Test bank BSN 366 HESI RN Exit Exam V3
(2025/2026) Questions and 100% Verified Answers
Cardiovascular (1-20)
1. A client with heart failure has an order for digoxin (Lanoxin) 0.25 mg daily.
Which finding would cause the nurse to withhold the medication and notify the
healthcare provider?
A) Heart rate of 68 beats per minute
B) Serum potassium level of 3.2 mEq/L
C) Blood pressure of 110/70 mmHg
D) Respiratory rate of 18 breaths per minute
Answer: B) Serum potassium level of 3.2 mEq/L
Rationale: Hypokalemia (potassium <3.5 mEq/L) increases the risk of digoxin toxicity,
which can cause life-threatening dysrhythmias such as ventricular tachycardia. The nurse
should hold the digoxin, notify the provider, and anticipate potassium supplementation.
A heart rate of 68 is within normal range (hold digoxin usually for <60 bpm). BP and
respiratory rate are normal.
2. A client with unstable angina is receiving a continuous infusion of heparin. The
nurse notes that the aPTT level is 120 seconds; the baseline is 30 seconds. What is
the priority nursing action?
A) Increase the heparin infusion rate
B) Continue the infusion as prescribed
C) Hold the heparin and notify the provider
D) Administer protamine sulfate immediately
Answer: C) Hold the heparin and notify the provider
Rationale: The therapeutic aPTT range for heparin therapy is typically 1.5-2.5 times the
normal baseline (45-75 seconds for a 30-second baseline). An aPTT of 120 seconds (4
times baseline) indicates excessive anticoagulation and increased bleeding risk. The
,nurse should hold the heparin infusion and notify the provider, who may order a rate
reduction or protamine sulfate if bleeding occurs.
3. A client is admitted with acute decompensated heart failure. Which assessment
finding is most concerning?
A) Jugular vein distention
B) Bilateral pedal edema
C) Weight gain of 2 kg in 24 hours
D) Crackles auscultated in all lung fields
Answer: D) Crackles auscultated in all lung fields
Rationale: Crackles in all lung fields indicate pulmonary edema, a life-threatening
complication of acute heart failure where fluid accumulates in the alveoli, impairing gas
exchange. This requires immediate intervention (oxygen, diuretics, positioning). JVD,
pedal edema, and weight gain all indicate fluid overload but are less immediately life-
threatening than pulmonary edema.
4. A client with hypertension is prescribed lisinopril (Prinivil). Which finding is a
priority to report to the healthcare provider?
A) Dry, nonproductive cough
B) Serum potassium level of 4.5 mEq/L
C) Blood pressure of 128/84 mmHg
D) Heart rate of 72 beats per minute
Answer: A) Dry, nonproductive cough
Rationale: A persistent dry cough is a common side effect of ACE inhibitors (lisinopril)
due to accumulation of bradykinin. While not immediately dangerous, it often leads to
medication discontinuation. The nurse should report it so the provider can consider
switching to an ARB. The other findings are normal and expected outcomes of
treatment.
5. A client 4 hours post-cardiac catheterization via the femoral artery reports
severe groin pain and lightheadedness. The nurse notes a large, expanding
hematoma in the groin and a heart rate of 120 bpm. What is the priority action?
A) Apply sandbags to the site for pressure
B) Assess the distal pulses in the affected leg
C) Apply firm pressure above the puncture site
D) Notify the healthcare provider immediately
,Answer: C) Apply firm pressure above the puncture site
Rationale: An expanding hematoma with tachycardia and lightheadedness indicates
active bleeding from the arterial puncture site. The priority is to apply firm pressure just
above the puncture site (the arterial entry point) to stop the bleeding. Sandbags provide
less effective pressure. While the provider must be notified, controlling the bleed is the
immediate priority. Distal pulse assessment comes after bleeding is controlled.
6. A client with atrial fibrillation is prescribed warfarin (Coumadin). Which client
statement indicates a need for further teaching?
A) "I will avoid eating large amounts of green leafy vegetables"
B) "I will use an electric razor for shaving"
C) "I will take ibuprofen for my headaches"
D) "I will have my INR checked regularly"
Answer: C) "I will take ibuprofen for my headaches"
Rationale: Ibuprofen (NSAID) increases the risk of bleeding and should be avoided by
clients taking warfarin. Acetaminophen (Tylenol) is a safer choice for pain or headache.
Avoiding consistent large amounts of vitamin K-rich foods (A) is correct to maintain
steady INR. Electric razors (B) reduce bleeding risk. Regular INR monitoring (D) is
essential.
7. The nurse is assessing a client with right-sided heart failure. Which finding is
most consistent with this diagnosis?
A) Paroxysmal nocturnal dyspnea
B) Crackles in the lung bases
C) Jugular vein distention and peripheral edema
D) Orthopnea requiring three pillows to sleep
Answer: C) Jugular vein distention and peripheral edema
Rationale: Right-sided heart failure presents with signs of systemic venous congestion:
JVD, peripheral edema, hepatomegaly, ascites, and weight gain. Left-sided heart failure
presents with pulmonary congestion: crackles, dyspnea, orthopnea, PND. The question
specifically asks for right-sided failure findings.
8. A client with a history of deep vein thrombosis (DVT) is prescribed rivaroxaban
(Xarelto). Which instruction should the nurse include?
, A) "Take this medication on an empty stomach"
B) "You will need monthly INR blood tests"
C) "Report any unusual bruising or bleeding to your provider"
D) "This medication requires daily injections"
Answer: C) "Report any unusual bruising or bleeding to your provider"
Rationale: Rivaroxaban is a direct oral anticoagulant (DOAC) that increases bleeding
risk. Clients should report signs of bleeding (unusual bruising, blood in urine/stool,
bleeding gums). Rivaroxaban can be taken with or without food (A) depending on dose
(15-20 mg with food). DOACs do not require routine INR monitoring (B) like warfarin.
Rivaroxaban is an oral medication, not injectable (D).
9. The nurse is caring for a client with an acute myocardial infarction (MI). Which
finding indicates a possible complication of a papillary muscle rupture?
A) New, loud holosystolic murmur
B) Decreased level of consciousness
C) ST-segment elevation on ECG
D) Sudden onset of pleuritic chest pain
Answer: A) New, loud holosystolic murmur
Rationale: Papillary muscle rupture is a life-threatening complication of MI (usually 2-7
days post-MI). It causes acute mitral regurgitation, producing a new, loud, holosystolic
murmur best heard at the apex with radiation to the axilla. This leads to acute
pulmonary edema and cardiogenic shock requiring emergency surgery.
10. A client with peripheral artery disease (PAD) reports leg pain when walking
that is relieved by rest. Which intervention should the nurse include in the plan of
care?
A) Encourage a daily walking program to build collateral circulation
B) Elevate the legs above heart level when resting
C) Apply heat packs to the legs for pain relief
D) Instruct the client to avoid walking due to pain
Answer: A) Encourage a daily walking program to build collateral circulation
Rationale: A supervised walking program is the cornerstone of PAD management.
Walking to the point of pain, resting until pain resolves, and walking again stimulates
the development of collateral circulation, improving symptoms over time. Legs should
(2025/2026) Questions and 100% Verified Answers
Cardiovascular (1-20)
1. A client with heart failure has an order for digoxin (Lanoxin) 0.25 mg daily.
Which finding would cause the nurse to withhold the medication and notify the
healthcare provider?
A) Heart rate of 68 beats per minute
B) Serum potassium level of 3.2 mEq/L
C) Blood pressure of 110/70 mmHg
D) Respiratory rate of 18 breaths per minute
Answer: B) Serum potassium level of 3.2 mEq/L
Rationale: Hypokalemia (potassium <3.5 mEq/L) increases the risk of digoxin toxicity,
which can cause life-threatening dysrhythmias such as ventricular tachycardia. The nurse
should hold the digoxin, notify the provider, and anticipate potassium supplementation.
A heart rate of 68 is within normal range (hold digoxin usually for <60 bpm). BP and
respiratory rate are normal.
2. A client with unstable angina is receiving a continuous infusion of heparin. The
nurse notes that the aPTT level is 120 seconds; the baseline is 30 seconds. What is
the priority nursing action?
A) Increase the heparin infusion rate
B) Continue the infusion as prescribed
C) Hold the heparin and notify the provider
D) Administer protamine sulfate immediately
Answer: C) Hold the heparin and notify the provider
Rationale: The therapeutic aPTT range for heparin therapy is typically 1.5-2.5 times the
normal baseline (45-75 seconds for a 30-second baseline). An aPTT of 120 seconds (4
times baseline) indicates excessive anticoagulation and increased bleeding risk. The
,nurse should hold the heparin infusion and notify the provider, who may order a rate
reduction or protamine sulfate if bleeding occurs.
3. A client is admitted with acute decompensated heart failure. Which assessment
finding is most concerning?
A) Jugular vein distention
B) Bilateral pedal edema
C) Weight gain of 2 kg in 24 hours
D) Crackles auscultated in all lung fields
Answer: D) Crackles auscultated in all lung fields
Rationale: Crackles in all lung fields indicate pulmonary edema, a life-threatening
complication of acute heart failure where fluid accumulates in the alveoli, impairing gas
exchange. This requires immediate intervention (oxygen, diuretics, positioning). JVD,
pedal edema, and weight gain all indicate fluid overload but are less immediately life-
threatening than pulmonary edema.
4. A client with hypertension is prescribed lisinopril (Prinivil). Which finding is a
priority to report to the healthcare provider?
A) Dry, nonproductive cough
B) Serum potassium level of 4.5 mEq/L
C) Blood pressure of 128/84 mmHg
D) Heart rate of 72 beats per minute
Answer: A) Dry, nonproductive cough
Rationale: A persistent dry cough is a common side effect of ACE inhibitors (lisinopril)
due to accumulation of bradykinin. While not immediately dangerous, it often leads to
medication discontinuation. The nurse should report it so the provider can consider
switching to an ARB. The other findings are normal and expected outcomes of
treatment.
5. A client 4 hours post-cardiac catheterization via the femoral artery reports
severe groin pain and lightheadedness. The nurse notes a large, expanding
hematoma in the groin and a heart rate of 120 bpm. What is the priority action?
A) Apply sandbags to the site for pressure
B) Assess the distal pulses in the affected leg
C) Apply firm pressure above the puncture site
D) Notify the healthcare provider immediately
,Answer: C) Apply firm pressure above the puncture site
Rationale: An expanding hematoma with tachycardia and lightheadedness indicates
active bleeding from the arterial puncture site. The priority is to apply firm pressure just
above the puncture site (the arterial entry point) to stop the bleeding. Sandbags provide
less effective pressure. While the provider must be notified, controlling the bleed is the
immediate priority. Distal pulse assessment comes after bleeding is controlled.
6. A client with atrial fibrillation is prescribed warfarin (Coumadin). Which client
statement indicates a need for further teaching?
A) "I will avoid eating large amounts of green leafy vegetables"
B) "I will use an electric razor for shaving"
C) "I will take ibuprofen for my headaches"
D) "I will have my INR checked regularly"
Answer: C) "I will take ibuprofen for my headaches"
Rationale: Ibuprofen (NSAID) increases the risk of bleeding and should be avoided by
clients taking warfarin. Acetaminophen (Tylenol) is a safer choice for pain or headache.
Avoiding consistent large amounts of vitamin K-rich foods (A) is correct to maintain
steady INR. Electric razors (B) reduce bleeding risk. Regular INR monitoring (D) is
essential.
7. The nurse is assessing a client with right-sided heart failure. Which finding is
most consistent with this diagnosis?
A) Paroxysmal nocturnal dyspnea
B) Crackles in the lung bases
C) Jugular vein distention and peripheral edema
D) Orthopnea requiring three pillows to sleep
Answer: C) Jugular vein distention and peripheral edema
Rationale: Right-sided heart failure presents with signs of systemic venous congestion:
JVD, peripheral edema, hepatomegaly, ascites, and weight gain. Left-sided heart failure
presents with pulmonary congestion: crackles, dyspnea, orthopnea, PND. The question
specifically asks for right-sided failure findings.
8. A client with a history of deep vein thrombosis (DVT) is prescribed rivaroxaban
(Xarelto). Which instruction should the nurse include?
, A) "Take this medication on an empty stomach"
B) "You will need monthly INR blood tests"
C) "Report any unusual bruising or bleeding to your provider"
D) "This medication requires daily injections"
Answer: C) "Report any unusual bruising or bleeding to your provider"
Rationale: Rivaroxaban is a direct oral anticoagulant (DOAC) that increases bleeding
risk. Clients should report signs of bleeding (unusual bruising, blood in urine/stool,
bleeding gums). Rivaroxaban can be taken with or without food (A) depending on dose
(15-20 mg with food). DOACs do not require routine INR monitoring (B) like warfarin.
Rivaroxaban is an oral medication, not injectable (D).
9. The nurse is caring for a client with an acute myocardial infarction (MI). Which
finding indicates a possible complication of a papillary muscle rupture?
A) New, loud holosystolic murmur
B) Decreased level of consciousness
C) ST-segment elevation on ECG
D) Sudden onset of pleuritic chest pain
Answer: A) New, loud holosystolic murmur
Rationale: Papillary muscle rupture is a life-threatening complication of MI (usually 2-7
days post-MI). It causes acute mitral regurgitation, producing a new, loud, holosystolic
murmur best heard at the apex with radiation to the axilla. This leads to acute
pulmonary edema and cardiogenic shock requiring emergency surgery.
10. A client with peripheral artery disease (PAD) reports leg pain when walking
that is relieved by rest. Which intervention should the nurse include in the plan of
care?
A) Encourage a daily walking program to build collateral circulation
B) Elevate the legs above heart level when resting
C) Apply heat packs to the legs for pain relief
D) Instruct the client to avoid walking due to pain
Answer: A) Encourage a daily walking program to build collateral circulation
Rationale: A supervised walking program is the cornerstone of PAD management.
Walking to the point of pain, resting until pain resolves, and walking again stimulates
the development of collateral circulation, improving symptoms over time. Legs should
