BSN 366 HESI Exam 2026/2027: 150 Verified
Questions & Answers with Detailed Rationales | 100%
Guaranteed Pass!
,Question 1: A client is admitted to the hospital for alcohol dependency. What is the priority
nursing intervention during the first 48 hours following admission?
A. Administer thiamine (B1) to prevent Korsakoff's syndrome.
B. Monitor for increased blood pressure and pulse.
C. Administer a PRN benzodiazepine as needed for anxiety.
D. Encourage fluid intake of non-caffeinated beverages.
Correct Answer: B. Monitor for increased blood pressure and pulse.
Rationale: Clients with alcohol dependency experience withdrawal symptoms, which include
elevated blood pressure, pulse, and temperature. Monitoring these physical parameters has the
highest priority. Administering thiamine will prevent Korsakoff's syndrome, but this intervention
does not have the priority of monitoring vital signs.
Question 2: A child with Tetralogy of Fallot suffers a hyper cyanotic episode. Which immediate
action by the nurse can lessen the symptoms of this "TET spell?"
A. Remove child's constrictive clothing.
B. Place child in knee-chest position.
C. Have child stop all current activity.
D. Administer a dose of digoxin stat.
,Correct Answer: B. Place child in knee-chest position.
Rationale: The child should be placed in the knee-chest position to increase blood vessel
resistance. The increased pressure reduces the rush of blood through the septal hole and
improves blood circulation. Removing tight clothing has nominal effects in hyper cyanosis.
Stopping current activity is self-regulating. A dose of digoxin is not indicated for immediate relief
of "tet spells."
Question 3: The nurse is assessing a client and identifies the presence of petechiae. Which
documentation best describes this finding?
A. Purplish-red pinpoint lesions of the skin.
B. Purple to bluish discoloration of the skin.
C. Small circumscribed elevations containing purulent fluid.
D. Generalized reddish discoloration of an area of skin.
Correct Answer: A. Purplish-red pinpoint lesions of the skin.
Rationale: Petechiae are described as purplish to red, non-blanchable, pinpoint lesions that are
tiny hemorrhages within the dermal or submucosal layers. Purplish skin discoloration describes
ecchymosis caused by trauma to the underlying blood vessels. Small elevations containing pus
describes pustules.
Question 4: A nurse is caring for a client with congestive heart failure (CHF) who is taking
digoxin. Which assessment finding indicates a potential complication of this medication?
A. Heart rate of 58 beats per minute.
B. Blood pressure of 110/70 mm Hg.
, C. Respiratory rate of 18 breaths per minute.
D. Serum potassium level of 4.2 mEq/L.
Correct Answer: A. Heart rate of 58 beats per minute.
Rationale: Digoxin slows the heart rate and increases contractility. A heart rate below 60 beats
per minute in an adult indicates bradycardia, which is a sign of digoxin toxicity. The nurse should
hold the medication and notify the provider. Blood pressure and respiratory rate are within
normal limits. A potassium level of 4.2 is normal, though hypokalemia increases the risk of
digoxin toxicity.
Question 5: A client is diagnosed with active pulmonary tuberculosis. Which type of isolation
precautions should the nurse initiate?
A. Standard precautions.
B. Contact precautions.
C. Droplet precautions.
D. Airborne precautions.
Correct Answer: D. Airborne precautions.
Rationale: Tuberculosis is transmitted via airborne droplet nuclei. Therefore, the nurse must
implement airborne precautions, which include a negative pressure room and the use of an N95
respirator mask. Standard precautions are used for all clients. Contact precautions are for
diseases spread by direct or indirect contact. Droplet precautions are for diseases spread by
large droplets, such as influenza.
Questions & Answers with Detailed Rationales | 100%
Guaranteed Pass!
,Question 1: A client is admitted to the hospital for alcohol dependency. What is the priority
nursing intervention during the first 48 hours following admission?
A. Administer thiamine (B1) to prevent Korsakoff's syndrome.
B. Monitor for increased blood pressure and pulse.
C. Administer a PRN benzodiazepine as needed for anxiety.
D. Encourage fluid intake of non-caffeinated beverages.
Correct Answer: B. Monitor for increased blood pressure and pulse.
Rationale: Clients with alcohol dependency experience withdrawal symptoms, which include
elevated blood pressure, pulse, and temperature. Monitoring these physical parameters has the
highest priority. Administering thiamine will prevent Korsakoff's syndrome, but this intervention
does not have the priority of monitoring vital signs.
Question 2: A child with Tetralogy of Fallot suffers a hyper cyanotic episode. Which immediate
action by the nurse can lessen the symptoms of this "TET spell?"
A. Remove child's constrictive clothing.
B. Place child in knee-chest position.
C. Have child stop all current activity.
D. Administer a dose of digoxin stat.
,Correct Answer: B. Place child in knee-chest position.
Rationale: The child should be placed in the knee-chest position to increase blood vessel
resistance. The increased pressure reduces the rush of blood through the septal hole and
improves blood circulation. Removing tight clothing has nominal effects in hyper cyanosis.
Stopping current activity is self-regulating. A dose of digoxin is not indicated for immediate relief
of "tet spells."
Question 3: The nurse is assessing a client and identifies the presence of petechiae. Which
documentation best describes this finding?
A. Purplish-red pinpoint lesions of the skin.
B. Purple to bluish discoloration of the skin.
C. Small circumscribed elevations containing purulent fluid.
D. Generalized reddish discoloration of an area of skin.
Correct Answer: A. Purplish-red pinpoint lesions of the skin.
Rationale: Petechiae are described as purplish to red, non-blanchable, pinpoint lesions that are
tiny hemorrhages within the dermal or submucosal layers. Purplish skin discoloration describes
ecchymosis caused by trauma to the underlying blood vessels. Small elevations containing pus
describes pustules.
Question 4: A nurse is caring for a client with congestive heart failure (CHF) who is taking
digoxin. Which assessment finding indicates a potential complication of this medication?
A. Heart rate of 58 beats per minute.
B. Blood pressure of 110/70 mm Hg.
, C. Respiratory rate of 18 breaths per minute.
D. Serum potassium level of 4.2 mEq/L.
Correct Answer: A. Heart rate of 58 beats per minute.
Rationale: Digoxin slows the heart rate and increases contractility. A heart rate below 60 beats
per minute in an adult indicates bradycardia, which is a sign of digoxin toxicity. The nurse should
hold the medication and notify the provider. Blood pressure and respiratory rate are within
normal limits. A potassium level of 4.2 is normal, though hypokalemia increases the risk of
digoxin toxicity.
Question 5: A client is diagnosed with active pulmonary tuberculosis. Which type of isolation
precautions should the nurse initiate?
A. Standard precautions.
B. Contact precautions.
C. Droplet precautions.
D. Airborne precautions.
Correct Answer: D. Airborne precautions.
Rationale: Tuberculosis is transmitted via airborne droplet nuclei. Therefore, the nurse must
implement airborne precautions, which include a negative pressure room and the use of an N95
respirator mask. Standard precautions are used for all clients. Contact precautions are for
diseases spread by direct or indirect contact. Droplet precautions are for diseases spread by
large droplets, such as influenza.
