2025/2026 BSN 266 HESI V2 Exit Exam 150 Questions and
Answers with Rationales (Latest, Verified & High Yield)
Q1. A client on furosemide has K+ 2.9 mEq/L. What is the priority action?
Answer: Notify HCP and anticipate potassium replacement.
Rationale: Severe hypokalemia can cause life-threatening arrhythmias.
Q2. What should the nurse assess before giving digoxin?
Answer: Apical pulse for one full minute.
Rationale: Hold if <60 bpm to prevent bradycardia.
Q3. A postpartum client is bleeding heavily. First action?
Answer: Assess and massage the fundus if boggy.
Rationale: Uterine atony is the most common cause of hemorrhage.
Q4. Teaching insulin use: how should sites be rotated?
Answer: Rotate within the same body region.
Rationale: Maintains consistent absorption and prevents lipodystrophy.
Q5. A client has K+ 6.2 mEq/L. What should the nurse monitor for?
Answer: Cardiac dysrhythmias.
Rationale: Hyperkalemia affects conduction and may cause cardiac arrest.
Q6. Priority action for suspected sepsis?
Answer: Obtain blood cultures, then start broad-spectrum antibiotics.
Rationale: Cultures must be drawn before antibiotics to identify organism.
Q7. A child with epiglottitis is drooling. Immediate action?
,Answer: Prepare for airway support, do not use tongue depressor.
Rationale: Airway obstruction risk.
Q8. Chest tube becomes disconnected. What should nurse do?
Answer: Place end in sterile water.
Rationale: Restores water seal and prevents pneumothorax.
Q9. Client with COPD on 2 L O₂ has O₂ sat 88%. Action?
Answer: Encourage pursed-lip breathing.
Rationale: Promotes CO₂ elimination; high O₂ can depress drive.
Q10. Before giving IV potassium, what must be verified?
Answer: Adequate urine output.
Rationale: Prevents hyperkalemia in renal failure.
Q11. Pregnant woman with painless vaginal bleeding in 3rd trimester. Likely cause?
Answer: Placenta previa.
Rationale: Classic presentation.
Q12. Post-thyroidectomy client reports tingling lips/fingers. Suspect?
Answer: Hypocalcemia from parathyroid removal.
Rationale: Tingling is early sign.
Q13. Client with chest pain, ECG shows ST elevation. First priority?
Answer: Administer oxygen.
Rationale: Increases myocardial oxygen supply.
, Q14. Best site for IM injection in infant <12 months?
Answer: Vastus lateralis.
Rationale: Safest muscle mass.
Q15. What to monitor closely when giving opioids?
Answer: Respiratory rate.
Rationale: Risk of respiratory depression.
Q16. Client with schizophrenia hears voices. Best response?
Answer: Acknowledge experience but present reality.
Rationale: Validates feelings without reinforcing hallucination.
Q17. Client receiving heparin has PTT 120 seconds. Action?
Answer: Hold dose and notify HCP.
Rationale: Therapeutic range 60–80; >100 is critical.
Q18. Post-stroke client has right-sided weakness. Which side should food be placed in
mouth?
Answer: Left side.
Rationale: Stronger side reduces aspiration risk.
Q19. Early sign of hypoxemia?
Answer: Restlessness.
Rationale: Brain is sensitive to low oxygen.
Q20. Pregnant client with seizures. First action?
Answer: Ensure airway and administer oxygen.
Answers with Rationales (Latest, Verified & High Yield)
Q1. A client on furosemide has K+ 2.9 mEq/L. What is the priority action?
Answer: Notify HCP and anticipate potassium replacement.
Rationale: Severe hypokalemia can cause life-threatening arrhythmias.
Q2. What should the nurse assess before giving digoxin?
Answer: Apical pulse for one full minute.
Rationale: Hold if <60 bpm to prevent bradycardia.
Q3. A postpartum client is bleeding heavily. First action?
Answer: Assess and massage the fundus if boggy.
Rationale: Uterine atony is the most common cause of hemorrhage.
Q4. Teaching insulin use: how should sites be rotated?
Answer: Rotate within the same body region.
Rationale: Maintains consistent absorption and prevents lipodystrophy.
Q5. A client has K+ 6.2 mEq/L. What should the nurse monitor for?
Answer: Cardiac dysrhythmias.
Rationale: Hyperkalemia affects conduction and may cause cardiac arrest.
Q6. Priority action for suspected sepsis?
Answer: Obtain blood cultures, then start broad-spectrum antibiotics.
Rationale: Cultures must be drawn before antibiotics to identify organism.
Q7. A child with epiglottitis is drooling. Immediate action?
,Answer: Prepare for airway support, do not use tongue depressor.
Rationale: Airway obstruction risk.
Q8. Chest tube becomes disconnected. What should nurse do?
Answer: Place end in sterile water.
Rationale: Restores water seal and prevents pneumothorax.
Q9. Client with COPD on 2 L O₂ has O₂ sat 88%. Action?
Answer: Encourage pursed-lip breathing.
Rationale: Promotes CO₂ elimination; high O₂ can depress drive.
Q10. Before giving IV potassium, what must be verified?
Answer: Adequate urine output.
Rationale: Prevents hyperkalemia in renal failure.
Q11. Pregnant woman with painless vaginal bleeding in 3rd trimester. Likely cause?
Answer: Placenta previa.
Rationale: Classic presentation.
Q12. Post-thyroidectomy client reports tingling lips/fingers. Suspect?
Answer: Hypocalcemia from parathyroid removal.
Rationale: Tingling is early sign.
Q13. Client with chest pain, ECG shows ST elevation. First priority?
Answer: Administer oxygen.
Rationale: Increases myocardial oxygen supply.
, Q14. Best site for IM injection in infant <12 months?
Answer: Vastus lateralis.
Rationale: Safest muscle mass.
Q15. What to monitor closely when giving opioids?
Answer: Respiratory rate.
Rationale: Risk of respiratory depression.
Q16. Client with schizophrenia hears voices. Best response?
Answer: Acknowledge experience but present reality.
Rationale: Validates feelings without reinforcing hallucination.
Q17. Client receiving heparin has PTT 120 seconds. Action?
Answer: Hold dose and notify HCP.
Rationale: Therapeutic range 60–80; >100 is critical.
Q18. Post-stroke client has right-sided weakness. Which side should food be placed in
mouth?
Answer: Left side.
Rationale: Stronger side reduces aspiration risk.
Q19. Early sign of hypoxemia?
Answer: Restlessness.
Rationale: Brain is sensitive to low oxygen.
Q20. Pregnant client with seizures. First action?
Answer: Ensure airway and administer oxygen.
