Nightingale BSN 246 HESI V1

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Sample questions from Nightingale BSN 246 HESI V1

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 74-year-old client 1 day after hip arthroplasty who rates incisional pain as 7 on a 0-to-10 scale
   • B.A 68-year-old client with pneumonia whose oxygen saturation decreased from 94% to 88% on 2 L/min by nasal cannula
   • C.A 52-year-old client with diabetes whose premeal blood glucose is 246 mg/dL and who reports thirst
   • D.A 43-year-old client receiving antibiotics who has a temperature of 38.0 C and chills

   Rationale: The client with pneumonia has a new decrease in oxygen saturation despite supplemental oxygen, indicating impaired oxygenation that requires immediate assessment. Hyperglycemia with thirst, postoperative pain, and fever with chills also require follow-up, but none takes precedence over a potential acute respiratory problem. The nurse should assess the client and intervene based on respiratory status before moving to the other clients. Prioritize new, potentially life-threatening changes using airway and breathing needs.

2. 2.During a home visit, a community health nurse learns that an adult client with limited mobility has missed two anticoagulant doses because the medication is difficult to obtain. Which action should the nurse take first?

   • A.Assess the client's current symptoms and determine the exact doses missed
   • B.Document the missed doses and revisit the client in 1 week
   • C.Tell the client to take twice the prescribed dose at the next administration
   • D.Ask the prescriber to discontinue the anticoagulant

   Rationale: The nurse should first assess the client's immediate condition and clarify the medication history to identify potential complications and guide safe follow-up. Discontinuing or doubling an anticoagulant without a prescriber's direction could cause harm. Waiting a week without addressing the access barrier leaves the client at continued risk. After assessment, the nurse should coordinate promptly with the prescriber and appropriate community resources to restore access.

3. 3.Refer to the client's chart. Which actions should the charge nurse take to manage this client's worsening condition? Select all that apply.

   • A.Notify the rapid response team according to facility criteria
   • B.Stay with the client and prepare to implement emergency interventions within the nurse's scope
   • C.Increase the oxygen flow above the prescribed rate without assessing the client or checking the oxygen order
   • D.Immediately assess the client's respiratory status and level of consciousness
   • E.Delegate the initial assessment to the unlicensed assistive personnel

   Rationale: The client's oxygen saturation fell from 95% to 86% on the prescribed oxygen, and the latest note describes new confusion and increased work of breathing; the nurse must immediately assess and remain with the client. Activating the rapid response team is appropriate for this acute deterioration and supports timely escalation. Increasing oxygen without assessment or regard for the prescribed plan is not the first action, and the initial assessment cannot be delegated to unlicensed personnel. The key is to recognize deterioration, assess promptly, and escalate while maintaining immediate nursing oversight.

4. 4.A charge nurse in a long-term care facility is assigning tasks for the morning. Which task is appropriate to delegate to an experienced unlicensed assistive personnel?

   • A.Evaluate whether a resident's pain medication was effective
   • B.Teach a resident how to use a newly prescribed inhaler
   • C.Obtain and record the routine morning weight of a stable resident
   • D.Assess a resident who reports new chest pressure

   Answer and rationale are in the full material.

5. 5.A provider prescribes the first dose of an intravenous antibiotic for a 6-year-old child in the pediatric clinic. The child has a documented allergy to a medication in the same antibiotic class, and the reaction is not described in the record. What should the nurse do?

   • A.Give half the prescribed dose and document the child's response
   • B.Ask the parent to decide whether the medication should be given
   • C.Administer the dose and observe the child for 30 minutes
   • D.Clarify the allergy and prescription with the prescriber before administering the dose

   Answer and rationale are in the full material.