Nightingale 261 HESI Latest Version

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Sample questions from Nightingale 261 HESI Latest Version

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 registered nurse receives report on four clients. Which client should the nurse assess first?

   • A.A 72-year-old client 2 days after hip replacement who reports pain of 7/10 after physical therapy
   • B.A 54-year-old client with diabetes who has a blood glucose of 248 mg/dL before breakfast and no symptoms
   • C.A 43-year-old client with a urinary tract infection who has a temperature of 38.1 C and is due for an antibiotic
   • D.A 68-year-old client with pneumonia whose oxygen saturation decreased from 95% to 89% on 2 L/min nasal cannula

   Rationale: The decreasing oxygen saturation despite supplemental oxygen may signal worsening gas exchange and requires immediate assessment. The elevated glucose, postoperative pain, and fever require timely care but are not as immediately threatening based on the information given. The priority is to assess and intervene for a potential airway or breathing problem before addressing stable concerns.

2. 2.During a home visit, a 76-year-old client with heart failure has a blood pressure of 148/84 mm Hg, HR 86/min, RR 18/min, and SpO2 95% on room air. The client reports a 2.3-kg (5-lb) weight gain in 3 days and new ankle swelling. Which actions should the nurse take? Select all that apply.

   • A.Review the client's daily weight record and reinforce when to report weight changes
   • B.Assess the client's medication use and recent dietary sodium intake
   • C.Advise the client to double the prescribed diuretic dose without an order
   • D.Encourage the client to drink extra fluids to reduce the ankle swelling
   • E.Contact the health care provider promptly to report the weight gain and swelling

   Rationale: Assessing medication use and sodium intake helps identify contributors to fluid retention, and the rapid weight gain with new edema warrants prompt provider notification. Reviewing daily weights supports early recognition of worsening heart failure and reinforces self-management. Independently doubling a diuretic is unsafe, and extra fluids may worsen fluid overload.

3. 3.On a postpartum unit, a 26-year-old client who delivered 2 hours ago has a boggy uterus, a large amount of lochia, HR 122/min, and BP 88/54 mm Hg. Which task is appropriate for the registered nurse to delegate to an experienced unlicensed assistive personnel (UAP) while the nurse intervenes?

   • A.Obtain and report the client's vital signs every 5 minutes
   • B.Evaluate the amount of blood loss and determine whether treatment is effective
   • C.Assess the uterine tone and determine whether it is midline
   • D.Massage the fundus until it becomes firm

   Rationale: Obtaining and promptly reporting vital signs is a predictable data-collection task that may be delegated to an experienced UAP. Assessment of uterine tone, fundal massage in an acute hemorrhage, and evaluation of treatment effectiveness require nursing judgment and remain the registered nurse's responsibility. The nurse should not delay direct intervention for postpartum hemorrhage while delegating appropriate support tasks.

4. 4.In a pediatric clinic, the parent of a 9-year-old scheduled for a procedure says, 'I signed the form, but I do not understand what the surgeon plans to do.' The child is alert and asks whether the procedure will hurt. What is the nurse's best action?

   • A.Tell the parent that signing the form means the procedure must proceed
   • B.Explain the procedure's risks and benefits in detail and ask the parent to sign again
   • C.Ask the surgeon to return and clarify the procedure before the child is transported
   • D.Reassure the child that the procedure will not hurt and continue preparation

   Answer and rationale are in the full material.

5. 5.A 16-year-old client arrives at an emergency department with a deep forearm laceration, active bleeding, HR 128/min, and BP 94/60 mm Hg. A family member asks the nurse to wait for the client's parent before treatment. Which action should the nurse take?

   • A.Transfer the client to the waiting area until the legal guardian can be reached
   • B.Begin emergency stabilization and notify the provider while following facility policy
   • C.Delay treatment until a parent arrives to provide consent
   • D.Ask the family member to sign the consent form because the client is a minor

   Answer and rationale are in the full material.