BSN 266 HESI Nightingale

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Sample questions from BSN 266 HESI Nightingale

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

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

   • A.A 68-year-old with pneumonia whose SpO2 decreased from 94% to 88% on 2 L/min oxygen
   • B.A 72-year-old awaiting discharge instructions for a new antihypertensive
   • C.A 50-year-old reporting incisional pain of 6/10 one hour after analgesia
   • D.A 45-year-old requesting assistance to the bathroom after receiving a diuretic

   Rationale: The decreasing oxygen saturation despite supplemental oxygen indicates worsening gas exchange and requires immediate assessment. The other clients have needs that can be addressed after the respiratory concern is evaluated. Prioritize acute threats to airway and breathing.

2. 2.During a home health visit, a client with heart failure says, "I stopped taking my water pill because it makes me urinate too much." The client has gained 2 kg (4.4 lb) in 3 days and has new ankle edema. What is the nurse's priority action?

   • A.Recommend limiting fluid intake to 500 mL daily
   • B.Schedule a routine follow-up visit in 1 month
   • C.Instruct the client to take two doses of the diuretic today
   • D.Notify the prescribing provider of the weight gain and medication interruption

   Rationale: Rapid weight gain and new edema suggest fluid retention, and the provider needs to review the client's worsening heart failure and medication barrier. Doubling a dose or imposing severe fluid restriction without an order may cause harm. Timely escalation is safer than delaying follow-up.

3. 3.Refer to the client's chart. Which actions should the nurse take now for this client with suspected sepsis? Select all that apply.

   • A.Administer the prescribed broad-spectrum antibiotic promptly
   • B.Reassess blood pressure, mental status, urine output, and perfusion frequently
   • C.Notify the provider that the client's blood pressure and lactate are worsening
   • D.Obtain the ordered blood cultures before the first antibiotic dose if this does not delay treatment
   • E.Wait for the culture results before starting antimicrobial therapy

   Rationale: The client has fever, tachycardia, hypotension, altered mentation, and elevated lactate, so rapid sepsis treatment and close reassessment are indicated. Cultures should be obtained first when feasible, but antibiotics must not be delayed while waiting for results. Reporting the worsening perfusion findings supports timely treatment.

4. 4.In a rehabilitation unit, an RN is assigning care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task is appropriate for the RN to delegate to the UAP?

   • A.Teach a client how to use an incentive spirometer
   • B.Assess a new report of calf pain after surgery
   • C.Obtain routine vital signs for a stable client 2 days after surgery
   • D.Evaluate whether an analgesic relieved a client's pain

   Answer and rationale are in the full material.

5. 5.A provider prescribes a medication dose that is ten times higher than the dose listed in the client's medication history. What should the nurse do first?

   • A.Ask another nurse to administer the prescribed dose
   • B.Hold the dose and clarify the prescription with the provider
   • C.Change the dose to match the medication history
   • D.Give the dose and monitor for adverse effects

   Answer and rationale are in the full material.