Nightingale College BSN 215 HESI

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Sample questions from Nightingale College BSN 215 HESI

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.At change of shift on a medical-surgical unit, the charge nurse receives report on four clients. Which client should the nurse assess first?

   • A.A 54-year-old client with diabetes whose blood glucose is 248 mg/dL before breakfast and who is asking for insulin
   • B.A 45-year-old client with pneumonia who has a temperature of 38.1 C and is due for an antipyretic
   • C.A 68-year-old client with heart failure who has new crackles, SpO2 88% on room air, and increased work of breathing
   • D.A 72-year-old client 1 day after hip replacement who reports pain of 7 out of 10 after physical therapy

   Rationale: The client with heart failure has impaired oxygenation and increased work of breathing, requiring immediate assessment and intervention. The elevated glucose, postoperative pain, and fever require timely care but do not take priority over an airway or breathing concern. Use the ABC framework to identify the client at greatest immediate risk.

2. 2.During a home visit, a 76-year-old client with limited mobility says, "I have been taking my blood thinner whenever I remember." The medication list shows warfarin 5 mg daily, and the client reports a recent fall without injury. Which action should the nurse take first?

   • A.Document the client's statement and discuss adherence at the next home visit
   • B.Assess for bleeding and contact the prescribing clinician to report the medication use and fall
   • C.Ask the client to stop warfarin until the next scheduled clinic appointment
   • D.Tell the client to take two tablets today to make up for missed doses

   Rationale: Inconsistent warfarin use and a recent fall create risks for both thromboembolism and bleeding, so the nurse should assess for bleeding and promptly communicate the findings to the prescriber. Doubling a dose can cause dangerous anticoagulation, and independently stopping therapy can increase clot risk. Deferring assessment and communication could delay identification of a serious complication.

3. 3.In a pediatric clinic, a 9-year-old client with asthma is scheduled for discharge after treatment. The client's respiratory rate is 20/min, SpO2 is 97% on room air, and the caregiver demonstrates correct inhaler use. Which task is appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Obtain and record the client's routine discharge weight
   • B.Evaluate whether the caregiver understands the written asthma action plan
   • C.Determine whether the client is ready for discharge
   • D.Teach the client how to use a spacer with the inhaler

   Rationale: Obtaining a routine weight is a predictable task that can be delegated to a UAP, with the nurse retaining responsibility for reviewing the result. Evaluating understanding, teaching inhaler technique, and determining discharge readiness require nursing assessment and judgment. Delegation decisions should match the task's predictability and the delegatee's scope.

4. 4.On a community health visit, a 16-year-old client with type 1 diabetes says they have been skipping insulin because of fear of weight gain. The client is alert, reports increased thirst, and has a blood glucose of 312 mg/dL. Which actions should the nurse take? Select all that apply.

   • A.Assess for symptoms of diabetic ketoacidosis, including nausea, abdominal pain, and deep respirations
   • B.Reassure the client that insulin omission is a safe way to manage weight
   • C.Tell the caregiver to administer extra insulin without consulting the prescribing clinician
   • D.Explore the client's concerns in private using a nonjudgmental approach
   • E.Arrange prompt contact with the diabetes care team and follow the client's sick-day or hyperglycemia plan

   Answer and rationale are in the full material.

5. 5.The provider prescribes a new medication for a 63-year-old client who reports a severe penicillin allergy. The electronic medication record shows that the prescribed antibiotic is in the same drug class as the medication that caused the client's prior reaction. What should the nurse do?

   • A.Give the medication with food to reduce the chance of an allergic response
   • B.Administer the first dose and observe the client closely for a reaction
   • C.Ask the client to sign a refusal form before administering the medication
   • D.Hold the medication and clarify the prescription with the prescriber and pharmacist

   Answer and rationale are in the full material.