BSN366 EXIT HESI Questions and
Answers | Latest Version | 2025/2026 |
Correct & Verified
A postoperative patient reports sudden chest pain and shortness of breath. What is the nurse’s
first action?
A. Sit with the patient
✔✔B. Assess vital signs and oxygen saturation
C. Administer pain medication
D. Document symptoms
A patient with diabetes reports dizziness and confusion. What should the nurse do first?
✔✔A. Check blood glucose and provide a rapid-acting carbohydrate
B. Call the provider immediately
C. Wait until next scheduled check
D. Encourage oral fluids
A client is scheduled for surgery and asks why preoperative labs are necessary. What is the
nurse’s best response?
1
,A. To practice drawing blood
B. To fill hospital paperwork
✔✔C. To detect abnormalities that could affect anesthesia or surgery
D. To speed up billing
A patient with a Foley catheter reports bladder spasms. What is the priority nursing action?
A. Remove the catheter immediately
✔✔B. Check for kinks and ensure patency
C. Give pain medication without assessment
D. Notify family
A patient develops sudden swelling of the lips after eating peanuts. What should the nurse do
first?
✔✔A. Assess airway and prepare emergency intervention
B. Give an oral antihistamine
C. Document and observe
D. Ask family to call the provider
2
,A child presents with fever and seizure activity. What is the priority nursing action?
A. Start IV fluids immediately
✔✔B. Ensure safety, maintain airway, and monitor seizure
C. Call provider after seizure
D. Document only
A patient is post-operative and refuses ambulation due to pain. What is the first nursing action?
A. Force the patient to ambulate
B. Wait until the patient feels ready
✔✔C. Assess pain and provide analgesia before assisting
D. Ignore the complaint
A patient develops a rash after IV antibiotics. What should the nurse do first?
A. Apply topical cream
B. Continue infusion while monitoring
✔✔C. Stop the infusion and notify the provider
D. Document only
3
, A patient is confused and attempting to remove their IV line. What is the priority nursing action?
A. Remove the IV immediately
B. Call security
✔✔C. Ensure patient safety and secure the IV line
D. Document only
A patient on anticoagulants reports black, tarry stools. What is the first action?
A. Document only
B. Continue the medication
✔✔C. Hold the medication and notify the provider immediately
D. Monitor at next shift
A patient reports severe postoperative pain unrelieved by medication. What should the nurse do
first?
A. Give another dose immediately
B. Call family
✔✔C. Assess for complications such as infection or compartment syndrome
D. Document only
4
Answers | Latest Version | 2025/2026 |
Correct & Verified
A postoperative patient reports sudden chest pain and shortness of breath. What is the nurse’s
first action?
A. Sit with the patient
✔✔B. Assess vital signs and oxygen saturation
C. Administer pain medication
D. Document symptoms
A patient with diabetes reports dizziness and confusion. What should the nurse do first?
✔✔A. Check blood glucose and provide a rapid-acting carbohydrate
B. Call the provider immediately
C. Wait until next scheduled check
D. Encourage oral fluids
A client is scheduled for surgery and asks why preoperative labs are necessary. What is the
nurse’s best response?
1
,A. To practice drawing blood
B. To fill hospital paperwork
✔✔C. To detect abnormalities that could affect anesthesia or surgery
D. To speed up billing
A patient with a Foley catheter reports bladder spasms. What is the priority nursing action?
A. Remove the catheter immediately
✔✔B. Check for kinks and ensure patency
C. Give pain medication without assessment
D. Notify family
A patient develops sudden swelling of the lips after eating peanuts. What should the nurse do
first?
✔✔A. Assess airway and prepare emergency intervention
B. Give an oral antihistamine
C. Document and observe
D. Ask family to call the provider
2
,A child presents with fever and seizure activity. What is the priority nursing action?
A. Start IV fluids immediately
✔✔B. Ensure safety, maintain airway, and monitor seizure
C. Call provider after seizure
D. Document only
A patient is post-operative and refuses ambulation due to pain. What is the first nursing action?
A. Force the patient to ambulate
B. Wait until the patient feels ready
✔✔C. Assess pain and provide analgesia before assisting
D. Ignore the complaint
A patient develops a rash after IV antibiotics. What should the nurse do first?
A. Apply topical cream
B. Continue infusion while monitoring
✔✔C. Stop the infusion and notify the provider
D. Document only
3
, A patient is confused and attempting to remove their IV line. What is the priority nursing action?
A. Remove the IV immediately
B. Call security
✔✔C. Ensure patient safety and secure the IV line
D. Document only
A patient on anticoagulants reports black, tarry stools. What is the first action?
A. Document only
B. Continue the medication
✔✔C. Hold the medication and notify the provider immediately
D. Monitor at next shift
A patient reports severe postoperative pain unrelieved by medication. What should the nurse do
first?
A. Give another dose immediately
B. Call family
✔✔C. Assess for complications such as infection or compartment syndrome
D. Document only
4
