BSN 266 HESI V1 Exam | 140 Questions with
Verified Answers | Latest 2024/2025 Grade A+
1. A client who underwent cardiac stent placement four days ago arrives to the
emergency department reporting a sudden onset of chest pressure and shortness of
breath. Which action should the nurse take next?
a. Listen for extra heart sounds, murmurs, and rhythm with the bell of the
stethoscope.
b. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting
edema.
c. Verify troponin level assessments are scheduled every 3-6 hours for a series of
three.
d. Obtain a 12-lead electrocardiogram and begin continuous cardiac
monitoring.
*Explanation: Sudden chest pressure and shortness of breath after stent placement
suggest possible stent thrombosis or acute myocardial infarction. The priority is to
obtain a 12-lead ECG and initiate continuous cardiac monitoring to assess for
ischemic changes and guide immediate intervention.*
2. A client with chronic heart failure reports a weight gain of 3 pounds in 24 hours
and increased dyspnea. Which action should the nurse take first?
a. Encourage the client to restrict oral fluids to 1 liter per day.
b. Auscultate lung sounds for crackles or wheezes.
c. Assess for jugular vein distention and peripheral edema.
d. Administer a prescribed PRN dose of furosemide.
Explanation: The nurse should first assess for signs of fluid overload, including
jugular vein distention and peripheral edema, to confirm worsening heart failure
before implementing interventions such as diuretic administration or fluid
restriction.
3. A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of
weakness and palpitations. Which finding should the nurse recognize as a possible
complication?
,a. anxiety and sighing
b. myalgia in wrists and hands
c. hyperactive bowel sounds
d. dark yellow urine
Explanation: Dark yellow urine may indicate dehydration, which is a common
complication in clients with diabetes mellitus due to hyperglycemia-induced
osmotic diuresis. Weakness and palpitations can be related to electrolyte
imbalances from dehydration.
4. While completing a health assessment for a client with migraine headaches, the
nurse assesses bilateral weakness in the clients hand grips. The client reports joint
pain and trouble twisting a door knob due to weaknesses. Which action should the
nurses take in response to these figures?
a. Implement fall precautions to reduce the clients risk of injury.
b. Explain that relief of the migraine pain will reduce related symptoms.
c. Gather additional assessment data about the pain and weakness.
d. Consult with the occupational therapist for a functional assessment.
Explanation: The nurse should gather additional assessment data about the pain
and weakness to better understand the client's condition and to determine if there
is an underlying issue or if the symptoms are related to the migraine headaches.
5. A client who has developed acute kidney injury (AKI) due to aminoglycoside
antibiotics has moved from the oliguric phase to the diuretic phase of AKI. Which
parameters are most important for the nurse to plan to carefully monitor?
a. Uremic irritation of mucous membranes and skin surfaces.
b. Hypovolemia and electrocardiographic (ECG) changes.
c. Side effects of total parental nutrition (TPN) and Intralipids.
d. Elevated creatinine and blood urea nitrogen (BUN).
Explanation: During the diuretic phase of AKI, the client may experience
increased urine output, which can lead to hypovolemia and electrolyte imbalances.
Monitoring for hypovolemia and ECG changes can help detect any complications
or worsening of the client's condition.
,6. The nurse is caring for a client diagnosed with psoriasis vulgaris who is
receiving psoralen and ultraviolet A light (PUVA) treatment. Which assessment
finding indicates that the client has been overexposed to the treatment?
a. Thick skin plaques topped by silvery white scales
b. Tenderness upon palpation and generalized erythema
c. Brown, rough, greasy, wart-like papules on the face
d. Requires sunglasses because sunlight hurts eyes
Explanation: Overexposure to PUVA treatment can cause skin irritation,
tenderness, and erythema. If the client exhibits these symptoms, the nurse should
notify the healthcare provider for possible treatment modifications.
7. An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with
possible anastomosis leakage. The client's abdomen is tender to touch, and the vital
signs are temperature 101° F (38.3° C). heart rate 130 beats/minute, respiratory rate
26 breaths/minute, and blood pressure 100/50 mmHg. Which intervention is most
important for the nurse to include in the client's plan of care?
a. Encourage regular turning.
b. Monitor skin for breakdown.
c. Strict IV fluid replacement.
d. Assess wound drainage daily.
Explanation: The client's vital signs indicate possible sepsis or systemic infection.
Strict IV fluid replacement is important to maintain adequate circulation, support
blood pressure, and treat potential sepsis. The other interventions are also
essential but not as critical as fluid replacement in this situation.
8. A client who was recently diagnosed with Raynaud’s disease is concerned about
pain management. Which nursing instructions should the nurse provide?
a. Painful areas should be rubbed gently until the pain subsides.
b. Return appointments will be needed for IV pain medications.
c. Enrolling in a pain clinic can provide relief alternatives.
d. Wearing gloves when handling cold items guards against painful spasms.
Explanation: For clients with Raynaud's disease, cold temperatures can trigger
painful episodes. Instructing the client to wear gloves when handling cold items
can help protect against these episodes and manage pain.
, 9. A client with newly diagnosed Crohn’s disease asks the nurse about dietary
modifications. Which recommendation should the nurse provide?
a. Increase intake of high-fiber foods such as whole grains and raw vegetables.
b. Avoid all dairy products to prevent lactose intolerance symptoms.
c. Maintain a low-residue diet during active flare-ups to reduce bowel
irritation.
d. Drink caffeinated beverages to stimulate bowel motility.
Explanation: During active flare-ups of Crohn’s disease, a low-residue diet helps
reduce stool volume and bowel irritation. High-fiber foods can exacerbate
symptoms. Dairy may be tolerated in small amounts, and caffeine can increase
diarrhea.
10. A client with cirrhosis of the liver presents with asterixis, confusion, and a
serum ammonia level of 120 mcg/dL. Which medication should the nurse
anticipate administering?
a. Spironolactone
b. Lactulose
c. Furosemide
d. Metoclopramide
Explanation: Lactulose is used to reduce serum ammonia levels by promoting
excretion of ammonia in the stool. It is the first-line treatment for hepatic
encephalopathy.
11. The nurse is caring for a client receiving a continuous heparin infusion for deep
vein thrombosis. Which laboratory value requires immediate action by the nurse?
a. Platelet count of 180,000/mm³
b. aPTT of 110 seconds
c. INR of 1.2
d. Hemoglobin of 12 g/dL
*Explanation: An aPTT of 110 seconds is significantly elevated (therapeutic range
is typically 60-80 seconds for heparin therapy), indicating a high risk of bleeding.
The nurse should notify the healthcare provider and consider stopping or reducing
the infusion.*
Verified Answers | Latest 2024/2025 Grade A+
1. A client who underwent cardiac stent placement four days ago arrives to the
emergency department reporting a sudden onset of chest pressure and shortness of
breath. Which action should the nurse take next?
a. Listen for extra heart sounds, murmurs, and rhythm with the bell of the
stethoscope.
b. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting
edema.
c. Verify troponin level assessments are scheduled every 3-6 hours for a series of
three.
d. Obtain a 12-lead electrocardiogram and begin continuous cardiac
monitoring.
*Explanation: Sudden chest pressure and shortness of breath after stent placement
suggest possible stent thrombosis or acute myocardial infarction. The priority is to
obtain a 12-lead ECG and initiate continuous cardiac monitoring to assess for
ischemic changes and guide immediate intervention.*
2. A client with chronic heart failure reports a weight gain of 3 pounds in 24 hours
and increased dyspnea. Which action should the nurse take first?
a. Encourage the client to restrict oral fluids to 1 liter per day.
b. Auscultate lung sounds for crackles or wheezes.
c. Assess for jugular vein distention and peripheral edema.
d. Administer a prescribed PRN dose of furosemide.
Explanation: The nurse should first assess for signs of fluid overload, including
jugular vein distention and peripheral edema, to confirm worsening heart failure
before implementing interventions such as diuretic administration or fluid
restriction.
3. A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of
weakness and palpitations. Which finding should the nurse recognize as a possible
complication?
,a. anxiety and sighing
b. myalgia in wrists and hands
c. hyperactive bowel sounds
d. dark yellow urine
Explanation: Dark yellow urine may indicate dehydration, which is a common
complication in clients with diabetes mellitus due to hyperglycemia-induced
osmotic diuresis. Weakness and palpitations can be related to electrolyte
imbalances from dehydration.
4. While completing a health assessment for a client with migraine headaches, the
nurse assesses bilateral weakness in the clients hand grips. The client reports joint
pain and trouble twisting a door knob due to weaknesses. Which action should the
nurses take in response to these figures?
a. Implement fall precautions to reduce the clients risk of injury.
b. Explain that relief of the migraine pain will reduce related symptoms.
c. Gather additional assessment data about the pain and weakness.
d. Consult with the occupational therapist for a functional assessment.
Explanation: The nurse should gather additional assessment data about the pain
and weakness to better understand the client's condition and to determine if there
is an underlying issue or if the symptoms are related to the migraine headaches.
5. A client who has developed acute kidney injury (AKI) due to aminoglycoside
antibiotics has moved from the oliguric phase to the diuretic phase of AKI. Which
parameters are most important for the nurse to plan to carefully monitor?
a. Uremic irritation of mucous membranes and skin surfaces.
b. Hypovolemia and electrocardiographic (ECG) changes.
c. Side effects of total parental nutrition (TPN) and Intralipids.
d. Elevated creatinine and blood urea nitrogen (BUN).
Explanation: During the diuretic phase of AKI, the client may experience
increased urine output, which can lead to hypovolemia and electrolyte imbalances.
Monitoring for hypovolemia and ECG changes can help detect any complications
or worsening of the client's condition.
,6. The nurse is caring for a client diagnosed with psoriasis vulgaris who is
receiving psoralen and ultraviolet A light (PUVA) treatment. Which assessment
finding indicates that the client has been overexposed to the treatment?
a. Thick skin plaques topped by silvery white scales
b. Tenderness upon palpation and generalized erythema
c. Brown, rough, greasy, wart-like papules on the face
d. Requires sunglasses because sunlight hurts eyes
Explanation: Overexposure to PUVA treatment can cause skin irritation,
tenderness, and erythema. If the client exhibits these symptoms, the nurse should
notify the healthcare provider for possible treatment modifications.
7. An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with
possible anastomosis leakage. The client's abdomen is tender to touch, and the vital
signs are temperature 101° F (38.3° C). heart rate 130 beats/minute, respiratory rate
26 breaths/minute, and blood pressure 100/50 mmHg. Which intervention is most
important for the nurse to include in the client's plan of care?
a. Encourage regular turning.
b. Monitor skin for breakdown.
c. Strict IV fluid replacement.
d. Assess wound drainage daily.
Explanation: The client's vital signs indicate possible sepsis or systemic infection.
Strict IV fluid replacement is important to maintain adequate circulation, support
blood pressure, and treat potential sepsis. The other interventions are also
essential but not as critical as fluid replacement in this situation.
8. A client who was recently diagnosed with Raynaud’s disease is concerned about
pain management. Which nursing instructions should the nurse provide?
a. Painful areas should be rubbed gently until the pain subsides.
b. Return appointments will be needed for IV pain medications.
c. Enrolling in a pain clinic can provide relief alternatives.
d. Wearing gloves when handling cold items guards against painful spasms.
Explanation: For clients with Raynaud's disease, cold temperatures can trigger
painful episodes. Instructing the client to wear gloves when handling cold items
can help protect against these episodes and manage pain.
, 9. A client with newly diagnosed Crohn’s disease asks the nurse about dietary
modifications. Which recommendation should the nurse provide?
a. Increase intake of high-fiber foods such as whole grains and raw vegetables.
b. Avoid all dairy products to prevent lactose intolerance symptoms.
c. Maintain a low-residue diet during active flare-ups to reduce bowel
irritation.
d. Drink caffeinated beverages to stimulate bowel motility.
Explanation: During active flare-ups of Crohn’s disease, a low-residue diet helps
reduce stool volume and bowel irritation. High-fiber foods can exacerbate
symptoms. Dairy may be tolerated in small amounts, and caffeine can increase
diarrhea.
10. A client with cirrhosis of the liver presents with asterixis, confusion, and a
serum ammonia level of 120 mcg/dL. Which medication should the nurse
anticipate administering?
a. Spironolactone
b. Lactulose
c. Furosemide
d. Metoclopramide
Explanation: Lactulose is used to reduce serum ammonia levels by promoting
excretion of ammonia in the stool. It is the first-line treatment for hepatic
encephalopathy.
11. The nurse is caring for a client receiving a continuous heparin infusion for deep
vein thrombosis. Which laboratory value requires immediate action by the nurse?
a. Platelet count of 180,000/mm³
b. aPTT of 110 seconds
c. INR of 1.2
d. Hemoglobin of 12 g/dL
*Explanation: An aPTT of 110 seconds is significantly elevated (therapeutic range
is typically 60-80 seconds for heparin therapy), indicating a high risk of bleeding.
The nurse should notify the healthcare provider and consider stopping or reducing
the infusion.*
