Nightingale BSN 225 HESI

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Sample questions from Nightingale BSN 225 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 29-year-old with a urinary tract infection who has a temperature of 38.1 C and is due for an antibiotic
   • B.A 68-year-old with pneumonia whose SpO2 decreased from 95% to 89% on 2 L/min oxygen and who is newly confused
   • C.A 72-year-old with chronic back pain who requests the prescribed analgesic
   • D.A 45-year-old scheduled for discharge who needs instructions about a new low-sodium diet

   Rationale: The client with pneumonia has worsening oxygenation and new confusion, cues of impaired gas exchange that require immediate assessment and intervention. Discharge teaching and pain management are important but can wait until the acute change is evaluated. The client with a fever needs timely antibiotic administration, but the declining oxygen saturation and altered mental status indicate the greatest immediate threat. Prioritize unstable airway and breathing concerns over stable needs.

2. 2.During a home visit, a 76-year-old client with heart failure reports taking twice the prescribed dose of furosemide because of increased ankle swelling. The client is dizzy when standing; BP is 94/58 mm Hg, HR is 108/min, and the medication list includes digoxin. What should the nurse do first?

   • A.Tell the client to take the usual furosemide dose tomorrow and call the prescriber next week
   • B.Remove digoxin from the medication list because it interacts with furosemide
   • C.Recommend increasing fluid intake to 3 L per day without contacting the prescriber
   • D.Ask the client to sit or lie down and assess for signs of volume depletion and digoxin toxicity

   Rationale: Dizziness with hypotension and tachycardia after doubling a diuretic raises concern for volume depletion and possible electrolyte-related digoxin toxicity, so preventing a fall and assessing the client are immediate priorities. The nurse should then promptly contact the prescriber with the findings and medication history. Delaying notification or independently recommending a high fluid intake is unsafe, and furosemide and digoxin are not automatically incompatible. Medication reconciliation and focused assessment support safe coordination of care.

3. 3.In a pediatric clinic, a 10-year-old with type 1 diabetes is being discharged after treatment for mild hypoglycemia. The parent says they are unsure how to respond if the child becomes confused at school. Which instructions should the nurse include? Select all that apply.

   • A.Tell school staff to give oral glucose only when the child is awake and able to swallow safely
   • B.Wait for the next routine clinic appointment before reporting repeated hypoglycemic episodes
   • C.Give food or fluid by mouth if the child is unconscious, as long as a small amount is used
   • D.Keep the prescribed glucagon available and teach designated caregivers how to use it
   • E.After treating a conscious child's low blood glucose, recheck the glucose according to the child's care plan

   Rationale: Oral glucose is appropriate only when the child is alert enough to swallow, and follow-up glucose checks help determine whether treatment worked. Glucagon should be accessible, and school caregivers should know how to administer it for severe hypoglycemia when oral treatment is unsafe. Giving anything by mouth to an unconscious child risks aspiration. Repeated episodes should be reported promptly to the diabetes care team so the plan can be reassessed.

4. 4.A provider prescribes a first dose of an intravenous antibiotic for a 34-year-old client with cellulitis in an outpatient infusion clinic. The client reports a previous severe reaction to a related antibiotic, including throat swelling and difficulty breathing. What is the nurse's best action?

   • A.Ask the client to sign a waiver acknowledging the allergy risk
   • B.Give an antihistamine and then administer the antibiotic as prescribed
   • C.Hold the dose and clarify the prescription with the provider before administration
   • D.Administer the medication slowly while remaining at the bedside

   Answer and rationale are in the full material.

5. 5.In a long-term care facility, an 82-year-old resident with dementia becomes restless, pulls at the intravenous tubing, and attempts to climb out of bed. The resident is afebrile, HR is 96/min, and the call light is within reach. Which action should the nurse take first?

   • A.Assess for unmet needs and reversible causes of the new behavior
   • B.Ask the family to stay continuously so staff can complete other tasks
   • C.Request a sedative prescription before approaching the resident
   • D.Apply wrist restraints to protect the intravenous catheter

   Answer and rationale are in the full material.