HESI Exit BSN 366 Fall Semester Nightingale Study Guide

Free preview · Original latest version

Sample questions from HESI Exit BSN 366 Fall Semester Nightingale Study Guide

This material has 24 questions with answers and rationales. Here are the first 5.

1. 1.An older adult receiving chemotherapy is admitted with a temperature of 38.7 C (101.7 F), an absolute neutrophil count of 300/mm3, blood pressure of 82/46 mm Hg, heart rate of 128/min, and new confusion. Which nursing action has the highest priority?

   • A.Place the patient on protective precautions and reassess vital signs in 30 minutes.
   • B.Activate the rapid response team and initiate the sepsis protocol, including prescribed IV crystalloid and prompt broad-spectrum antibiotics.
   • C.Administer prescribed acetaminophen and determine whether the confusion improves as the fever decreases.
   • D.Obtain a complete dietary history to identify nutritional causes of impaired immunity.

   Rationale: Fever with severe neutropenia, hypotension, tachycardia, and altered mentation indicates suspected sepsis with impaired perfusion. Rapid escalation, fluid resuscitation, and prompt antibiotics are priorities; cultures should be obtained first if doing so does not delay antibiotics. Protective precautions are appropriate but do not treat shock, and waiting is unsafe. Acetaminophen treats fever rather than the underlying emergency. Nutrition assessment is useful later but cannot take priority over restoring perfusion.

2. 2.An adult with diabetic ketoacidosis has received initial IV isotonic fluid resuscitation. Current laboratory results include glucose 486 mg/dL, potassium 3.0 mEq/L, and bicarbonate 12 mEq/L. The prescription includes a continuous IV regular insulin infusion. What should the nurse do next?

   • A.Start the insulin infusion because correcting hyperglycemia will also correct the potassium deficit.
   • B.Give IV sodium bicarbonate before starting any other medication.
   • C.Withhold potassium replacement until urine ketones become negative.
   • D.Hold the insulin infusion, notify the prescriber, and administer prescribed potassium replacement with cardiac monitoring.

   Rationale: Insulin shifts potassium into cells and can worsen existing hypokalemia, causing life-threatening dysrhythmias. At a potassium level of 3.0 mEq/L, insulin should be delayed while potassium is replaced according to protocol and renal function is assessed. Starting insulin immediately is unsafe. Bicarbonate is not routinely indicated for DKA and can further lower potassium. Waiting for negative urine ketones delays essential electrolyte replacement; urine ketones are not a criterion for starting potassium.

3. 3.Thirty minutes after a vaginal birth, a patient has heavy vaginal bleeding. The uterus is boggy and above the umbilicus. Blood pressure is 92/54 mm Hg and heart rate is 118/min. While another nurse activates the obstetric hemorrhage response and obtains prescribed uterotonic medication, what should the bedside nurse do first?

   • A.Massage the uterine fundus while assessing its response.
   • B.Assist the patient to walk to the bathroom to empty the bladder.
   • C.Wait for the hemoglobin result before initiating further interventions.
   • D.Place a warm compress over the lower abdomen to relieve uterine discomfort.

   Rationale: A boggy uterus with heavy postpartum bleeding suggests uterine atony. Immediate fundal massage promotes contraction and helps reduce blood loss while the team prepares additional hemorrhage treatment. Bladder emptying may help uterine contraction, but an unstable patient should not ambulate; catheterization may be appropriate after immediate measures begin. Treatment must not wait for hemoglobin, which may initially underestimate acute blood loss. A warm compress does not correct atony and delays effective treatment.

4. 4.A 4-year-old child arrives in the emergency department with a high fever, drooling, a muffled voice, and inspiratory stridor. The child sits leaning forward and becomes distressed when approached. Which action is most appropriate?

   • A.Use a tongue depressor to inspect the pharynx for swelling.
   • B.Place the child supine and restrain the arms to obtain a throat culture.
   • C.Keep the child upright with the caregiver, minimize agitation, and immediately summon the airway team.
   • D.Offer small sips of cool water to determine whether the child can swallow safely.

   Answer and rationale are in the full material.

5. 5.An RN is caring for a patient admitted after an ischemic stroke. The patient is alert but has left-sided weakness and coughed during the initial swallowing screen. Which task is appropriate to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Repeat the swallowing screen using thickened liquids.
   • B.Measure and record urine output and report the amount to the RN.
   • C.Teach the family how to use a chin-tuck swallowing technique.
   • D.Evaluate whether the patient's weakness has improved since admission.

   Answer and rationale are in the full material.