HESI BSN 246

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Sample questions from HESI BSN 246

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

1. 1.A 72-year-old client admitted with pneumonia has a temperature of 39.1 C (102.4 F), respirations of 30/min, blood pressure of 86/48 mm Hg, and new confusion. Which action should the nurse take first?

   • A.Reorient the client and dim the room lights.
   • B.Activate the rapid response team and initiate the sepsis protocol.
   • C.Administer the prescribed acetaminophen.
   • D.Obtain a sputum specimen before starting treatment.

   Rationale: Hypotension, tachypnea, fever, and acute confusion suggest sepsis with impaired perfusion, so urgent escalation and protocol-based treatment are needed. Acetaminophen may reduce fever but does not address shock. A sputum specimen is useful, but obtaining it must not delay urgent stabilization. Reorientation does not treat the underlying deterioration.

2. 2.A 68-year-old client admitted with heart failure is being discharged with a new prescription for furosemide. Which instructions should the nurse include? Select all that apply.

   • A.Report new muscle weakness or palpitations to the clinician.
   • B.Change position slowly if you feel lightheaded.
   • C.Stop the medication once your ankle swelling improves.
   • D.Weigh yourself each morning after urinating, using the same scale.
   • E.Take the medication at bedtime to avoid daytime urination.

   Rationale: Daily weights under consistent conditions help identify fluid retention early. Bedtime dosing can cause disruptive nighttime urination, so a morning dose is generally more practical unless prescribed otherwise. Muscle weakness or palpitations can signal electrolyte disturbance and should be reported. Rising slowly can reduce orthostatic symptoms. Stopping the medication when swelling improves can lead to recurrent fluid overload.

3. 3.A charge nurse on a medical-surgical unit is assigning clients to an experienced registered nurse. Which client is most appropriate for the assignment?

   • A.A client with a rapidly falling oxygen saturation despite supplemental oxygen.
   • B.A client with new chest pain and diaphoresis requiring immediate evaluation.
   • C.A stable client returning from surgery who needs routine postoperative assessments.
   • D.A client with a new seizure who has not regained consciousness.

   Rationale: A stable postoperative client requiring routine assessment is an appropriate assignment for an experienced nurse. New chest pain with diaphoresis requires immediate assessment and likely rapid escalation. Falling oxygen saturation despite oxygen indicates acute deterioration. A client who has not regained consciousness after a seizure also requires urgent evaluation and close monitoring.

4. 4.A nurse on a medical unit is delegating care for a stable 76-year-old client who needs assistance with bathing and ambulation. Which task is appropriate to delegate to an unlicensed assistive personnel (UAP)?

   • A.Assist the client with bathing and report any new shortness of breath.
   • B.Teach the client how to use a walker on stairs.
   • C.Evaluate the client's response to a newly prescribed pain medication.
   • D.Assess whether the client's gait is safe after a recent fall.

   Answer and rationale are in the full material.

5. 5.A 64-year-old client is scheduled for an elective procedure at an ambulatory surgery center. The client says, "I signed the consent, but I do not understand what the surgeon plans to do." What should the nurse do?

   • A.Explain the procedure in detail and ask the client to proceed.
   • B.Witness the signature again so the consent is valid.
   • C.Ask a family member to explain the procedure to the client.
   • D.Pause the preparation and notify the surgeon that the client needs further explanation.

   Answer and rationale are in the full material.