BSN 246 HESI
Nursing Assessment & Management
Comprehensive Actual Exam
INSTITUTION: Nightingale COURSE CODE: BSN 246
ACADEMIC YEAR: 2026/27 TOTAL QUESTIONS: 100
FORMAT: Multiple choice EXAM TITLE: BSN 246 HESI
THIS EXAM CONTAINS:
• Questions & Answers Plus Rationales
• Graded A
• 100% Pass Guaranteed
• Latest 2026/27 Update (PDF)
• Instant Pdf Download
,SECTION 1: PRIORITIZATION & DELEGATION (Questions
1–10)
Question 1
The nurse is assigned to care for four clients. After receiving shift
report, which client should the nurse assess FIRST?
A. A client with fever of 38°C (100.4°F)
B. A client with blood pressure of 150/90 mmHg
C. A client with oxygen saturation of 85%
D. A client reporting mild postoperative pain
Answer: C
Rationale: Airway, breathing, and circulation (ABCs) always take
priority. An oxygen saturation of 85% indicates severe hypoxemia
and requires immediate intervention. Fever, hypertension, and mild
pain, while important, do not pose an immediate life-threatening
risk. The nurse must address oxygenation before other concerns.
Question 2
A client with myocardial infarction reports chest pain. What is the
nurse's FIRST action?
A. Administer morphine sulfate
B. Give aspirin
C. Apply oxygen
D. Obtain a 12-lead ECG
Answer: B
,Rationale: Aspirin reduces platelet aggregation immediately and is
the priority intervention for suspected MI. While oxygen, morphine,
and ECG are all important interventions, aspirin administration
should occur first to limit further clot formation and reduce
mortality. The mnemonic "MONA" is often used, but aspirin is the
most urgent.
Question 3
Which task can the nurse safely delegate to an unlicensed assistive
personnel (UAP)?
A. Assess a client's pain level
B. Administer oral medications
C. Measure and record vital signs
D. Evaluate response to interventions
Answer: C
Rationale: Measuring and recording vital signs is within the scope
of practice for UAPs. Assessment, medication administration, and
evaluation require nursing judgment and licensure and cannot be
delegated to unlicensed personnel. The nurse remains responsible
for interpreting vital signs and determining the plan of care.
Question 4
A client with a stroke suddenly becomes confused. What is the
priority nursing action?
A. Reorient the client to person, place, and time
B. Assess the client's airway and breathing
, C. Call the client's family
D. Document the change in mental status
Answer: B
Rationale: A sudden change in mental status in a stroke client may
indicate increased intracranial pressure, hypoxia, or another acute
neurological event. The priority is always to assess airway,
breathing, and circulation (ABCs) first. Reorientation, family
notification, and documentation are important but secondary to
ensuring physiological stability.
Question 5
After receiving a change-of-shift report, which task can the nurse
assign to a UAP?
A. Assess a client's surgical incision for signs of infection
B. Administer a tube feeding to a client with a PEG tube
C. Assist a client with feeding after the nurse has assessed swallowing
ability
D. Evaluate the effectiveness of a client's pain medication
Answer: C
Rationale: Assisting a client with feeding is within the scope of
practice for UAPs, provided the nurse has first assessed the client's
swallowing ability and determined it is safe. Assessment, medication
administration (including tube feedings), and evaluation of
interventions require nursing licensure and cannot be delegated to
UAPs.
Nursing Assessment & Management
Comprehensive Actual Exam
INSTITUTION: Nightingale COURSE CODE: BSN 246
ACADEMIC YEAR: 2026/27 TOTAL QUESTIONS: 100
FORMAT: Multiple choice EXAM TITLE: BSN 246 HESI
THIS EXAM CONTAINS:
• Questions & Answers Plus Rationales
• Graded A
• 100% Pass Guaranteed
• Latest 2026/27 Update (PDF)
• Instant Pdf Download
,SECTION 1: PRIORITIZATION & DELEGATION (Questions
1–10)
Question 1
The nurse is assigned to care for four clients. After receiving shift
report, which client should the nurse assess FIRST?
A. A client with fever of 38°C (100.4°F)
B. A client with blood pressure of 150/90 mmHg
C. A client with oxygen saturation of 85%
D. A client reporting mild postoperative pain
Answer: C
Rationale: Airway, breathing, and circulation (ABCs) always take
priority. An oxygen saturation of 85% indicates severe hypoxemia
and requires immediate intervention. Fever, hypertension, and mild
pain, while important, do not pose an immediate life-threatening
risk. The nurse must address oxygenation before other concerns.
Question 2
A client with myocardial infarction reports chest pain. What is the
nurse's FIRST action?
A. Administer morphine sulfate
B. Give aspirin
C. Apply oxygen
D. Obtain a 12-lead ECG
Answer: B
,Rationale: Aspirin reduces platelet aggregation immediately and is
the priority intervention for suspected MI. While oxygen, morphine,
and ECG are all important interventions, aspirin administration
should occur first to limit further clot formation and reduce
mortality. The mnemonic "MONA" is often used, but aspirin is the
most urgent.
Question 3
Which task can the nurse safely delegate to an unlicensed assistive
personnel (UAP)?
A. Assess a client's pain level
B. Administer oral medications
C. Measure and record vital signs
D. Evaluate response to interventions
Answer: C
Rationale: Measuring and recording vital signs is within the scope
of practice for UAPs. Assessment, medication administration, and
evaluation require nursing judgment and licensure and cannot be
delegated to unlicensed personnel. The nurse remains responsible
for interpreting vital signs and determining the plan of care.
Question 4
A client with a stroke suddenly becomes confused. What is the
priority nursing action?
A. Reorient the client to person, place, and time
B. Assess the client's airway and breathing
, C. Call the client's family
D. Document the change in mental status
Answer: B
Rationale: A sudden change in mental status in a stroke client may
indicate increased intracranial pressure, hypoxia, or another acute
neurological event. The priority is always to assess airway,
breathing, and circulation (ABCs) first. Reorientation, family
notification, and documentation are important but secondary to
ensuring physiological stability.
Question 5
After receiving a change-of-shift report, which task can the nurse
assign to a UAP?
A. Assess a client's surgical incision for signs of infection
B. Administer a tube feeding to a client with a PEG tube
C. Assist a client with feeding after the nurse has assessed swallowing
ability
D. Evaluate the effectiveness of a client's pain medication
Answer: C
Rationale: Assisting a client with feeding is within the scope of
practice for UAPs, provided the nurse has first assessed the client's
swallowing ability and determined it is safe. Assessment, medication
administration (including tube feedings), and evaluation of
interventions require nursing licensure and cannot be delegated to
UAPs.
