BSN 366 HESI RN EXIT EXAM
QUESTIONS AND VERIFIED ANSWERS |
100% CORRECT | GRADE A+
1. A client with chronic heart failure is prescribed digoxin. Which assessment finding should
the nurse prioritize as a potential sign of toxicity?
A. Increased appetite and weight gain
B. Visual disturbances such as yellow halos
C. Heart rate of 88 beats per minute
D. Hyperkalemia symptoms
Answer: B
Conceptual Explanation: Digoxin toxicity commonly presents with gastrointestinal
distress and visual changes, including yellow-green halos or blurred vision.
2. A patient is admitted with Autonomic Dysreflexia. What is the nurse’s immediate priority
action?
A. Administer an antihypertensive medication
B. Raise the head of the bed to 90 degrees
C. Assess for a full bladder or fecal impaction
D. Notify the primary healthcare provider
,Answer: B
Conceptual Explanation: Elevating the head of the bed is the first action to help lower
blood pressure through orthostatic changes before addressing the noxious stimulus.
3. The nurse is caring for a client with Magnesium Sulfate infusion for preeclampsia. Which
finding requires immediate intervention?
A. Urine output of 20 mL/hr
B. Deep tendon reflexes 2+
C. Respirations of 14 breaths/min
D. Client reports feeling warm and flushed
Answer: A
Conceptual Explanation: Magnesium is excreted by the kidneys. Urine output less than 30
mL/hr can lead to toxic accumulation of magnesium.
4. Which clinical manifestation is most characteristic of a client experiencing a tension
pneumothorax?
A. Tracheal deviation to the affected side
B. Increased breath sounds on the affected side
C. Tracheal deviation to the unaffected side
D. Flattened neck veins
Answer: C
, Conceptual Explanation: In a tension pneumothorax, pressure builds up and shifts the
mediastinum, causing the trachea to deviate toward the healthy lung.
5. A child is admitted with suspected Intussusception. Which stool characteristic does the
nurse expect to document?
A. Black tarry stools
B. Ribbon-like stools
C. Currant jelly-like stools
D. Steatorrhea
Answer: C
Conceptual Explanation: Intussusception causes blood and mucus to mix with stool,
creating a classic ‘currant jelly’ appearance.
6. Which laboratory value is most indicative of a therapeutic response to Heparin therapy?
A. aPTT 1.5 to 2.5 times the control
B. INR of 2.5
C. Platelet count of 150,000
D. PT of 12 seconds
Answer: A
Conceptual Explanation: Activated partial thromboplastin time (aPTT) is used to monitor
Heparin, while INR/PT are used for Warfarin.
QUESTIONS AND VERIFIED ANSWERS |
100% CORRECT | GRADE A+
1. A client with chronic heart failure is prescribed digoxin. Which assessment finding should
the nurse prioritize as a potential sign of toxicity?
A. Increased appetite and weight gain
B. Visual disturbances such as yellow halos
C. Heart rate of 88 beats per minute
D. Hyperkalemia symptoms
Answer: B
Conceptual Explanation: Digoxin toxicity commonly presents with gastrointestinal
distress and visual changes, including yellow-green halos or blurred vision.
2. A patient is admitted with Autonomic Dysreflexia. What is the nurse’s immediate priority
action?
A. Administer an antihypertensive medication
B. Raise the head of the bed to 90 degrees
C. Assess for a full bladder or fecal impaction
D. Notify the primary healthcare provider
,Answer: B
Conceptual Explanation: Elevating the head of the bed is the first action to help lower
blood pressure through orthostatic changes before addressing the noxious stimulus.
3. The nurse is caring for a client with Magnesium Sulfate infusion for preeclampsia. Which
finding requires immediate intervention?
A. Urine output of 20 mL/hr
B. Deep tendon reflexes 2+
C. Respirations of 14 breaths/min
D. Client reports feeling warm and flushed
Answer: A
Conceptual Explanation: Magnesium is excreted by the kidneys. Urine output less than 30
mL/hr can lead to toxic accumulation of magnesium.
4. Which clinical manifestation is most characteristic of a client experiencing a tension
pneumothorax?
A. Tracheal deviation to the affected side
B. Increased breath sounds on the affected side
C. Tracheal deviation to the unaffected side
D. Flattened neck veins
Answer: C
, Conceptual Explanation: In a tension pneumothorax, pressure builds up and shifts the
mediastinum, causing the trachea to deviate toward the healthy lung.
5. A child is admitted with suspected Intussusception. Which stool characteristic does the
nurse expect to document?
A. Black tarry stools
B. Ribbon-like stools
C. Currant jelly-like stools
D. Steatorrhea
Answer: C
Conceptual Explanation: Intussusception causes blood and mucus to mix with stool,
creating a classic ‘currant jelly’ appearance.
6. Which laboratory value is most indicative of a therapeutic response to Heparin therapy?
A. aPTT 1.5 to 2.5 times the control
B. INR of 2.5
C. Platelet count of 150,000
D. PT of 12 seconds
Answer: A
Conceptual Explanation: Activated partial thromboplastin time (aPTT) is used to monitor
Heparin, while INR/PT are used for Warfarin.
