BSN 366 EXIT HESI COMPREHENSIVE
PREPARATION QUESTIONS AND
VERIFIED ANSWERS | 100% CORRECT |
GRADE A+
1. A client is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which laboratory
finding should the nurse anticipate first?
A. Serum potassium of 3.2 mEq/L
B. Blood glucose of 650 mg/dL
C. Arterial pH of 7.45
D. Negative ketones in the urine
Answer: B
Conceptual Explanation: DKA is characterized by hyperglycemia (usually >300 mg/dL),
metabolic acidosis (pH <7.35), and the presence of ketones. A glucose of 650 is a hallmark
finding.
2. Which task is most appropriate for the RN to delegate to an unlicensed assistive personnel
(UAP)?
A. Feeding a client who has a high risk for aspiration
B. Assessing a client’s surgical incision
,C. Providing discharge instructions to a new mother
D. Collecting a midstream urine specimen
Answer: D
Conceptual Explanation: UAPs can perform non-invasive tasks such as specimen
collection. Assessment, high-risk feeding, and teaching require RN clinical judgment.
3. A client with chronic heart failure is prescribed Digoxin 0.125 mg. Which symptom indicates
potential toxicity?
A. Increased appetite
B. Hypokalemia
C. Sinus tachycardia
D. Yellow-green halos around lights
Answer: D
Conceptual Explanation: Visual disturbances, such as yellow or green halos, along with
nausea and bradycardia, are classic signs of digoxin toxicity.
4. The nurse notes continuous bubbling in the water seal chamber of a client’s chest tube.
How should the nurse interpret this?
A. The system is functioning normally
B. The lung has fully expanded
C. There is an air leak in the system
, D. The suction pressure is too high
Answer: C
Conceptual Explanation: Intermittent bubbling is normal in a pneumothorax, but
continuous bubbling in the water seal chamber indicates a leak between the client and the
drainage system.
5. A client presents with a BP of 210/120 mmHg, a severe headache, and confusion. Which
medication should the nurse expect to administer?
A. Metoprolol PO
B. Sodium Nitroprusside
C. Lisinopril
D. Furosemide
Answer: B
Conceptual Explanation: The client is in a hypertensive crisis. Sodium Nitroprusside is a
potent IV vasodilator used for rapid reduction of blood pressure.
6. Following a thyroidectomy, a client reports tingling in the fingers and around the mouth.
Which action is the priority?
A. Check the surgical dressing for bleeding
B. Assess for Chvostek’s sign
C. Administer a PRN sedative
PREPARATION QUESTIONS AND
VERIFIED ANSWERS | 100% CORRECT |
GRADE A+
1. A client is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which laboratory
finding should the nurse anticipate first?
A. Serum potassium of 3.2 mEq/L
B. Blood glucose of 650 mg/dL
C. Arterial pH of 7.45
D. Negative ketones in the urine
Answer: B
Conceptual Explanation: DKA is characterized by hyperglycemia (usually >300 mg/dL),
metabolic acidosis (pH <7.35), and the presence of ketones. A glucose of 650 is a hallmark
finding.
2. Which task is most appropriate for the RN to delegate to an unlicensed assistive personnel
(UAP)?
A. Feeding a client who has a high risk for aspiration
B. Assessing a client’s surgical incision
,C. Providing discharge instructions to a new mother
D. Collecting a midstream urine specimen
Answer: D
Conceptual Explanation: UAPs can perform non-invasive tasks such as specimen
collection. Assessment, high-risk feeding, and teaching require RN clinical judgment.
3. A client with chronic heart failure is prescribed Digoxin 0.125 mg. Which symptom indicates
potential toxicity?
A. Increased appetite
B. Hypokalemia
C. Sinus tachycardia
D. Yellow-green halos around lights
Answer: D
Conceptual Explanation: Visual disturbances, such as yellow or green halos, along with
nausea and bradycardia, are classic signs of digoxin toxicity.
4. The nurse notes continuous bubbling in the water seal chamber of a client’s chest tube.
How should the nurse interpret this?
A. The system is functioning normally
B. The lung has fully expanded
C. There is an air leak in the system
, D. The suction pressure is too high
Answer: C
Conceptual Explanation: Intermittent bubbling is normal in a pneumothorax, but
continuous bubbling in the water seal chamber indicates a leak between the client and the
drainage system.
5. A client presents with a BP of 210/120 mmHg, a severe headache, and confusion. Which
medication should the nurse expect to administer?
A. Metoprolol PO
B. Sodium Nitroprusside
C. Lisinopril
D. Furosemide
Answer: B
Conceptual Explanation: The client is in a hypertensive crisis. Sodium Nitroprusside is a
potent IV vasodilator used for rapid reduction of blood pressure.
6. Following a thyroidectomy, a client reports tingling in the fingers and around the mouth.
Which action is the priority?
A. Check the surgical dressing for bleeding
B. Assess for Chvostek’s sign
C. Administer a PRN sedative
