BSN 246
BSN 246 – HESI PRIORITY QUESTIONS WITH RATIONALES
Which client should the nurse assess first? - correct answer Client with
sudden change in mental status | RATIONALE: Acute confusion may
indicate hypoxia, infection, or neurological compromise and is a priority
over chronic or expected findings.
What is the nurse's first action when a client becomes acutely
confused? - correct answer Assess airway, breathing, and circulation |
RATIONALE: HESI prioritizes ABCs for any sudden change in condition
before other assessments.
Which patient is the priority assignment? - correct answer Client reporting
new chest pain | RATIONALE: New chest pain suggests possible cardiac
compromise and requires immediate assessment.
A client with chronic illness reports worsening shortness of breath.
What is the priority? - correct answer Assess respiratory status |
, BSN 246
RATIONALE: Shortness of breath affects oxygenation and must be
assessed before interventions.
Which finding requires immediate nursing action? - correct answer Oxygen
saturation of 85% | RATIONALE: An SpO₂ below 90% indicates impaired
oxygenation and is life-threatening.
What should the nurse do first when a client reports severe anxiety? -
correct answer Remain with the client and speak calmly | RATIONALE:
Presence and calming measures reduce anxiety and promote safety
before teaching or medications.
Which action takes priority for a client experiencing panic? - correct answer
Ensure safety and reduce environmental stimuli | RATIONALE: Panic can
impair judgment and increase risk of injury; safety comes first.
What is the priority nursing intervention for acute pain? - correct answer
Assess pain characteristics | RATIONALE: Assessment must occur before
administering pain medication.
Which patient should be seen first? - correct answer Client with new-onset
confusion and restlessness | RATIONALE: Acute neurological changes
are higher priority than stable or chronic conditions.
BSN 246 – HESI PRIORITY QUESTIONS WITH RATIONALES
Which client should the nurse assess first? - correct answer Client with
sudden change in mental status | RATIONALE: Acute confusion may
indicate hypoxia, infection, or neurological compromise and is a priority
over chronic or expected findings.
What is the nurse's first action when a client becomes acutely
confused? - correct answer Assess airway, breathing, and circulation |
RATIONALE: HESI prioritizes ABCs for any sudden change in condition
before other assessments.
Which patient is the priority assignment? - correct answer Client reporting
new chest pain | RATIONALE: New chest pain suggests possible cardiac
compromise and requires immediate assessment.
A client with chronic illness reports worsening shortness of breath.
What is the priority? - correct answer Assess respiratory status |
, BSN 246
RATIONALE: Shortness of breath affects oxygenation and must be
assessed before interventions.
Which finding requires immediate nursing action? - correct answer Oxygen
saturation of 85% | RATIONALE: An SpO₂ below 90% indicates impaired
oxygenation and is life-threatening.
What should the nurse do first when a client reports severe anxiety? -
correct answer Remain with the client and speak calmly | RATIONALE:
Presence and calming measures reduce anxiety and promote safety
before teaching or medications.
Which action takes priority for a client experiencing panic? - correct answer
Ensure safety and reduce environmental stimuli | RATIONALE: Panic can
impair judgment and increase risk of injury; safety comes first.
What is the priority nursing intervention for acute pain? - correct answer
Assess pain characteristics | RATIONALE: Assessment must occur before
administering pain medication.
Which patient should be seen first? - correct answer Client with new-onset
confusion and restlessness | RATIONALE: Acute neurological changes
are higher priority than stable or chronic conditions.
