Nightingale BSN 246 HESI

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Sample questions from Nightingale BSN 246 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, a nurse receives report on four clients. Which client should the nurse assess first?

   • A.A 68-year-old with chronic heart failure who has gained 1 kg (2.2 lb) in 3 days and has 1+ ankle edema
   • B.A 54-year-old 2 hours after thyroidectomy who has new inspiratory stridor and an oxygen saturation of 88% on room air
   • C.A 42-year-old with diabetes whose premeal glucose is 246 mg/dL and who reports thirst
   • D.A 77-year-old with a urinary tract infection who has a temperature of 38.1 C (100.6 F) and is receiving antibiotics

   Rationale: New stridor and hypoxemia after thyroid surgery suggest airway obstruction, which can rapidly become fatal and takes priority under the ABC framework. The heart failure client needs assessment for fluid overload, but the reported findings do not indicate immediate respiratory compromise. Hyperglycemia with thirst and a fever during treatment also require follow-up, but neither is as urgent as a threatened airway. Assess the postoperative client and initiate emergency airway support according to protocol.

2. 2.During a home visit, a 76-year-old client with limited mobility is preparing for discharge after a stroke. The client has mild right-sided weakness and takes an anticoagulant. Which actions should the nurse take to reduce preventable harm at home? Select all that apply.

   • A.Teach the client to use a medication organizer only after the regimen is reconciled with the prescriber or pharmacist.
   • B.Discuss use of an assistive device and a plan for supervised mobility.
   • C.Recommend that the client walk unassisted to build strength as quickly as possible.
   • D.Arrange a home safety assessment and remove loose rugs from walking paths.
   • E.Confirm that frequently used items are placed within easy reach.
   • F.Teach the client to stop the anticoagulant if a minor bruise appears.

   Rationale: Removing loose rugs, placing needed items within reach, and planning supervised mobility with an appropriate device reduce fall risk for a client with weakness. Medication reconciliation before using an organizer helps prevent errors, especially with a high-risk anticoagulant. Unassisted walking increases the risk of a fall, and the client should not stop an anticoagulant for a minor bruise without contacting the prescriber. Fall prevention and medication safety should be addressed together during discharge planning.

3. 3.A provider prescribes IV potassium chloride for a 19-year-old client with a potassium level of 2.9 mEq/L. Before administration, which action is most important for the nurse to take?

   • A.Verify that the medication will be diluted and administered using an infusion pump.
   • B.Hold the medication until the client reports muscle weakness.
   • C.Ask the client to increase oral fluids before starting the infusion.
   • D.Administer the medication by slow IV push to correct the level promptly.

   Rationale: IV potassium must be diluted and infused at a controlled rate using an infusion pump because rapid administration can cause fatal dysrhythmias. Potassium is never administered by IV push, making that option unsafe. Oral fluids do not replace the required administration safeguards, and waiting for symptoms is inappropriate when a low laboratory value has prompted a prescription. Verify the prescription, concentration, access, and monitoring requirements before starting the infusion.

4. 4.In a pediatric clinic, a 6-year-old with a new prescription for an oral antibiotic is ready to leave with a caregiver. Which action best evaluates whether the caregiver can safely administer the medication?

   • A.Provide a printed medication handout and ask the caregiver to read it at home.
   • B.Ask the caregiver whether the medication has been given to another child before.
   • C.Ask the caregiver to repeat the medication's purpose.
   • D.Have the caregiver demonstrate measuring the prescribed dose with an oral syringe.

   Answer and rationale are in the full material.

5. 5.Refer to the client's chart. Which actions should the charge nurse take in response to the changes documented for the 13-year-old client? Select all that apply.

   • A.Review the medication administration record and report the recent opioid dose during escalation.
   • B.Reassess the client promptly and obtain a focused neurologic assessment.
   • C.Wait until the next scheduled vital-sign check because the client is resting.
   • D.Delegate reassessment of the client's neurologic status to unlicensed assistive personnel.
   • E.Notify the rapid response team or follow the facility's escalation protocol.

   Answer and rationale are in the full material.