BSN 266 HESI

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Sample questions from BSN 266 HESI

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

1. 1.A 68-year-old client in the emergency department reports crushing chest pressure for 40 minutes. The client is pale and diaphoretic, with BP 92/58 mm Hg, HR 112/min, RR 24/min, and SpO2 95% on room air. The ECG shows ST elevation in leads II, III, and aVF. Which action should the nurse prioritize?

   • A.Administer sublingual nitroglycerin for chest pain.
   • B.Activate the STEMI response and prepare for emergency reperfusion.
   • C.Apply oxygen at 6 L/min by nasal cannula.
   • D.Wait for the troponin result before notifying cardiology.

   Rationale: ST elevation with ischemic symptoms requires immediate activation of the reperfusion pathway. Nitroglycerin can worsen this client's hypotension, especially if right ventricular involvement is present. Supplemental oxygen is not routinely needed at an SpO2 of 95%, and waiting for troponin delays treatment of an ECG-confirmed emergency. The priority is restoring coronary blood flow without waiting for additional confirmation.

2. 2.A 72-year-old client on a medical unit suddenly develops severe dyspnea and pink, frothy sputum. Findings include diffuse crackles, BP 184/98 mm Hg, HR 118/min, RR 32/min, and SpO2 82% on room air. While another nurse activates the rapid response team, which action should the nurse take first?

   • A.Place the client supine and elevate the legs.
   • B.Administer the scheduled oral beta blocker.
   • C.Sit the client upright and begin supplemental oxygen.
   • D.Obtain a daily weight before administering medication.

   Rationale: Upright positioning and supplemental oxygen immediately support breathing during acute pulmonary edema. Supine positioning with elevated legs can worsen pulmonary congestion. An oral beta blocker and daily weight do not address the immediate threat of severe hypoxemia. Stabilize oxygenation before completing routine assessment and medication tasks.

3. 3.A 64-year-old client hospitalized with pneumonia becomes confused. Temperature is 39.2 C, BP 82/46 mm Hg, HR 124/min, RR 30/min, and lactate is 4.8 mmol/L. The nurse activates the sepsis protocol. Which prescribed intervention should the nurse initiate immediately to address impaired perfusion?

   • A.Begin a rapid IV balanced crystalloid infusion with frequent reassessment.
   • B.Administer acetaminophen and reassess the temperature in one hour.
   • C.Restrict fluids until a central venous catheter is inserted.
   • D.Collect a sputum specimen before beginning circulatory support.

   Rationale: Hypotension, altered mentation, and elevated lactate indicate sepsis-associated hypoperfusion requiring prompt crystalloid resuscitation. Acetaminophen treats fever but does not restore circulating volume. Fluids should not wait for central access, and sputum collection must not delay stabilization. Treat perfusion urgently while cultures, antimicrobials, and other sepsis measures proceed.

4. 4.A 70-year-old client arrives at a stroke center 75 minutes after sudden right arm weakness and difficulty speaking. BP is 176/94 mm Hg, glucose is 108 mg/dL, and a noncontrast head CT shows no bleeding. Medication reconciliation identifies apixaban taken three hours earlier. Which finding requires immediate communication before IV thrombolytic therapy is considered?

   • A.The blood pressure of 176/94 mm Hg.
   • B.The symptom duration of 75 minutes.
   • C.The normal serum glucose.
   • D.The recent apixaban dose.

   Answer and rationale are in the full material.

5. 5.A 45-year-old client in the ICU has a traumatic brain injury. Over 30 minutes, the Glasgow Coma Scale score decreases from 13 to 9, the right pupil becomes dilated, BP rises to 178/62 mm Hg, and HR falls to 48/min. While emergency assistance is summoned, which action is most appropriate?

   • A.Lower the head of the bed to improve cerebral blood flow.
   • B.Elevate the head of the bed about 30 degrees and maintain neutral neck alignment.
   • C.Perform repeated deep suctioning to stimulate a cough.
   • D.Flex the client's hips to reduce restlessness.

   Answer and rationale are in the full material.