BSNl 366l HESIl RNl Exitl Practicel Examl
(2025/l 2026l Update)l Questionsl &l
Answers|l Gradel A|l 100%l Correctl
(Verifiedl Solutions)-l Nightingale
Q:l Al 16-year-oldl malel clientl isl admittedl tol thel hospitall afterl fallingl offl al bikel andl
sustainingl al fracturedl bone.l Thel HCPl explainsl thel surgeryl neededl tol immobilizel thel
fracture.l Whichl actionl shouldl bel implementedl tol obtainl al validl informedl consent?
Answer:
Obtainl thel permissionl ofl thel custodiall parentl forl thel surgery.
Ptl isl al minorl andl cannotl legallyl signl hisl ownl consentl unlessl hel isl anl emancipatedl
minor.l Consentl shouldl bel obtainedl froml thel guardian,l custodiall parent.
Q:l Duringl al clientl assessment,l thel clientl says,l "Il can'tl walkl veryl well."l Whichl actionl
shouldl thel nursel implementl first?
Answer:
Identifyl thel problem
Sequentiall probleml solvingl steps:l 1)l Identifyl thel problem,l 2)l considerl alternatives,l 3)l
considerl outcomesl ofl thel alternatives,l 4)l predictl thel likelihoodl ofl thel outcomesl
occurringl andl choosel bestl chancel ofl success.
Q:l Thel nursel identifiesl al client'sl needsl andl formulatesl thel nursingl probleml of,l
"Imbalancedl nutrition:l lessl thanl bodyl requirements,l relatedl tol mentall impairmentl andl
decreasedl intake,l asl evidencedl byl increasingl confusionl andl weightl lossl ofl morel thanl
30l lbsl overl thel lastl 6l months."l Whichl shortl terml goall isl bestl forl thisl pt?
Answer:
Eatl 50%l ofl sixl smalll mealsl eachl dayl byl thel endl ofl onel week
Shortl terml goals:l realisticl &l attainable,l timel framel 7-10l daysl beforel discharge
,Q:l Al malel clientl isl angryl andl isl leavingl thel hospitall AMA.l Thel clientl demandsl tol
takel hisl chartl withl himl andl statesl it'sl "his"l andl doesn'tl wantl contactl withl thel hospitall
anymore.l Howl shouldl thel nursel respond?
Answer:
Thel chartl isl thel propertyl ofl thel hospitall butl Il willl seel thatl al copel isl madel forl you.
Ptl hasl legall rightl tol thel informationl inl itl evenl ifl leavingl AMA
Q:l Thel nursel managerl isl assistingl al nursel withl improvingl organizationall skillsl andl
timel management.l Whichl nursingl activityl isl thel priorityl inl pre-planningl al schedulel forl
selectedl nursingl activitiesl inl thel dailyl assignment?
Answer:
Medicationl administration
Medl adminl isl basedl onl al prescribedl schedulel thatl isl time-sensitivel inl thel deliveryl ofl
nursingl carel andl shouldl bel priorityl inl schedulingl nursingl activitiesl inl al dailyl
assignment.
Q:l Whatl nursingl deliveryl ofl carel providesl thel nursel tol planl andl directl carel ofl al
groupl ofl clientsl overl al 24-hourl period?
Answer:
Primaryl nursing
isl al modell ofl deliveryl ofl carel wherel al nursel usl accountablel forl planningl carel forl
clientsl aroundl thel clock.
Q:l Twol unlicensedl assistivel personnell (UAP)l arel arguingl onl thel unitl aboutl whol
deservesl tol takel al breakl first.l Whatl isl thel mostl importantl basicl guidelinel thatl thel
nursel shouldl followl inl resolvingl thel conflict?
,Answer:
Deall withl thel issuesl andl notl personalities
Issuesl arel concretel andl isl 1l ofl 7l importantl keyl behaviorsl inl managingl conflict.l
Personalitiesl includel emotionall reactionsl (notl concrete).
Q:l Thel nursel isl caringl forl al clientl whol isl unablel tol void.l Thel planl ofl carel
establishesl anl objectivel forl thel clientl tol ingestl atl leastl 1000l mLl ofl fluidl betweenl 7al
andl 330p.l Whichl clientl responsel shouldl thel nursel documentl thatl indicatesl successfull
outcome?
Answer:
Drinksl 240l mLl ofl fluidl 5l timesl duringl thel shift
whichl indicatesl fluidl intakel ofl 1220-1440l mLl meetingl thel objective.
Q:l Thel nursel plansl al teachingl sessionl withl al clientl butl postponesl thel plannedl
sessionl basedl onl whichl nursingl problem?
Answer:
Activityl intolerancel relatedl tol post-opl pain
Pain,l fatigue,l orl anxietyl canl interferel withl thel abilityl tol payl attentionl &l participatel inl
learning.
Q:l Al clientl whol hasl activel TBl isl admittedl tol thel medicall unit.l Whatl actionl isl mostl
importantl forl thel nursel tol implement?
Answer:
Assignl thel clientl tol al negativel air-flowl room
activel TBl requiresl airbornel precautions
, Q:l Al clientl isl receivingl atenololl (Tenormin)l 25l mgl POl afterl al MI.l Thel nursel
determinesl thel client'sl apicall pulsel isl 65l bpm.l Whatl actionl shouldl thel nursel implementl
next?
Answer:
Administerl thel medication
Apicall pulsel isl >60l bpm
Q:l Thel nursel isl assessingl al clientl andl identifiesl al bruitl overl thel thyroid.l Thisl
findingl isl consistentl withl whichl interpretation?
Answer:
Hyperthyroidism
enlargementl ofl thel thyroidl glandl (AKAl goiter).l Bruitl mayl bel auscultatedl d/tl increasel inl
glandularl vascularityl whichl increasesl asl itl becomesl hyperactive.
Q:l Al 6-year-oldl childl isl alertl byl quietl whenl broughtl thel thel ERl withl periorbitall
ecchymosisl andl ecchymosisl behindl thel ears.l Thel nursel suspectsl potentiall childl abusel
andl continuesl tol assessl thel childl forl additionall manifestationsl ofl al basilarl skulll
fracture.l Whatl assessmentl findingl wouldl bel consistentl withl al basilarl skulll fracture?
Answer:
Rhinorrhoeal orl otorrhoeal withl Halol sign
Raccoonl eyesl (periorbitall ecchymosis)l andl Battle'sl signl (ecchymosisl behindl thel earsl
overl mastoidl process)l arel bothl signsl ofl al basilarl skilll fracture.l Nursel shouldl assessl
possiblel meningeall tearl thatl manifestl asl al Halol signl withl CSFl leakagel froml earsl orl
nose.
Q:l Thel nursel isl assessingl al clientl whol complainsl ofl weightl loss,l racingl heartl rate,l
andl difficultyl sleeping.l Thel nursel determinesl thel clientl hasl moistl skinl withl finel hair,l
prominentl eyes,l lidl retraction,l andl al staringl expression.l Thesel findingsl arel consistentl
withl whichl disorder?
(2025/l 2026l Update)l Questionsl &l
Answers|l Gradel A|l 100%l Correctl
(Verifiedl Solutions)-l Nightingale
Q:l Al 16-year-oldl malel clientl isl admittedl tol thel hospitall afterl fallingl offl al bikel andl
sustainingl al fracturedl bone.l Thel HCPl explainsl thel surgeryl neededl tol immobilizel thel
fracture.l Whichl actionl shouldl bel implementedl tol obtainl al validl informedl consent?
Answer:
Obtainl thel permissionl ofl thel custodiall parentl forl thel surgery.
Ptl isl al minorl andl cannotl legallyl signl hisl ownl consentl unlessl hel isl anl emancipatedl
minor.l Consentl shouldl bel obtainedl froml thel guardian,l custodiall parent.
Q:l Duringl al clientl assessment,l thel clientl says,l "Il can'tl walkl veryl well."l Whichl actionl
shouldl thel nursel implementl first?
Answer:
Identifyl thel problem
Sequentiall probleml solvingl steps:l 1)l Identifyl thel problem,l 2)l considerl alternatives,l 3)l
considerl outcomesl ofl thel alternatives,l 4)l predictl thel likelihoodl ofl thel outcomesl
occurringl andl choosel bestl chancel ofl success.
Q:l Thel nursel identifiesl al client'sl needsl andl formulatesl thel nursingl probleml of,l
"Imbalancedl nutrition:l lessl thanl bodyl requirements,l relatedl tol mentall impairmentl andl
decreasedl intake,l asl evidencedl byl increasingl confusionl andl weightl lossl ofl morel thanl
30l lbsl overl thel lastl 6l months."l Whichl shortl terml goall isl bestl forl thisl pt?
Answer:
Eatl 50%l ofl sixl smalll mealsl eachl dayl byl thel endl ofl onel week
Shortl terml goals:l realisticl &l attainable,l timel framel 7-10l daysl beforel discharge
,Q:l Al malel clientl isl angryl andl isl leavingl thel hospitall AMA.l Thel clientl demandsl tol
takel hisl chartl withl himl andl statesl it'sl "his"l andl doesn'tl wantl contactl withl thel hospitall
anymore.l Howl shouldl thel nursel respond?
Answer:
Thel chartl isl thel propertyl ofl thel hospitall butl Il willl seel thatl al copel isl madel forl you.
Ptl hasl legall rightl tol thel informationl inl itl evenl ifl leavingl AMA
Q:l Thel nursel managerl isl assistingl al nursel withl improvingl organizationall skillsl andl
timel management.l Whichl nursingl activityl isl thel priorityl inl pre-planningl al schedulel forl
selectedl nursingl activitiesl inl thel dailyl assignment?
Answer:
Medicationl administration
Medl adminl isl basedl onl al prescribedl schedulel thatl isl time-sensitivel inl thel deliveryl ofl
nursingl carel andl shouldl bel priorityl inl schedulingl nursingl activitiesl inl al dailyl
assignment.
Q:l Whatl nursingl deliveryl ofl carel providesl thel nursel tol planl andl directl carel ofl al
groupl ofl clientsl overl al 24-hourl period?
Answer:
Primaryl nursing
isl al modell ofl deliveryl ofl carel wherel al nursel usl accountablel forl planningl carel forl
clientsl aroundl thel clock.
Q:l Twol unlicensedl assistivel personnell (UAP)l arel arguingl onl thel unitl aboutl whol
deservesl tol takel al breakl first.l Whatl isl thel mostl importantl basicl guidelinel thatl thel
nursel shouldl followl inl resolvingl thel conflict?
,Answer:
Deall withl thel issuesl andl notl personalities
Issuesl arel concretel andl isl 1l ofl 7l importantl keyl behaviorsl inl managingl conflict.l
Personalitiesl includel emotionall reactionsl (notl concrete).
Q:l Thel nursel isl caringl forl al clientl whol isl unablel tol void.l Thel planl ofl carel
establishesl anl objectivel forl thel clientl tol ingestl atl leastl 1000l mLl ofl fluidl betweenl 7al
andl 330p.l Whichl clientl responsel shouldl thel nursel documentl thatl indicatesl successfull
outcome?
Answer:
Drinksl 240l mLl ofl fluidl 5l timesl duringl thel shift
whichl indicatesl fluidl intakel ofl 1220-1440l mLl meetingl thel objective.
Q:l Thel nursel plansl al teachingl sessionl withl al clientl butl postponesl thel plannedl
sessionl basedl onl whichl nursingl problem?
Answer:
Activityl intolerancel relatedl tol post-opl pain
Pain,l fatigue,l orl anxietyl canl interferel withl thel abilityl tol payl attentionl &l participatel inl
learning.
Q:l Al clientl whol hasl activel TBl isl admittedl tol thel medicall unit.l Whatl actionl isl mostl
importantl forl thel nursel tol implement?
Answer:
Assignl thel clientl tol al negativel air-flowl room
activel TBl requiresl airbornel precautions
, Q:l Al clientl isl receivingl atenololl (Tenormin)l 25l mgl POl afterl al MI.l Thel nursel
determinesl thel client'sl apicall pulsel isl 65l bpm.l Whatl actionl shouldl thel nursel implementl
next?
Answer:
Administerl thel medication
Apicall pulsel isl >60l bpm
Q:l Thel nursel isl assessingl al clientl andl identifiesl al bruitl overl thel thyroid.l Thisl
findingl isl consistentl withl whichl interpretation?
Answer:
Hyperthyroidism
enlargementl ofl thel thyroidl glandl (AKAl goiter).l Bruitl mayl bel auscultatedl d/tl increasel inl
glandularl vascularityl whichl increasesl asl itl becomesl hyperactive.
Q:l Al 6-year-oldl childl isl alertl byl quietl whenl broughtl thel thel ERl withl periorbitall
ecchymosisl andl ecchymosisl behindl thel ears.l Thel nursel suspectsl potentiall childl abusel
andl continuesl tol assessl thel childl forl additionall manifestationsl ofl al basilarl skulll
fracture.l Whatl assessmentl findingl wouldl bel consistentl withl al basilarl skulll fracture?
Answer:
Rhinorrhoeal orl otorrhoeal withl Halol sign
Raccoonl eyesl (periorbitall ecchymosis)l andl Battle'sl signl (ecchymosisl behindl thel earsl
overl mastoidl process)l arel bothl signsl ofl al basilarl skilll fracture.l Nursel shouldl assessl
possiblel meningeall tearl thatl manifestl asl al Halol signl withl CSFl leakagel froml earsl orl
nose.
Q:l Thel nursel isl assessingl al clientl whol complainsl ofl weightl loss,l racingl heartl rate,l
andl difficultyl sleeping.l Thel nursel determinesl thel clientl hasl moistl skinl withl finel hair,l
prominentl eyes,l lidl retraction,l andl al staringl expression.l Thesel findingsl arel consistentl
withl whichl disorder?
