BSN 246 Nightingale HESI

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Sample questions from BSN 246 Nightingale 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 charge nurse assess first?

   • A.A 54-year-old client with diabetes whose blood glucose is 248 mg/dL and who is due for scheduled insulin
   • B.A 73-year-old client 1 day after hip replacement who reports pain of 7/10 after physical therapy
   • C.A 42-year-old client with pneumonia who has a temperature of 38.1 C and is due for an antibiotic
   • D.A 68-year-old client with heart failure who has new confusion, oxygen saturation of 88% on room air, and crackles halfway up both lung fields

   Rationale: New confusion, hypoxemia, and worsening crackles suggest acute respiratory compromise and require immediate assessment and intervention. The client with pneumonia needs timely antibiotic administration, but the reported fever alone does not indicate a more immediate threat. The elevated glucose and postoperative pain require follow-up, but neither takes priority over impaired oxygenation. Prioritize an unstable change in airway or breathing over scheduled care and expected symptoms.

2. 2.In a pediatric clinic, a 7-year-old with a new seizure disorder is prescribed phenytoin. The parent reports difficulty measuring liquid doses and says the child sometimes spits out the medication. Which action should the nurse take first?

   • A.Ask the parent to demonstrate how the dose is measured and administered
   • B.Teach the parent to give an extra dose when medication is spit out
   • C.Request a change to a chewable formulation before the next dose
   • D.Arrange for the school nurse to administer every dose

   Rationale: First assess the specific administration problem by having the parent demonstrate the technique; this identifies whether the issue is measurement, administration, or adherence. A different formulation may help but should follow assessment and prescriber consultation. Giving an extra dose without knowing how much was swallowed risks toxicity, particularly with a narrow-therapeutic-index medication. School administration does not address doses given at home.

3. 3.During a home visit, a 79-year-old client with heart failure and chronic kidney disease reports taking warfarin and digoxin. The client has new nausea and yellow-green vision; apical pulse is 52/min, and the medication organizer contains both drugs in the wrong day compartments. Which actions should the nurse take? Select all that apply.

   • A.Have the client take the misplaced warfarin doses now to restore the schedule
   • B.Check the most recent digoxin level, potassium, and renal function results
   • C.Ask the client to independently reorganize the medications and continue the current regimen
   • D.Withhold the next digoxin dose and promptly contact the prescribing clinician
   • E.Assess for bleeding and verify the latest INR before advising about warfarin

   Rationale: Bradycardia, nausea, and altered color vision are concerning for digoxin toxicity, so the dose should be held and the prescriber notified. Checking digoxin concentration, potassium, and renal function helps evaluate toxicity risk, which is increased by impaired renal clearance and electrolyte changes. Warfarin should not be doubled or rescheduled without verifying the dose history and INR; assessing for bleeding and obtaining the INR are appropriate. Having the client continue independently ignores the demonstrated medication-management problem and current toxicity cues.

4. 4.On a postpartum unit, a 29-year-old client 2 hours after a vaginal birth has a boggy uterus and heavy lochia. The experienced UAP is obtaining vital signs while the nurse is assisting another client. Which task is appropriate for the nurse to delegate to the UAP?

   • A.Ask the UAP to massage the fundus until it becomes firm
   • B.Ask the UAP to assess the amount and cause of the bleeding
   • C.Ask the UAP to report the client's current vital signs immediately and remain available for repeat measurements
   • D.Ask the UAP to decide whether the client needs emergency treatment

   Answer and rationale are in the full material.

5. 5.The provider prescribes a continuous heparin infusion for a 63-year-old client with a newly diagnosed pulmonary embolism. The prescription specifies a bolus and infusion rate, but the electronic medication record shows a different bolus dose. The client is hemodynamically stable. What should the nurse do?

   • A.Ask another nurse to select the dose that best matches the protocol
   • B.Pause administration and clarify the discrepancy with the prescriber before giving the bolus
   • C.Administer the lower bolus dose because it presents less bleeding risk
   • D.Begin the infusion at the prescribed rate and clarify the bolus afterward

   Answer and rationale are in the full material.