BSN 366 HESI RN Exit Exam – Nightingale College 2026/2027
Nightingale College
BSN 366 HESI RN EXIT EXAM
Concepts of Nursing IV
Official Practice Exam 2026/2027
Name: ______________ Date: ______________ Score: ________
Total Questions: 50 | Time: 120 minutes | Passing Score: 85% (750/900 scaled)
Instructions: Choose the single best answer unless otherwise indicated. Select-all-that-apply (SATA) questions are marked.
Ordered response questions ask you to prioritize nursing actions in the correct sequence.
Section 1: Med-Surg 25% | Section 2: Pharm 20% | Section 3: Maternal/Peds/MH 20% | Section 4: Leadership 20% | Section 5: NGN 15%
SECTION 1: MEDICAL-SURGICAL NURSING & COMPLEX CARE Q1 – Q10
Question 1 of 50
A 58-year-old patient arrives in the emergency department reporting severe substernal chest pain that began 45
minutes ago, radiating to the left arm and jaw. The patient is diaphoretic, pale, and appears anxious. Vital signs
are BP 88/54 mmHg, HR 112 bpm, RR 24 breaths/min. The 12-lead ECG shows ST-segment elevation in leads
II, III, and aVF. What is the priority nursing action at this time?
A. Obtain IV access and prepare the patient for emergent reperfusion therapy ✓ CORRECT
B. Administer sublingual nitroglycerin and reassess pain in 5 minutes
C. Provide supplemental oxygen at 2 L/min via nasal cannula and monitor SpO2
D. Draw cardiac biomarkers and complete the admission assessment before intervening
Correct Answer: A
Rationale: ST-segment elevation in II, III, and aVF indicates an acute inferior wall myocardial infarction, and the
hypotension with diaphoresis signals cardiogenic shock. The priority is to obtain IV access and prepare for
emergent reperfusion, as time to revascularization directly determines myocardial salvage and survival.
Administering nitroglycerin would be dangerous in this hypotensive patient, and delaying intervention for
biomarkers wastes critical time when every minute of ischemia causes irreversible damage.
Question 2 of 50
A patient with acute pancreatitis has been receiving total parenteral nutrition (TPN) for the past 48 hours after
being NPO for 5 days. The morning labs reveal serum phosphorus of 1.8 mg/dL, potassium of 3.0 mEq/L, and
magnesium of 1.2 mg/dL. The patient reports generalized weakness and muscle cramping. What is the most
likely explanation for these findings?
A. The pancreatitis is causing increased gastrointestinal losses of electrolytes through vomiting
B. Refeeding syndrome is causing rapid intracellular shifts of phosphorus, potassium, and magnesium ✓
CORRECT
C. The TPN formula is deficient in electrolytes and requires an adjustment by the pharmacy
D. The patient is developing acute kidney injury secondary to hypovolemia from the pancreatitis
Correct Answer: B
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, BSN 366 HESI RN Exit Exam – Nightingale College 2026/2027
Rationale: Refeeding syndrome occurs when nutrition is reintroduced after prolonged starvation, driving insulin
release that rapidly shifts phosphorus, potassium, and magnesium intracellularly, producing life-threatening
hypokalemia and hypophosphatemia. The TPN formula itself typically contains adequate electrolytes; the problem is
the metabolic shift, not a formulation error. While pancreatitis can cause vomiting and GI losses, the timing with
TPN initiation and the specific pattern of all three electrolytes being low simultaneously points to refeeding
syndrome as the cause.
Question 3 of 50
A 72-year-old patient with heart failure (ejection fraction 30%) is admitted with increasing dyspnea on exertion,
3-pillow orthopnea, and bilateral 2+ pitting edema of the lower extremities. Current medications include
furosemide 40 mg PO daily, lisinopril 10 mg PO daily, and carvedilol 6.25 mg PO BID. Daily weight shows a 4-
pound gain over the past 3 days. What adjustment to the medication regimen should the nurse anticipate?
A. Increase carvedilol to 12.5 mg PO BID to further reduce cardiac workload and improve ejection fraction
B. Hold lisinopril until blood pressure stabilizes and symptoms of fluid overload resolve completely
C. Increase furosemide to 80 mg PO daily or switch to IV diuretic therapy to achieve effective diuresis ✓
CORRECT
D. Add digoxin 0.125 mg PO daily to increase myocardial contractility and reduce fluid accumulation
Correct Answer: C
Rationale: The 4-pound weight gain, worsening orthopnea, and bilateral pitting edema indicate decompensated
heart failure with significant volume overload, so the priority is to augment diuresis by increasing furosemide or
transitioning to IV diuretics. Increasing the beta-blocker dose during acute decompensation would worsen the
patient's cardiac output and fluid retention. Holding the ACE inhibitor is not indicated unless the patient is
hypotensive or has hyperkalemia, and adding digoxin does not address the acute volume overload that is driving the
current presentation.
Question 4 of 50
A patient with type 1 diabetes presents to the emergency department with nausea, vomiting, abdominal pain, and
Kussmaul respirations. Laboratory results show blood glucose 520 mg/dL, pH 7.21, bicarbonate 14 mEq/L, and
serum potassium 5.8 mEq/L. The physician orders regular insulin IV bolus followed by a continuous infusion.
What should the nurse monitor most closely during the first 4 hours of insulin therapy?
A. Serum sodium levels for signs of hypernatremia as glucose levels rapidly decrease
B. Serum calcium levels for hypocalcemia resulting from intracellular shifting during correction
C. Serum phosphate levels for hypophosphatemia caused by increased cellular uptake
D. Serum potassium levels for hypokalemia as insulin drives potassium back into cells ✓ CORRECT
Correct Answer: D
Rationale: Insulin rapidly drives potassium into cells, so a patient who initially presents with hyperkalemia from
acidosis can quickly develop life-threatening hypokalemia once insulin therapy begins. The initial potassium of 5.8
mEq/L will drop as insulin corrects the acidosis and facilitates intracellular potassium uptake, requiring frequent
monitoring and potential potassium replacement. While phosphate and calcium shifts can occur, potassium is the
most immediate life-threatening concern and the one most directly affected by insulin therapy in DKA.
Question 5 of 50
A 65-year-old patient returns from the operating room after a right total knee arthroplasty. The surgical dressing
is intact with minimal sanguineous drainage. Two hours post-operatively, the nurse assesses the right foot and
2
, BSN 366 HESI RN Exit Exam – Nightingale College 2026/2027
finds it pale, cool to touch, with diminished pedal pulses compared to the left foot. The patient reports numbness
and tingling in the toes. What is the nurse's priority action?
A. Notify the surgeon immediately and maintain the leg in its current position ✓ CORRECT
B. Apply warm blankets to the right foot and reassess circulation in 30 minutes
C. Elevate the right leg on two pillows to reduce edema and improve venous return
D. Document the findings as expected post-operative edema and continue routine monitoring
Correct Answer: A
Rationale: A pale, cool foot with diminished pulses and new-onset numbness after knee surgery suggests
compromised arterial circulation or compartment syndrome, both of which require immediate surgical evaluation to
prevent permanent tissue damage. Elevating the leg would further reduce arterial perfusion pressure, and applying
warmth masks the clinical picture by causing vasodilation that does not address the underlying obstruction. These
findings are not expected post-operative findings and waiting 30 minutes could result in irreversible ischemia or
limb loss.
Question 6 of 50
A patient with severe COPD is admitted with an acute exacerbation triggered by a viral respiratory infection.
Current vital signs are BP 134/82 mmHg, HR 98 bpm, RR 28 breaths/min, SpO2 88% on room air. The
physician orders oxygen via Venturi mask at 28%. Thirty minutes later, the SpO2 is 92% but the patient appears
more somnolent and the respiratory rate has decreased to 20 breaths/min. What is the nurse's best interpretation
of this change?
A. The patient is experiencing improved oxygenation and the respiratory fatigue is resolving
B. The patient may be retaining carbon dioxide due to blunting of the hypoxic respiratory drive ✓
CORRECT
C. The Venturi mask is not delivering adequate FiO2 and needs to be increased to 35%
D. The patient is developing metabolic acidosis from the respiratory infection and needs bicarbonate
Correct Answer: B
Rationale: In patients with severe COPD, the hypoxic drive is often the primary stimulus for breathing, and
excessive oxygen supplementation can suppress this drive, causing CO2 retention and CO2 narcosis, which presents
as somnolence and decreased respiratory effort. The slight improvement in SpO2 has come at the cost of rising
PaCO2, and this trade-off is dangerous in COPD patients who chronically retain CO2. Increasing the FiO2 would
worsen the problem, and metabolic acidosis would not explain the decreased respiratory rate in this clinical
context.
Question 7 of 50
A 45-year-old patient is admitted with community-acquired pneumonia affecting the right lower lobe. The
patient has a temperature of 102.4°F (39.1°C), productive cough with rust-colored sputum, and pleuritic chest
pain. The physician orders ceftriaxone 1 g IV and azithromycin 500 mg IV. Which finding during the first 24
hours of antibiotic therapy would indicate that the treatment is effective?
A. The patient reports a decrease in pleuritic chest pain and the cough becomes nonproductive
B. Chest x-ray shows complete resolution of the right lower lobe infiltrate within 24 hours
C. The white blood cell count decreases from 18,000/mm3 to 14,500/mm3 and the temperature drops to
100.8°F ✓ CORRECT
D. The patient's SpO2 improves from 92% to 98% on room air and respiratory rate normalizes
Correct Answer: C
3
Nightingale College
BSN 366 HESI RN EXIT EXAM
Concepts of Nursing IV
Official Practice Exam 2026/2027
Name: ______________ Date: ______________ Score: ________
Total Questions: 50 | Time: 120 minutes | Passing Score: 85% (750/900 scaled)
Instructions: Choose the single best answer unless otherwise indicated. Select-all-that-apply (SATA) questions are marked.
Ordered response questions ask you to prioritize nursing actions in the correct sequence.
Section 1: Med-Surg 25% | Section 2: Pharm 20% | Section 3: Maternal/Peds/MH 20% | Section 4: Leadership 20% | Section 5: NGN 15%
SECTION 1: MEDICAL-SURGICAL NURSING & COMPLEX CARE Q1 – Q10
Question 1 of 50
A 58-year-old patient arrives in the emergency department reporting severe substernal chest pain that began 45
minutes ago, radiating to the left arm and jaw. The patient is diaphoretic, pale, and appears anxious. Vital signs
are BP 88/54 mmHg, HR 112 bpm, RR 24 breaths/min. The 12-lead ECG shows ST-segment elevation in leads
II, III, and aVF. What is the priority nursing action at this time?
A. Obtain IV access and prepare the patient for emergent reperfusion therapy ✓ CORRECT
B. Administer sublingual nitroglycerin and reassess pain in 5 minutes
C. Provide supplemental oxygen at 2 L/min via nasal cannula and monitor SpO2
D. Draw cardiac biomarkers and complete the admission assessment before intervening
Correct Answer: A
Rationale: ST-segment elevation in II, III, and aVF indicates an acute inferior wall myocardial infarction, and the
hypotension with diaphoresis signals cardiogenic shock. The priority is to obtain IV access and prepare for
emergent reperfusion, as time to revascularization directly determines myocardial salvage and survival.
Administering nitroglycerin would be dangerous in this hypotensive patient, and delaying intervention for
biomarkers wastes critical time when every minute of ischemia causes irreversible damage.
Question 2 of 50
A patient with acute pancreatitis has been receiving total parenteral nutrition (TPN) for the past 48 hours after
being NPO for 5 days. The morning labs reveal serum phosphorus of 1.8 mg/dL, potassium of 3.0 mEq/L, and
magnesium of 1.2 mg/dL. The patient reports generalized weakness and muscle cramping. What is the most
likely explanation for these findings?
A. The pancreatitis is causing increased gastrointestinal losses of electrolytes through vomiting
B. Refeeding syndrome is causing rapid intracellular shifts of phosphorus, potassium, and magnesium ✓
CORRECT
C. The TPN formula is deficient in electrolytes and requires an adjustment by the pharmacy
D. The patient is developing acute kidney injury secondary to hypovolemia from the pancreatitis
Correct Answer: B
1
, BSN 366 HESI RN Exit Exam – Nightingale College 2026/2027
Rationale: Refeeding syndrome occurs when nutrition is reintroduced after prolonged starvation, driving insulin
release that rapidly shifts phosphorus, potassium, and magnesium intracellularly, producing life-threatening
hypokalemia and hypophosphatemia. The TPN formula itself typically contains adequate electrolytes; the problem is
the metabolic shift, not a formulation error. While pancreatitis can cause vomiting and GI losses, the timing with
TPN initiation and the specific pattern of all three electrolytes being low simultaneously points to refeeding
syndrome as the cause.
Question 3 of 50
A 72-year-old patient with heart failure (ejection fraction 30%) is admitted with increasing dyspnea on exertion,
3-pillow orthopnea, and bilateral 2+ pitting edema of the lower extremities. Current medications include
furosemide 40 mg PO daily, lisinopril 10 mg PO daily, and carvedilol 6.25 mg PO BID. Daily weight shows a 4-
pound gain over the past 3 days. What adjustment to the medication regimen should the nurse anticipate?
A. Increase carvedilol to 12.5 mg PO BID to further reduce cardiac workload and improve ejection fraction
B. Hold lisinopril until blood pressure stabilizes and symptoms of fluid overload resolve completely
C. Increase furosemide to 80 mg PO daily or switch to IV diuretic therapy to achieve effective diuresis ✓
CORRECT
D. Add digoxin 0.125 mg PO daily to increase myocardial contractility and reduce fluid accumulation
Correct Answer: C
Rationale: The 4-pound weight gain, worsening orthopnea, and bilateral pitting edema indicate decompensated
heart failure with significant volume overload, so the priority is to augment diuresis by increasing furosemide or
transitioning to IV diuretics. Increasing the beta-blocker dose during acute decompensation would worsen the
patient's cardiac output and fluid retention. Holding the ACE inhibitor is not indicated unless the patient is
hypotensive or has hyperkalemia, and adding digoxin does not address the acute volume overload that is driving the
current presentation.
Question 4 of 50
A patient with type 1 diabetes presents to the emergency department with nausea, vomiting, abdominal pain, and
Kussmaul respirations. Laboratory results show blood glucose 520 mg/dL, pH 7.21, bicarbonate 14 mEq/L, and
serum potassium 5.8 mEq/L. The physician orders regular insulin IV bolus followed by a continuous infusion.
What should the nurse monitor most closely during the first 4 hours of insulin therapy?
A. Serum sodium levels for signs of hypernatremia as glucose levels rapidly decrease
B. Serum calcium levels for hypocalcemia resulting from intracellular shifting during correction
C. Serum phosphate levels for hypophosphatemia caused by increased cellular uptake
D. Serum potassium levels for hypokalemia as insulin drives potassium back into cells ✓ CORRECT
Correct Answer: D
Rationale: Insulin rapidly drives potassium into cells, so a patient who initially presents with hyperkalemia from
acidosis can quickly develop life-threatening hypokalemia once insulin therapy begins. The initial potassium of 5.8
mEq/L will drop as insulin corrects the acidosis and facilitates intracellular potassium uptake, requiring frequent
monitoring and potential potassium replacement. While phosphate and calcium shifts can occur, potassium is the
most immediate life-threatening concern and the one most directly affected by insulin therapy in DKA.
Question 5 of 50
A 65-year-old patient returns from the operating room after a right total knee arthroplasty. The surgical dressing
is intact with minimal sanguineous drainage. Two hours post-operatively, the nurse assesses the right foot and
2
, BSN 366 HESI RN Exit Exam – Nightingale College 2026/2027
finds it pale, cool to touch, with diminished pedal pulses compared to the left foot. The patient reports numbness
and tingling in the toes. What is the nurse's priority action?
A. Notify the surgeon immediately and maintain the leg in its current position ✓ CORRECT
B. Apply warm blankets to the right foot and reassess circulation in 30 minutes
C. Elevate the right leg on two pillows to reduce edema and improve venous return
D. Document the findings as expected post-operative edema and continue routine monitoring
Correct Answer: A
Rationale: A pale, cool foot with diminished pulses and new-onset numbness after knee surgery suggests
compromised arterial circulation or compartment syndrome, both of which require immediate surgical evaluation to
prevent permanent tissue damage. Elevating the leg would further reduce arterial perfusion pressure, and applying
warmth masks the clinical picture by causing vasodilation that does not address the underlying obstruction. These
findings are not expected post-operative findings and waiting 30 minutes could result in irreversible ischemia or
limb loss.
Question 6 of 50
A patient with severe COPD is admitted with an acute exacerbation triggered by a viral respiratory infection.
Current vital signs are BP 134/82 mmHg, HR 98 bpm, RR 28 breaths/min, SpO2 88% on room air. The
physician orders oxygen via Venturi mask at 28%. Thirty minutes later, the SpO2 is 92% but the patient appears
more somnolent and the respiratory rate has decreased to 20 breaths/min. What is the nurse's best interpretation
of this change?
A. The patient is experiencing improved oxygenation and the respiratory fatigue is resolving
B. The patient may be retaining carbon dioxide due to blunting of the hypoxic respiratory drive ✓
CORRECT
C. The Venturi mask is not delivering adequate FiO2 and needs to be increased to 35%
D. The patient is developing metabolic acidosis from the respiratory infection and needs bicarbonate
Correct Answer: B
Rationale: In patients with severe COPD, the hypoxic drive is often the primary stimulus for breathing, and
excessive oxygen supplementation can suppress this drive, causing CO2 retention and CO2 narcosis, which presents
as somnolence and decreased respiratory effort. The slight improvement in SpO2 has come at the cost of rising
PaCO2, and this trade-off is dangerous in COPD patients who chronically retain CO2. Increasing the FiO2 would
worsen the problem, and metabolic acidosis would not explain the decreased respiratory rate in this clinical
context.
Question 7 of 50
A 45-year-old patient is admitted with community-acquired pneumonia affecting the right lower lobe. The
patient has a temperature of 102.4°F (39.1°C), productive cough with rust-colored sputum, and pleuritic chest
pain. The physician orders ceftriaxone 1 g IV and azithromycin 500 mg IV. Which finding during the first 24
hours of antibiotic therapy would indicate that the treatment is effective?
A. The patient reports a decrease in pleuritic chest pain and the cough becomes nonproductive
B. Chest x-ray shows complete resolution of the right lower lobe infiltrate within 24 hours
C. The white blood cell count decreases from 18,000/mm3 to 14,500/mm3 and the temperature drops to
100.8°F ✓ CORRECT
D. The patient's SpO2 improves from 92% to 98% on room air and respiratory rate normalizes
Correct Answer: C
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