Nightingale BSN 315 HESI

Free preview · Original latest version

Sample questions from Nightingale BSN 315 HESI

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

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

   • A.A 7-year-old with asthma who has new suprasternal retractions and can speak only one word at a time
   • B.A 14-year-old with a fractured wrist who reports pain of 8 on a 0-to-10 scale
   • C.A 17-year-old awaiting discharge whose parent requests medication instructions
   • D.A 4-year-old with a temperature of 38.2 C (100.8 F) who is drinking juice and watching a video

   Rationale: The 7-year-old has signs of worsening respiratory distress and needs immediate assessment and intervention to protect airway and breathing. The child with fever is currently drinking and engaged, suggesting no immediate instability; the wrist fracture requires timely pain management but is not the first priority. Discharge teaching can wait until the unstable client is addressed. Prioritize acute threats to airway and breathing over pain and routine teaching.

2. 2.In a home health visit, a nurse plans care for a 67-year-old client with heart failure who has stable vital signs and needs assistance with bathing and daily weights. Which task is appropriate to delegate to an unlicensed assistive personnel (UAP)?

   • A.Assess the client's lung sounds before assisting with the bath
   • B.Determine whether the client's edema has increased since yesterday
   • C.Obtain and record the client's weight using the same scale
   • D.Teach the client how to recognize worsening heart failure

   Rationale: Obtaining and recording a routine weight is a predictable task that can be delegated to a UAP when the nurse provides clear instructions. Lung assessment, teaching, and evaluating a change in edema require nursing judgment and remain the nurse's responsibility. The nurse should review the recorded weight and respond to concerning changes. Delegate tasks, not assessment, teaching, or evaluation.

3. 3.During a home visit, the parent of a 2-year-old recovering from gastroenteritis reports that the child has had three wet diapers today and is less active than usual. The child has dry lips and a capillary refill time of 3 seconds; temperature is 37.4 C, HR 132/min, RR 28/min, and BP 88/54 mm Hg. Which actions should the nurse take? Select all that apply.

   • A.Assess the child's level of alertness and ability to drink
   • B.Advise the parent to give small, frequent amounts of oral rehydration solution if the child can drink
   • C.Document the findings and schedule a routine visit in one week
   • D.Recommend giving a large volume of plain water quickly
   • E.Arrange prompt medical evaluation for possible dehydration

   Rationale: Assessing alertness and ability to drink helps identify the severity of dehydration and whether oral fluids are appropriate. Reduced urine output, dry lips, delayed capillary refill, and decreased activity warrant prompt medical evaluation. Small, frequent amounts of oral rehydration solution can replace fluid and electrolytes when the child is alert and able to drink. A large amount of plain water does not provide appropriate electrolyte replacement, and delaying evaluation for a week is unsafe.

4. 4.In the operating room, a 42-year-old client scheduled for a left-sided procedure says, "I thought the surgery was on my right side." The consent form and the site mark indicate the left side. What should the circulating nurse do?

   • A.Proceed because the signed consent and site mark agree
   • B.Ask the client to sign a corrected consent form before anesthesia is administered
   • C.Ask the client's family to confirm which side the client discussed during the office visit
   • D.Pause the procedure and notify the surgeon to resolve the discrepancy

   Answer and rationale are in the full material.

5. 5.At 0900 in an outpatient clinic, a 23-year-old client tells the nurse that a newly prescribed medication causes facial swelling and difficulty breathing. The client is alert; HR is 118/min, RR is 26/min, BP is 92/58 mm Hg, and SpO2 is 91% on room air. Which action should the nurse take first?

   • A.Call the prescribing provider to ask whether the medication should be discontinued
   • B.Activate emergency response and support the client's airway and breathing
   • C.Teach the client to avoid taking the next dose until the follow-up appointment
   • D.Ask the client to complete the medication reaction form

   Answer and rationale are in the full material.