BSN 246 HESI COMPLETE EXAM 2026/2027 EXAM with
Questions and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
EXAM COVERAGE
1. Fundamentals of Nursing and Clinical Assessment
2. Medical-Surgical Nursing and Pathophysiology
3. Pharmacology and Parenteral Therapies
4. Maternal-Newborn and Pediatric Nursing
5. Mental Health and Psychiatric Nursing
1. A nurse is caring for a 68-year-old client admitted with acute decompensated heart failure. The
client exhibits jugular venous distension, bilateral 3+ pitting pedal edema, and a weight gain of
2.5 kg over the past 48 hours. Which of the following nursing interventions is the highest
priority?
A. Administering prescribed oral potassium chloride supplements
B. Administering intravenous loop diuretics as ordered
C. Encouraging oral fluid intake up to 2,000 mL per day
D. Applying sequential compression devices to the lower extremities
CORRECT ANSWER : B
Rationale: Administering intravenous loop diuretics is the priority intervention to reduce fluid
overload and relieve cardiac workload in acute decompensated heart failure. Potassium
supplements (Option A) may be necessary later depending on lab values, but fluid removal is
urgent. Forcing fluids (Option C) would exacerbate hypervolemia, and compression devices
(Option D) are used for deep vein thrombosis prophylaxis, not acute volume overload.
2. A nurse is evaluating a client receiving a continuous intravenous infusion of heparin sodium for
deep vein thrombosis. Which laboratory value should the nurse monitor to evaluate the
therapeutic efficacy of this medication?
, A. Prothrombin time (PT)
B. Activated partial thromboplastin time (aPTT)
C. International normalized ratio (INR)
D. Platelet count
CORRECT ANSWER : B
Rationale: The activated partial thromboplastin time (aPTT) is used to monitor the therapeutic
efficacy of unfractionated heparin therapy. PT and INR (Options A and C) are used to monitor
oral anticoagulant therapy such as warfarin. Platelet count (Option D) is monitored to detect
heparin-induced thrombocytopenia, not therapeutic clotting time.
3. A client with type 1 diabetes mellitus is brought to the emergency department unresponsive, with
deep, rapid respirations and a fruity odor to their breath. Blood glucose is 480 mg/dL and arterial
blood gases confirm metabolic acidosis. What is the initial and most critical nursing
intervention?
A. Administering subcutaneous regular insulin according to sliding scale
B. Initiating an intravenous infusion of 0.9% sodium chloride rapidly
C. Administering 50% dextrose intravenous push immediately
D. Encouraging oral hydration with electrolyte replacement solutions
CORRECT ANSWER : B
Rationale: Fluid resuscitation with 0.9% sodium chloride is the initial and critical priority in
diabetic ketoacidosis (DKA) to restore intravascular volume and renal perfusion. Subcutaneous
insulin (Option A) is inadequate for rapid clearance in severe DKA, and intravenous regular
insulin infusion is required. Dextrose (Option C) would dangerously raise blood glucose. Oral
hydration (Option D) is impossible in an unresponsive client.
4. A nurse is assessing a postpartum client 6 hours following a vaginal delivery. The nurse notes
the client's fundus is boggy, displaced to the right, and two centimeters above the umbilicus.
Moderate lochia rubra is present. What is the immediate nursing action?
A. Document the findings as a normal postpartum variation
B. Assist the client to void immediately and reassess fundal tone
C. Prepare to administer methylergonovine sublingually
, D. Notify the primary healthcare provider of impending hemorrhage
CORRECT ANSWER : B
Rationale: A boggy, right-shifted fundus is a classic indicator of a distended bladder displacing
the uterus; assisting the client to empty the bladder resolves the displacement and allows the
uterus to contract effectively. Documenting as normal (Option A) ignores a risk factor for
postpartum hemorrhage. Medication (Option C) or provider notification (Option D) may be
required if bladder emptying fails to resolve uterine atony.
5. A client diagnosed with schizophrenia is prescribed clozapine. Which of the following baseline
and ongoing laboratory assessments is mandatory due to the severe, life-threatening adverse
effect profile of this medication?
A. Liver function tests every three months
B. Absolute neutrophil count (ANC) and white blood cell count
C. Serum thyroid-stimulating hormone levels
D. Therapeutic drug monitoring trough levels weekly
CORRECT ANSWER : B
Rationale: Clozapine carries a severe risk of agranulocytosis; therefore, strict monitoring of
white blood cell count and absolute neutrophil count is mandatory. Liver tests (Option A) and
thyroid levels (Option C) are monitored periodically for other atypical antipsychotics but do not
replace the mandatory hematological monitoring protocol for clozapine. Trough levels (Option
D) are not routinely used for dosage titration.
6. A nurse is caring for an adult client with a chest tube connected to a water-seal suction system
following a lobectomy. The nurse notes continuous, vigorous bubbling in the water-seal
chamber. What is the most appropriate initial action?
A. Document the finding as expected progress of lung re-expansion
B. Check the entire chest tube system meticulously for an air leak
C. Clamp the chest tube immediately near the insertion site
D. Increase the wall suction pressure until bubbling ceases
CORRECT ANSWER : B
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak within the
system or the client's pleural space, requiring systematic inspection to locate and correct it.
, Documenting as normal (Option A) is incorrect because intermittent bubbling is normal, but
vigorous continuous bubbling indicates a leak. Clamping the chest tube (Option C) can cause
tension pneumothorax and should be avoided. Increasing suction (Option D) does not resolve an
air leak.
7. A nurse is preparing to administer digoxin to a client with heart failure. Before giving the
medication, the nurse checks the apical pulse and records a rate of 52 beats per minute. What is
the correct nursing action?
A. Administer the dose and document the heart rate
B. Withhold the dose and notify the primary healthcare provider
C. Administer half the prescribed dose and recheck pulse in one hour
D. Give the medication with a glass of orange juice to boost potassium
CORRECT ANSWER : B
Rationale: Digoxin should be withheld if the adult apical pulse is below 60 beats per minute, and
the provider must be notified to prevent digitalis toxicity. Giving the medication (Option A) or
half the dose (Option C) without authorization is unsafe. Orange juice (Option D) does not
substitute for clinical safety checks regarding heart rate.
8. A client admitted with acute pancreatitis reports severe, constant boring epigastric pain radiating
to the back. Which nursing intervention is essential to reduce pancreatic stimulation and
secretions?
A. Providing a high-protein, low-fat mechanical soft diet
B. Maintaining the client on strict nothing-by-mouth (NPO) status
C. Encouraging frequent ambulation in the hallway
D. Administering enteral tube feedings continuously
CORRECT ANSWER : B
Rationale: Strict NPO status is vital in acute pancreatitis to rest the pancreas and minimize the
secretion of pancreatic enzymes. Feeding the client (Options A and D) or encouraging vigorous
activity (Option C) increases metabolic demand and pancreatic stimulation, worsening
inflammation.
9. A nurse is monitoring a client receiving a blood transfusion of packed red blood cells. Fifteen
minutes into the infusion, the client develops chills, lower back pain, and tachycardia. What is
the immediate nursing action?
Questions and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
EXAM COVERAGE
1. Fundamentals of Nursing and Clinical Assessment
2. Medical-Surgical Nursing and Pathophysiology
3. Pharmacology and Parenteral Therapies
4. Maternal-Newborn and Pediatric Nursing
5. Mental Health and Psychiatric Nursing
1. A nurse is caring for a 68-year-old client admitted with acute decompensated heart failure. The
client exhibits jugular venous distension, bilateral 3+ pitting pedal edema, and a weight gain of
2.5 kg over the past 48 hours. Which of the following nursing interventions is the highest
priority?
A. Administering prescribed oral potassium chloride supplements
B. Administering intravenous loop diuretics as ordered
C. Encouraging oral fluid intake up to 2,000 mL per day
D. Applying sequential compression devices to the lower extremities
CORRECT ANSWER : B
Rationale: Administering intravenous loop diuretics is the priority intervention to reduce fluid
overload and relieve cardiac workload in acute decompensated heart failure. Potassium
supplements (Option A) may be necessary later depending on lab values, but fluid removal is
urgent. Forcing fluids (Option C) would exacerbate hypervolemia, and compression devices
(Option D) are used for deep vein thrombosis prophylaxis, not acute volume overload.
2. A nurse is evaluating a client receiving a continuous intravenous infusion of heparin sodium for
deep vein thrombosis. Which laboratory value should the nurse monitor to evaluate the
therapeutic efficacy of this medication?
, A. Prothrombin time (PT)
B. Activated partial thromboplastin time (aPTT)
C. International normalized ratio (INR)
D. Platelet count
CORRECT ANSWER : B
Rationale: The activated partial thromboplastin time (aPTT) is used to monitor the therapeutic
efficacy of unfractionated heparin therapy. PT and INR (Options A and C) are used to monitor
oral anticoagulant therapy such as warfarin. Platelet count (Option D) is monitored to detect
heparin-induced thrombocytopenia, not therapeutic clotting time.
3. A client with type 1 diabetes mellitus is brought to the emergency department unresponsive, with
deep, rapid respirations and a fruity odor to their breath. Blood glucose is 480 mg/dL and arterial
blood gases confirm metabolic acidosis. What is the initial and most critical nursing
intervention?
A. Administering subcutaneous regular insulin according to sliding scale
B. Initiating an intravenous infusion of 0.9% sodium chloride rapidly
C. Administering 50% dextrose intravenous push immediately
D. Encouraging oral hydration with electrolyte replacement solutions
CORRECT ANSWER : B
Rationale: Fluid resuscitation with 0.9% sodium chloride is the initial and critical priority in
diabetic ketoacidosis (DKA) to restore intravascular volume and renal perfusion. Subcutaneous
insulin (Option A) is inadequate for rapid clearance in severe DKA, and intravenous regular
insulin infusion is required. Dextrose (Option C) would dangerously raise blood glucose. Oral
hydration (Option D) is impossible in an unresponsive client.
4. A nurse is assessing a postpartum client 6 hours following a vaginal delivery. The nurse notes
the client's fundus is boggy, displaced to the right, and two centimeters above the umbilicus.
Moderate lochia rubra is present. What is the immediate nursing action?
A. Document the findings as a normal postpartum variation
B. Assist the client to void immediately and reassess fundal tone
C. Prepare to administer methylergonovine sublingually
, D. Notify the primary healthcare provider of impending hemorrhage
CORRECT ANSWER : B
Rationale: A boggy, right-shifted fundus is a classic indicator of a distended bladder displacing
the uterus; assisting the client to empty the bladder resolves the displacement and allows the
uterus to contract effectively. Documenting as normal (Option A) ignores a risk factor for
postpartum hemorrhage. Medication (Option C) or provider notification (Option D) may be
required if bladder emptying fails to resolve uterine atony.
5. A client diagnosed with schizophrenia is prescribed clozapine. Which of the following baseline
and ongoing laboratory assessments is mandatory due to the severe, life-threatening adverse
effect profile of this medication?
A. Liver function tests every three months
B. Absolute neutrophil count (ANC) and white blood cell count
C. Serum thyroid-stimulating hormone levels
D. Therapeutic drug monitoring trough levels weekly
CORRECT ANSWER : B
Rationale: Clozapine carries a severe risk of agranulocytosis; therefore, strict monitoring of
white blood cell count and absolute neutrophil count is mandatory. Liver tests (Option A) and
thyroid levels (Option C) are monitored periodically for other atypical antipsychotics but do not
replace the mandatory hematological monitoring protocol for clozapine. Trough levels (Option
D) are not routinely used for dosage titration.
6. A nurse is caring for an adult client with a chest tube connected to a water-seal suction system
following a lobectomy. The nurse notes continuous, vigorous bubbling in the water-seal
chamber. What is the most appropriate initial action?
A. Document the finding as expected progress of lung re-expansion
B. Check the entire chest tube system meticulously for an air leak
C. Clamp the chest tube immediately near the insertion site
D. Increase the wall suction pressure until bubbling ceases
CORRECT ANSWER : B
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak within the
system or the client's pleural space, requiring systematic inspection to locate and correct it.
, Documenting as normal (Option A) is incorrect because intermittent bubbling is normal, but
vigorous continuous bubbling indicates a leak. Clamping the chest tube (Option C) can cause
tension pneumothorax and should be avoided. Increasing suction (Option D) does not resolve an
air leak.
7. A nurse is preparing to administer digoxin to a client with heart failure. Before giving the
medication, the nurse checks the apical pulse and records a rate of 52 beats per minute. What is
the correct nursing action?
A. Administer the dose and document the heart rate
B. Withhold the dose and notify the primary healthcare provider
C. Administer half the prescribed dose and recheck pulse in one hour
D. Give the medication with a glass of orange juice to boost potassium
CORRECT ANSWER : B
Rationale: Digoxin should be withheld if the adult apical pulse is below 60 beats per minute, and
the provider must be notified to prevent digitalis toxicity. Giving the medication (Option A) or
half the dose (Option C) without authorization is unsafe. Orange juice (Option D) does not
substitute for clinical safety checks regarding heart rate.
8. A client admitted with acute pancreatitis reports severe, constant boring epigastric pain radiating
to the back. Which nursing intervention is essential to reduce pancreatic stimulation and
secretions?
A. Providing a high-protein, low-fat mechanical soft diet
B. Maintaining the client on strict nothing-by-mouth (NPO) status
C. Encouraging frequent ambulation in the hallway
D. Administering enteral tube feedings continuously
CORRECT ANSWER : B
Rationale: Strict NPO status is vital in acute pancreatitis to rest the pancreas and minimize the
secretion of pancreatic enzymes. Feeding the client (Options A and D) or encouraging vigorous
activity (Option C) increases metabolic demand and pancreatic stimulation, worsening
inflammation.
9. A nurse is monitoring a client receiving a blood transfusion of packed red blood cells. Fifteen
minutes into the infusion, the client develops chills, lower back pain, and tachycardia. What is
the immediate nursing action?
