Nightingale BSN 366 Exam 4 Actual Style V3 | 200 Questions
& Verified Answers | BSN366 HESI RN Exit Practice Bank | A+
Graded
SECTION 1: PRIORITIZATION, SAFETY & MEDICALSURGICAL NURSING (Questions 1–40)
1. A patient arrives at the emergency department with chest pain, diaphoresis, and nausea. What is the
nurse's first action?
A) Obtain a 12lead ECG
B) Give an antacid for suspected indigestion
C) Offer the patient food
D) Document the patient's history
Correct Answer: A
Explanation: Chest pain with diaphoresis and nausea are classic signs of an acute myocardial infarction
(MI). The priority is to obtain an ECG to identify ischemic changes and guide immediate treatment. This
is a lifethreatening situation that requires rapid assessment.
2. A postoperative patient becomes tachycardic and hypotensive. The nurse suspects which
complication first?
A) Hemorrhage
B) Anxiety
C) Constipation
D) Fluid overload
Correct Answer: A
,Explanation: Tachycardia and hypotension in a postoperative patient are classic signs of hypovolemic
shock, most commonly caused by internal or external hemorrhage. This requires immediate intervention
to identify and stop the bleeding and restore circulating volume.
3. A patient with a history of asthma is having an exacerbation. Which medication should the nurse
administer first?
A) Albuterol
B) Insulin
C) Morphine
D) Furosemide (Lasix)
Correct Answer: A
Explanation: Albuterol is a shortacting betaagonist (SABA) bronchodilator that provides rapid relief of
bronchospasm during an acute asthma attack. It is the firstline medication for acute symptoms.
4. A patient with chest pain, diaphoresis, and nausea. First action?
A) Obtain ECG
B) Give antacid
C) Offer food
D) Document
Correct Answer: A
Explanation: ECG is priority to identify myocardial infarction.
,5. Which finding is most critical in a patient with respiratory distress?
A) SpO₂ 82%
B) BP 130/80
C) Temp 37°C
D) RR 18
Correct Answer: A
Explanation: Severe hypoxia (SpO₂ < 90%) is lifethreatening and requires immediate intervention.
6. The nurse is providing discharge teaching to a client with COPD. Which statement indicates a need for
further education?
A) "I will stop smoking to slow the progression of my disease."
B) "I should eat more canned vegetables to reduce my sodium intake."
C) "I should use a salt substitute."
D) "I will eat more oatmeal for breakfast."
Correct Answer: B
Explanation: Canned vegetables are often high in sodium, which can exacerbate fluid retention in COPD
patients. The client should be taught to choose fresh or lowsodium vegetables. Smoking cessation and a
hearthealthy diet are appropriate.
7. What is the best indicator of perfusion in a critically ill patient?
A) Urine output
B) Hair growth
C) Nail color
D) Appetite
, Correct Answer: A
Explanation: Urine output reflects renal blood flow and is a reliable indicator of adequate perfusion to
vital organs. Output should be at least 0.5 mL/kg/hr.
8. An early sign of shock is:
A) Tachycardia
B) Bradycardia
C) Cyanosis
D) Hypothermia
Correct Answer: A
Explanation: Tachycardia is an early compensatory response to shock as the body attempts to maintain
cardiac output and perfusion to vital organs.
9. A patient who is 12 hours postoperative has not voided and is complaining of suprapubic discomfort.
What is the nurse's priority action?
A) Encourage oral fluids
B) Perform a bladder scan
C) Insert a Foley catheter
D) Administer pain medication
Correct Answer: B
Explanation: The nurse should first perform a bladder scan to assess for urinary retention before any
invasive intervention. This provides objective data about bladder volume.
& Verified Answers | BSN366 HESI RN Exit Practice Bank | A+
Graded
SECTION 1: PRIORITIZATION, SAFETY & MEDICALSURGICAL NURSING (Questions 1–40)
1. A patient arrives at the emergency department with chest pain, diaphoresis, and nausea. What is the
nurse's first action?
A) Obtain a 12lead ECG
B) Give an antacid for suspected indigestion
C) Offer the patient food
D) Document the patient's history
Correct Answer: A
Explanation: Chest pain with diaphoresis and nausea are classic signs of an acute myocardial infarction
(MI). The priority is to obtain an ECG to identify ischemic changes and guide immediate treatment. This
is a lifethreatening situation that requires rapid assessment.
2. A postoperative patient becomes tachycardic and hypotensive. The nurse suspects which
complication first?
A) Hemorrhage
B) Anxiety
C) Constipation
D) Fluid overload
Correct Answer: A
,Explanation: Tachycardia and hypotension in a postoperative patient are classic signs of hypovolemic
shock, most commonly caused by internal or external hemorrhage. This requires immediate intervention
to identify and stop the bleeding and restore circulating volume.
3. A patient with a history of asthma is having an exacerbation. Which medication should the nurse
administer first?
A) Albuterol
B) Insulin
C) Morphine
D) Furosemide (Lasix)
Correct Answer: A
Explanation: Albuterol is a shortacting betaagonist (SABA) bronchodilator that provides rapid relief of
bronchospasm during an acute asthma attack. It is the firstline medication for acute symptoms.
4. A patient with chest pain, diaphoresis, and nausea. First action?
A) Obtain ECG
B) Give antacid
C) Offer food
D) Document
Correct Answer: A
Explanation: ECG is priority to identify myocardial infarction.
,5. Which finding is most critical in a patient with respiratory distress?
A) SpO₂ 82%
B) BP 130/80
C) Temp 37°C
D) RR 18
Correct Answer: A
Explanation: Severe hypoxia (SpO₂ < 90%) is lifethreatening and requires immediate intervention.
6. The nurse is providing discharge teaching to a client with COPD. Which statement indicates a need for
further education?
A) "I will stop smoking to slow the progression of my disease."
B) "I should eat more canned vegetables to reduce my sodium intake."
C) "I should use a salt substitute."
D) "I will eat more oatmeal for breakfast."
Correct Answer: B
Explanation: Canned vegetables are often high in sodium, which can exacerbate fluid retention in COPD
patients. The client should be taught to choose fresh or lowsodium vegetables. Smoking cessation and a
hearthealthy diet are appropriate.
7. What is the best indicator of perfusion in a critically ill patient?
A) Urine output
B) Hair growth
C) Nail color
D) Appetite
, Correct Answer: A
Explanation: Urine output reflects renal blood flow and is a reliable indicator of adequate perfusion to
vital organs. Output should be at least 0.5 mL/kg/hr.
8. An early sign of shock is:
A) Tachycardia
B) Bradycardia
C) Cyanosis
D) Hypothermia
Correct Answer: A
Explanation: Tachycardia is an early compensatory response to shock as the body attempts to maintain
cardiac output and perfusion to vital organs.
9. A patient who is 12 hours postoperative has not voided and is complaining of suprapubic discomfort.
What is the nurse's priority action?
A) Encourage oral fluids
B) Perform a bladder scan
C) Insert a Foley catheter
D) Administer pain medication
Correct Answer: B
Explanation: The nurse should first perform a bladder scan to assess for urinary retention before any
invasive intervention. This provides objective data about bladder volume.
