BSN315 HESI

Free preview · Original latest version

Sample questions from BSN315 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 nurse receives report on four clients. Which client should the nurse assess first?

   • A.A 68-year-old who is 1 day postoperative and reports incisional pain of 7 out of 10
   • B.A 76-year-old with diabetes whose premeal blood glucose is 212 mg/dL
   • C.A 42-year-old awaiting discharge who needs clarification about a new prescription
   • D.A 54-year-old with pneumonia whose oxygen saturation decreased from 94% to 88% on 2 L/min by nasal cannula

   Rationale: The client with pneumonia has worsening oxygenation despite supplemental oxygen, an immediate threat to breathing that requires prompt assessment and intervention. Pain, discharge teaching, and a moderately elevated glucose also need attention but are less urgent in the absence of additional instability. Prioritize changes in airway, breathing, and circulation over routine care and planning.

2. 2.In a long-term care facility, a 79-year-old resident with stable osteoarthritis needs assistance with morning care. Which task is appropriate for the registered nurse to delegate to an unlicensed assistive personnel (UAP)?

   • A.Evaluate whether the analgesic relieved the resident's pain
   • B.Assist the resident with bathing and report any new skin changes
   • C.Teach the resident how to use a newly prescribed walker
   • D.Assess the resident's pain after the prescribed analgesic is given

   Rationale: Bathing is a routine task for a stable resident, and the UAP can report observations such as new skin changes to the RN. Pain assessment, teaching, and evaluation of medication effectiveness require nursing judgment and remain the RN's responsibility. Delegate tasks, not assessment, teaching, or evaluation.

3. 3.During a home visit, a 71-year-old client with heart failure says, "I am more short of breath than usual." The client has new ankle edema and has gained 2.3 kg (5 lb) in 3 days. Which actions should the nurse take? Select all that apply.

   • A.Assess respiratory effort, lung sounds, and oxygen saturation
   • B.Advise the client to wait a week and recheck weight if symptoms persist
   • C.Contact the client's health care provider to report the findings
   • D.Review the prescribed daily-weight plan and when to report weight gain
   • E.Reconcile the client's medications and ask about missed doses
   • F.Tell the client to increase fluid intake to prevent dehydration

   Rationale: Assessing respiratory status helps determine the urgency of the client's worsening dyspnea, and medication reconciliation can identify missed doses or other contributors. The rapid weight gain, edema, and increased shortness of breath warrant prompt communication with the provider and reinforcement of the prescribed daily-weight reporting plan. Increasing fluids without an order may worsen fluid overload, and waiting a week delays needed evaluation.

4. 4.A provider prescribes an elective procedure for a 16-year-old client. The client says, "I do not understand what the procedure involves, and I do not want it." Which action should the nurse take?

   • A.Explain the procedure in detail and obtain the client's signature
   • B.Document the client's statement and continue the preoperative checklist
   • C.Pause the preparation and notify the provider that the client needs further discussion
   • D.Ask the parent to sign the consent form so the procedure can proceed

   Answer and rationale are in the full material.

5. 5.In the emergency department, a 3-year-old with a fever and a new generalized seizure arrives with a parent. The child is now drowsy but breathing spontaneously; oxygen saturation is 95% on room air. Which nursing action has priority?

   • A.Position the child on the side and maintain a patent airway
   • B.Obtain a detailed history of the child's immunizations
   • C.Ask the parent to describe the events leading up to the seizure
   • D.Prepare discharge teaching about fever management

   Answer and rationale are in the full material.