BSN366 Final Exam Actual Exam Style V2
| BSN 366 HESI RN Exit | Nightingale
1. A client is prescribed Digoxin for heart failure. Which clinical manifestation should the
nurse recognize as an early sign of Digoxin toxicity?
A. Increased urinary output
B. Sudden increase in heart rate
C. Anorexia and nausea
D. Hypertension
Answer: C
Rationale: Early signs of digoxin toxicity include gastrointestinal symptoms such as
anorexia, nausea, and vomiting. If these signs are ignored, the client may progress to
neurological symptoms like blurred vision or yellow-green halos. The nurse must assess
the apical pulse and potassium levels prior to administration to ensure safety.
2. Which electrolyte imbalance is a client with chronic kidney disease most at risk for
developing?
A. Hypokalemia
B. Hypercalcemia
C. Hyperkalemia
,D. Hyponatremia
Answer: C
Rationale: Chronic kidney disease impairs the kidneys’ ability to excrete potassium,
leading to dangerous elevations in the blood. Hyperkalemia is a critical concern because it
can lead to lethal cardiac dysrhythmias. Patients are often placed on a low-potassium diet
to mitigate this risk.
3. A nurse is caring for a client with a chest tube. What should the nurse do first if the chest
tube becomes accidentally disconnected from the drainage system?
A. Clamp the chest tube immediately
B. Submerge the end of the tube in sterile water
C. Apply a sterile occlusive dressing
D. Call the healthcare provider immediately
Answer: B
Rationale: Submerging the tube in sterile water creates a temporary water seal to prevent
atmospheric air from entering the pleural space. Clamping the tube is generally avoided as
it can cause a tension pneumothorax. Once the seal is established, the nurse should prepare
a new drainage system for connection.
4. Which arterial blood gas (ABG) result is consistent with a client in uncompensated
respiratory acidosis?
A. pH 7.45, PaCO2 40, HCO3 26
, B. pH 7.50, PaCO2 30, HCO3 22
C. pH 7.32, PaCO2 35, HCO3 18
D. pH 7.30, PaCO2 50, HCO3 24
Answer: D
Rationale: Respiratory acidosis is characterized by a low pH and an elevated PaCO2 level.
In an uncompensated state, the bicarbonate (HCO3) remains within the normal range
because the kidneys have not yet adjusted. This condition is frequently seen in patients
with hypoventilation or COPD exacerbations.
5. A nurse is delegating tasks to a Unlicensed Assistive Personnel (UAP). Which task is most
appropriate to delegate?
A. Evaluating the effectiveness of pain medication
B. Teaching a client how to use an incentive spirometer
C. Performing an admission skin assessment
D. Assisting a stable client with range-of-motion exercises
Answer: D
Rationale: UAPs can perform routine tasks such as range-of-motion exercises for stable
clients. Tasks that involve assessment, teaching, or clinical judgment must be performed by
the Registered Nurse. The nurse remains accountable for the outcome of the delegated task
even after assigning it to the UAP.
| BSN 366 HESI RN Exit | Nightingale
1. A client is prescribed Digoxin for heart failure. Which clinical manifestation should the
nurse recognize as an early sign of Digoxin toxicity?
A. Increased urinary output
B. Sudden increase in heart rate
C. Anorexia and nausea
D. Hypertension
Answer: C
Rationale: Early signs of digoxin toxicity include gastrointestinal symptoms such as
anorexia, nausea, and vomiting. If these signs are ignored, the client may progress to
neurological symptoms like blurred vision or yellow-green halos. The nurse must assess
the apical pulse and potassium levels prior to administration to ensure safety.
2. Which electrolyte imbalance is a client with chronic kidney disease most at risk for
developing?
A. Hypokalemia
B. Hypercalcemia
C. Hyperkalemia
,D. Hyponatremia
Answer: C
Rationale: Chronic kidney disease impairs the kidneys’ ability to excrete potassium,
leading to dangerous elevations in the blood. Hyperkalemia is a critical concern because it
can lead to lethal cardiac dysrhythmias. Patients are often placed on a low-potassium diet
to mitigate this risk.
3. A nurse is caring for a client with a chest tube. What should the nurse do first if the chest
tube becomes accidentally disconnected from the drainage system?
A. Clamp the chest tube immediately
B. Submerge the end of the tube in sterile water
C. Apply a sterile occlusive dressing
D. Call the healthcare provider immediately
Answer: B
Rationale: Submerging the tube in sterile water creates a temporary water seal to prevent
atmospheric air from entering the pleural space. Clamping the tube is generally avoided as
it can cause a tension pneumothorax. Once the seal is established, the nurse should prepare
a new drainage system for connection.
4. Which arterial blood gas (ABG) result is consistent with a client in uncompensated
respiratory acidosis?
A. pH 7.45, PaCO2 40, HCO3 26
, B. pH 7.50, PaCO2 30, HCO3 22
C. pH 7.32, PaCO2 35, HCO3 18
D. pH 7.30, PaCO2 50, HCO3 24
Answer: D
Rationale: Respiratory acidosis is characterized by a low pH and an elevated PaCO2 level.
In an uncompensated state, the bicarbonate (HCO3) remains within the normal range
because the kidneys have not yet adjusted. This condition is frequently seen in patients
with hypoventilation or COPD exacerbations.
5. A nurse is delegating tasks to a Unlicensed Assistive Personnel (UAP). Which task is most
appropriate to delegate?
A. Evaluating the effectiveness of pain medication
B. Teaching a client how to use an incentive spirometer
C. Performing an admission skin assessment
D. Assisting a stable client with range-of-motion exercises
Answer: D
Rationale: UAPs can perform routine tasks such as range-of-motion exercises for stable
clients. Tasks that involve assessment, teaching, or clinical judgment must be performed by
the Registered Nurse. The nurse remains accountable for the outcome of the delegated task
even after assigning it to the UAP.
