BSN 366 HESI RN Exit Exam V3 (2025/2026) Ultimate Test Bank:
300+ Practice Questions with 100% Verified Answers and Detailed
Clinical Rationales for Prioritization, Pharmacology, Medical-
Surgical, Maternity, and Mental Health Nursing.
SAFETY & INFECTION CONTROL (Questions 1-25)
1. A nurse is preparing to administer a blood transfusion. Which action should the nurse take first?
• Answer: B) Verify the client's blood type with a second nurse.
• Rationale: The two-nurse verification of the blood product and client identity is the most critical
step to prevent a fatal transfusion reaction. Baseline vital signs are done after verification.
2. A nurse is caring for a client with a new diagnosis of Clostridium difficile. Which infection control
precaution should be implemented?
• Answer: C) Contact precautions.
• Rationale: C. difficile is transmitted via spores on contaminated surfaces. Contact precautions
(gown, gloves, dedicated equipment) are required. Alcohol hand sanitizer is ineffective; soap
and water must be used.
3. A nurse is caring for a client who has a sealed radiation implant for cervical cancer. Which action is
appropriate?
• Answer: A) Wear a lead apron while providing care.
• Rationale: Time, distance, and shielding principles apply. Staff should wear lead aprons. Visitors
should be limited to 30 minutes per day. Linens are handled as radioactive waste.
4. A nurse is preparing to insert an indwelling urinary catheter. Which action demonstrates proper
sterile technique?
• Answer: C) Holding the catheter with sterile gloves and maintaining it within the sterile field.
• Rationale: The catheter must remain within the sterile field. The outer package can be opened on
a clean surface, but the inner wrap creates the sterile field.
,5. A client has a positive reaction to a purified protein derivative (PPD) test. Which action should the
nurse take?
• Answer: Refer for further diagnostic evaluation (chest x-ray).
• Rationale: A positive PPD indicates exposure or latent infection, but a chest x-ray is needed to
rule out active disease before treatment begins.
6. After an in-service about EHR security, the nurse observes a colleague going home with printed
copies of client information. Which action should the nurse take?
• Answer: A) File a detailed incident report with the specific hiring facility.
• Rationale: Any HIPAA/privacy breach necessitates formal documentation. The incident report
initiates an official investigatory process.
7. A client with HIV develops herpes zoster (shingles). Which precaution should the nurse implement?
• Answer: Standard and Contact Precautions.
• Rationale: Herpes zoster spreads via direct contact with the rash.
8. The rapid COVID-19 test is positive. Which action should the nurse take?
• Answer: Move the client to a private room, keep the door closed, and initiate droplet
precautions.
• Rationale: COVID-19 requires droplet and contact precautions.
9. A client is receiving a blood transfusion and reports chills and back pain. What should the nurse do
first?
• Answer: C) Stop the transfusion and start normal saline.
• Rationale: Chills and back pain are signs of a transfusion reaction. The priority is to stop the
transfusion, maintain IV access with new tubing, and notify the provider.
10. The nurse is preparing a client for discharge following in-patient treatment for pulmonary
tuberculosis. Which instruction should be given?
• Answer: Continue medication use as prescribed for the full duration (typically 6-9 months).
• Rationale: TB treatment requires completion of the full course to prevent drug resistance and
relapse.
11. A 64-year-old client scheduled for surgery with a general anesthetic refuses to remove dentures
prior to leaving the unit. What is the most appropriate intervention?
, • Answer: D) Ask the client if the preference would be to remove the dentures in the operating
room receiving area.
• Rationale: This respects the client's preference while ensuring safety (dentures must be removed
before anesthesia).
12. The nurse is caring for a client with a sealed radiation implant. The nurse finds the implant
dislodged on the bed linens. What is the priority action?
• Answer: Use long-handled forceps to place the implant in a lead container.
• Rationale: Staff must use shielding and tools to minimize exposure while securing the
radioactive material.
13. A client with a new tracheostomy has thick, tenacious secretions. Which intervention should the
nurse implement first?
• Answer: Instill 3-5 mL of sterile normal saline before suctioning.
• Rationale: Saline helps loosen thick secretions for easier removal, but pre-oxygenation is also
critical to prevent hypoxia.
14. The nurse is preparing to administer a medication via a metered-dose inhaler (MDI). Which action
is correct?
• Answer: D) Hold the breath for 5 to 10 seconds after inhalation.
• Rationale: Breath-holding allows the aerosol medication to deposit in the lungs.
15. A client with a chest tube has continuous bubbling in the water seal chamber. Which action should
the nurse take?
• Answer: Assess the chest tube system for an air leak.
• Rationale: Continuous bubbling indicates an air leak, which could be from loose connections or
the insertion site.
16. The nurse is caring for a client with a central venous catheter. Which action helps prevent catheter-
related bloodstream infection?
• Answer: D) All of the above (sterile dressing changes, scheduled tubing changes, hub
disinfection).
• Rationale: Aseptic technique, scheduled tubing changes, and hub disinfection are key infection
prevention measures.
, 17. A client with a prescription for "Do Not Resuscitate" (DNR) begins to manifest signs of impending
death. After notifying the family, what priority action should the nurse implement?
• Answer: C) The client's need for pain medication should be determined.
• Rationale: Comfort and dignity are priorities when death is imminent, even with a DNR order.
18. The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility. Which
behaviors indicate the client understands how to maintain balance safely? (Select all that apply.)
• Answer: A) Brings a heavy can close to body before lifting. C) Widens stance while working near
the sink.
• Rationale: Keeping objects close maintains center of gravity; widening stance increases base of
support.
19. A client receiving a blood transfusion develops a fever. The nurse stops the transfusion and infuses
normal saline. Which type of transfusion reaction is most likely?
• Answer: Febrile reaction (non-hemolytic).
• Rationale: Febrile reactions are caused by antibodies to donor WBCs and manifest as fever/chills
during or shortly after transfusion.
20. A client is on contact precautions due to an infected draining wound and is being discharged home.
What discharge instruction should the nurse include?
• Answer: Dispose of soiled dressings in plastic bags that are securely closed.
• Rationale: Contact precautions require a barrier preventing contact with wound secretions.
21. The nurse is caring for a client with a new tracheostomy. Which action should the nurse take to
maintain a patent airway?
• Answer: B) Hyperoxygenate with 100% oxygen before suctioning.
• Rationale: Preoxygenation prevents hypoxemia during suctioning.
22. A client is admitted with a diagnosis of bacterial meningitis. Which type of precaution should the
nurse initiate?
• Answer: Droplet precautions.
• Rationale: Meningitis is transmitted via respiratory droplets; private room and masks are
required for all entering the room.
300+ Practice Questions with 100% Verified Answers and Detailed
Clinical Rationales for Prioritization, Pharmacology, Medical-
Surgical, Maternity, and Mental Health Nursing.
SAFETY & INFECTION CONTROL (Questions 1-25)
1. A nurse is preparing to administer a blood transfusion. Which action should the nurse take first?
• Answer: B) Verify the client's blood type with a second nurse.
• Rationale: The two-nurse verification of the blood product and client identity is the most critical
step to prevent a fatal transfusion reaction. Baseline vital signs are done after verification.
2. A nurse is caring for a client with a new diagnosis of Clostridium difficile. Which infection control
precaution should be implemented?
• Answer: C) Contact precautions.
• Rationale: C. difficile is transmitted via spores on contaminated surfaces. Contact precautions
(gown, gloves, dedicated equipment) are required. Alcohol hand sanitizer is ineffective; soap
and water must be used.
3. A nurse is caring for a client who has a sealed radiation implant for cervical cancer. Which action is
appropriate?
• Answer: A) Wear a lead apron while providing care.
• Rationale: Time, distance, and shielding principles apply. Staff should wear lead aprons. Visitors
should be limited to 30 minutes per day. Linens are handled as radioactive waste.
4. A nurse is preparing to insert an indwelling urinary catheter. Which action demonstrates proper
sterile technique?
• Answer: C) Holding the catheter with sterile gloves and maintaining it within the sterile field.
• Rationale: The catheter must remain within the sterile field. The outer package can be opened on
a clean surface, but the inner wrap creates the sterile field.
,5. A client has a positive reaction to a purified protein derivative (PPD) test. Which action should the
nurse take?
• Answer: Refer for further diagnostic evaluation (chest x-ray).
• Rationale: A positive PPD indicates exposure or latent infection, but a chest x-ray is needed to
rule out active disease before treatment begins.
6. After an in-service about EHR security, the nurse observes a colleague going home with printed
copies of client information. Which action should the nurse take?
• Answer: A) File a detailed incident report with the specific hiring facility.
• Rationale: Any HIPAA/privacy breach necessitates formal documentation. The incident report
initiates an official investigatory process.
7. A client with HIV develops herpes zoster (shingles). Which precaution should the nurse implement?
• Answer: Standard and Contact Precautions.
• Rationale: Herpes zoster spreads via direct contact with the rash.
8. The rapid COVID-19 test is positive. Which action should the nurse take?
• Answer: Move the client to a private room, keep the door closed, and initiate droplet
precautions.
• Rationale: COVID-19 requires droplet and contact precautions.
9. A client is receiving a blood transfusion and reports chills and back pain. What should the nurse do
first?
• Answer: C) Stop the transfusion and start normal saline.
• Rationale: Chills and back pain are signs of a transfusion reaction. The priority is to stop the
transfusion, maintain IV access with new tubing, and notify the provider.
10. The nurse is preparing a client for discharge following in-patient treatment for pulmonary
tuberculosis. Which instruction should be given?
• Answer: Continue medication use as prescribed for the full duration (typically 6-9 months).
• Rationale: TB treatment requires completion of the full course to prevent drug resistance and
relapse.
11. A 64-year-old client scheduled for surgery with a general anesthetic refuses to remove dentures
prior to leaving the unit. What is the most appropriate intervention?
, • Answer: D) Ask the client if the preference would be to remove the dentures in the operating
room receiving area.
• Rationale: This respects the client's preference while ensuring safety (dentures must be removed
before anesthesia).
12. The nurse is caring for a client with a sealed radiation implant. The nurse finds the implant
dislodged on the bed linens. What is the priority action?
• Answer: Use long-handled forceps to place the implant in a lead container.
• Rationale: Staff must use shielding and tools to minimize exposure while securing the
radioactive material.
13. A client with a new tracheostomy has thick, tenacious secretions. Which intervention should the
nurse implement first?
• Answer: Instill 3-5 mL of sterile normal saline before suctioning.
• Rationale: Saline helps loosen thick secretions for easier removal, but pre-oxygenation is also
critical to prevent hypoxia.
14. The nurse is preparing to administer a medication via a metered-dose inhaler (MDI). Which action
is correct?
• Answer: D) Hold the breath for 5 to 10 seconds after inhalation.
• Rationale: Breath-holding allows the aerosol medication to deposit in the lungs.
15. A client with a chest tube has continuous bubbling in the water seal chamber. Which action should
the nurse take?
• Answer: Assess the chest tube system for an air leak.
• Rationale: Continuous bubbling indicates an air leak, which could be from loose connections or
the insertion site.
16. The nurse is caring for a client with a central venous catheter. Which action helps prevent catheter-
related bloodstream infection?
• Answer: D) All of the above (sterile dressing changes, scheduled tubing changes, hub
disinfection).
• Rationale: Aseptic technique, scheduled tubing changes, and hub disinfection are key infection
prevention measures.
, 17. A client with a prescription for "Do Not Resuscitate" (DNR) begins to manifest signs of impending
death. After notifying the family, what priority action should the nurse implement?
• Answer: C) The client's need for pain medication should be determined.
• Rationale: Comfort and dignity are priorities when death is imminent, even with a DNR order.
18. The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility. Which
behaviors indicate the client understands how to maintain balance safely? (Select all that apply.)
• Answer: A) Brings a heavy can close to body before lifting. C) Widens stance while working near
the sink.
• Rationale: Keeping objects close maintains center of gravity; widening stance increases base of
support.
19. A client receiving a blood transfusion develops a fever. The nurse stops the transfusion and infuses
normal saline. Which type of transfusion reaction is most likely?
• Answer: Febrile reaction (non-hemolytic).
• Rationale: Febrile reactions are caused by antibodies to donor WBCs and manifest as fever/chills
during or shortly after transfusion.
20. A client is on contact precautions due to an infected draining wound and is being discharged home.
What discharge instruction should the nurse include?
• Answer: Dispose of soiled dressings in plastic bags that are securely closed.
• Rationale: Contact precautions require a barrier preventing contact with wound secretions.
21. The nurse is caring for a client with a new tracheostomy. Which action should the nurse take to
maintain a patent airway?
• Answer: B) Hyperoxygenate with 100% oxygen before suctioning.
• Rationale: Preoxygenation prevents hypoxemia during suctioning.
22. A client is admitted with a diagnosis of bacterial meningitis. Which type of precaution should the
nurse initiate?
• Answer: Droplet precautions.
• Rationale: Meningitis is transmitted via respiratory droplets; private room and masks are
required for all entering the room.
