BSN 266 HESI Exam

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Sample questions from BSN 266 HESI Exam

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

1. 1.At change of shift on a surgical unit, a 68-year-old client's condition has changed. Refer to the client's chart. Which action should the nurse take first?

   • A.Reassess the blood pressure in 30 minutes.
   • B.Activate the rapid response team.
   • C.Encourage oral fluids.
   • D.Administer the prescribed as-needed analgesic.

   Rationale: The blood pressure decrease to 86/50 mm Hg, heart rate increase to 124/min, new confusion, and increasing bloody drainage indicate possible hemorrhagic shock requiring immediate escalation. Analgesia does not address impaired perfusion, and waiting 30 minutes delays emergency treatment. Oral fluids are inadequate for shock and may be unsafe if urgent surgery is needed.

2. 2.On a rehabilitation unit, a 72-year-old client recovering from a stroke has stable vital signs and an established mobility plan. Which task is appropriate for the RN to delegate to experienced unlicensed assistive personnel (UAP)?

   • A.Assist the client with ambulation using the prescribed walker.
   • B.Evaluate whether the client's gait has improved.
   • C.Teach the client how to transfer without assistance.
   • D.Determine whether the client needs a different assistive device.

   Rationale: Assisting a stable client with an established ambulation plan is a routine task that can be delegated to competent UAP. Evaluating gait and determining equipment needs require clinical judgment. Initial transfer teaching is an RN responsibility; delegation transfers task performance, not assessment or evaluation.

3. 3.During discharge planning, a 59-year-old client with newly prescribed insulin says, 'I cannot afford these supplies, and I cannot read the small print.' Glucose is 186 mg/dL, and the client lives alone. Which actions should the nurse take? Select all that apply.

   • A.Document that the client is nonadherent before exploring barriers.
   • B.Provide large-print instructions and verify understanding.
   • C.Ask the client to demonstrate glucose testing and insulin administration.
   • D.Recommend omitting insulin whenever food is unavailable.
   • E.Ask a case manager to identify affordable medication resources.

   Rationale: Case management can address cost barriers, and large-print instructions accommodate the client's stated visual limitation. Return demonstration verifies the ability to safely perform essential skills rather than assuming comprehension. Advising insulin omission without an individualized plan can cause dangerous hyperglycemia. Labeling the client nonadherent before assessing barriers is inaccurate and undermines client-centered planning.

4. 4.In the preoperative holding area, a 46-year-old client scheduled for a hysterectomy says, 'I signed the form, but I still do not know whether I will be able to have children.' No sedating medication has been given. What should the nurse do next?

   • A.Explain the procedure fully and obtain another signature.
   • B.Proceed because the signed form establishes consent.
   • C.Pause preparation and notify the surgeon of the client's question.
   • D.Ask the client's spouse to confirm agreement with surgery.

   Answer and rationale are in the full material.

5. 5.A daughter asks the hospice nurse to call emergency services when her 81-year-old father stops breathing at home. His valid portable medical order specifies no cardiopulmonary resuscitation, and his previously expressed wishes are documented. Which response is appropriate?

   • A.Ask the daughter to sign a new order canceling resuscitation.
   • B.Begin chest compressions until the daughter feels ready to stop.
   • C.Start resuscitation because family requests override prior orders.
   • D.Honor the medical order and provide support to the daughter.

   Answer and rationale are in the full material.