiac glycoside that exerts a negative chronotropic effect, slowing the
heart rate. The nurse must assess the apical pulse for one full minute prior to administration. If the pulse
is less than 60 beats/minute in an adult, the dose should be withheld and the provider notified due to the
risk of worsening bradycardia and digoxin toxicity. The nurse cannot independently alter a medication
dose.
Q4. A client diagnosed with schizophrenia is admitted to the psychiatric unit. The client stands in the
corner of the dayroom, avoids eye contact, and states, "The government has placed microchips in the
light fixtures to read my thoughts." Which response by the nurse is therapeutic?
A. "The light fixtures only contain lightbulbs; no one can read your thoughts."
B. "I know you believe that is happening, but I do not see any microchips there."
C. "Why do you think the government is targeted at you specifically?"
D. "Let's go to your room so we can look for the microchips together."
🟢 Correct answer: B. "I know you believe that is happening, but I do not see any microchips there."
🔴 RATIONALE: This response validates the client's feelings and experience of the delusion without
reinforcing or validating the false belief itself. It presents reality gently without challenging, arguing, or
mocking the client. Arguing with a delusional client can increase anxiety and damage the therapeutic
relationship, while looking for microchips reinforces the delusion. "Why" questions can make the client
defensive.
Q5. A nurse in the emergency department is assessing an 8-month-old infant brought in by a parent.
Which finding is the most reliable indicator of severe dehydration?
A. Sunken fontanels and dry mucous membranes.
B. Capillary refill time of 4 seconds and mottled skin.
, C. Absence of tears when crying.
D. Decreased wet diapers reported by the caregiver.
🟢 Correct answer: B. Capillary refill time of 4 seconds and mottled skin.
🔴 RATIONALE: While sunken fontanels, dry mucous membranes, and lack of tears indicate
dehydration, a prolonged capillary refill time (greater than 3 seconds) combined with cool, mottled skin
indicates poor peripheral perfusion and systemic hemodynamic compromise, signaling severe
dehydration and impending hypovolemic shock. This requires urgent fluid resuscitation.
Q6. A client at 34 weeks gestation presents to the labor and delivery unit reporting sudden, severe
abdominal pain and dark red vaginal bleeding. The nurse notes that the client's abdomen is rigid and
tender to touch. Which complication should the nurse suspect?
A. Placenta previa.
B. Abruptio placentae.
C. Uterine rupture.
D. Preterm labor.
🟢 Correct answer: B. Abruptio placentae.
🔴 RATIONALE: Abruptio placentae is the premature separation of a normally implanted placenta from
the uterine wall. Classic signs include sudden onset of severe abdominal pain, a rigid or board-like
abdomen, uterine tenderness, and dark red vaginal bleeding. Placenta previa typically presents with
painless, bright red vaginal bleeding. Preterm labor involves rhythmic uterine contractions, and uterine
rupture is usually associated with a history of a previous cesarean section and sudden loss of fetal
station.
Q7. A nurse is caring for a client who is receiving a continuous intravenous infusion of heparin for a deep
vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 110 seconds. Which action
should the nurse anticipate taking?
A. Increase the heparin infusion rate.
B. Stop the infusion and prepare to administer protamine sulfate.
