BSN HESI 266 Med Surg Exam V1 Questions and Answers and
Explanations | Latest For Nightingale
1. A patient with Type 2 Diabetes is prescribed Metformin. Which education
point is most important for the nurse to emphasize?
A. Take the medication only when blood glucose is above 200 mg/dL.
B. Stop taking the medication 48 hours before any procedure involving IV contrast dye.
C. This medication works by stimulating the pancreas to release more insulin.
D. Monitor for weight gain as a common side effect of this drug.
Answer: B
Explanation: Metformin must be held 48 hours before and after procedures using IV
contrast to prevent lactic acidosis and acute renal failure.
2. A nurse is assessing a patient with suspected left-sided heart failure. Which
clinical manifestation should the nurse expect?
A. Peripheral edema in the lower extremities.
B. Jugular venous distension (JVD).
C. Abdominal girth increase and hepatomegaly.
D. Crackles heard upon auscultation of the lungs.
Answer: D
,Explanation: Left-sided heart failure results in pulmonary congestion, leading to
symptoms like crackles, dyspnea, and orthopnea.
3. A patient with COPD is receiving oxygen therapy. What is the primary reason
the nurse maintains a low oxygen flow rate (1-2 L/min)?
A. Patients with COPD rely on a hypoxic drive to breathe.
B. High levels of oxygen can cause rupture of pulmonary blebs.
C. To prevent oxygen toxicity to the lung tissues.
D. High flow rates cause excessive drying of the nasal mucosa.
Answer: A
Explanation: In chronic CO2 retainers, high oxygen levels can suppress the hypoxic drive,
which is their primary stimulus for respiration.
4. An arterial blood gas (ABG) result shows: pH 7.48, PaCO2 30 mmHg, and
HCO3 24 mEq/L. How should the nurse interpret these findings?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Metabolic Acidosis
Answer: B
Explanation: A pH > 7.45 indicates alkalosis, and a PaCO2 < 35 mmHg indicates a
respiratory cause. The normal HCO3 suggests it is uncompensated.
,5. Which food choice indicates that a patient with Celiac disease understands
their dietary restrictions?
A. Whole wheat toast with butter.
B. Spaghetti with meat sauce.
C. Grilled chicken with steamed white rice.
D. Cream of mushroom soup with barley.
Answer: C
Explanation: Celiac disease requires a gluten-free diet. Rice and chicken are gluten-free,
whereas wheat, barley, and rye contain gluten.
6. A nurse enters the room of a patient who is having a tonic-clonic seizure.
What is the nurse’s priority action?
A. Turn the patient to a side-lying position.
B. Restrain the patient’s limbs to prevent injury.
C. Insert a tongue blade into the patient’s mouth.
D. Administer oral diazepam immediately.
Answer: A
Explanation: The priority is maintaining a patent airway and preventing aspiration by
turning the patient to the side. Never insert anything into the mouth.
, 7. A patient is being treated for Deep Vein Thrombosis (DVT) with a Heparin
infusion. Which laboratory value should the nurse monitor?
A. Prothrombin Time (PT)
B. International Normalized Ratio (INR)
C. Activated Partial Thromboplastin Time (aPTT)
D. Platelet count only
Answer: C
Explanation: aPTT is used to monitor the effectiveness of Heparin therapy, whereas
PT/INR is used for Warfarin.
8. What is the first sign of hypovolemic shock that a nurse should monitor for in
a post-operative patient?
A. Decreased urine output
B. Hypotension
C. Tachycardia
D. Bradypnea
Answer: C
Explanation: Tachycardia is an early compensatory mechanism for decreased blood
volume as the heart tries to maintain cardiac output.
Explanations | Latest For Nightingale
1. A patient with Type 2 Diabetes is prescribed Metformin. Which education
point is most important for the nurse to emphasize?
A. Take the medication only when blood glucose is above 200 mg/dL.
B. Stop taking the medication 48 hours before any procedure involving IV contrast dye.
C. This medication works by stimulating the pancreas to release more insulin.
D. Monitor for weight gain as a common side effect of this drug.
Answer: B
Explanation: Metformin must be held 48 hours before and after procedures using IV
contrast to prevent lactic acidosis and acute renal failure.
2. A nurse is assessing a patient with suspected left-sided heart failure. Which
clinical manifestation should the nurse expect?
A. Peripheral edema in the lower extremities.
B. Jugular venous distension (JVD).
C. Abdominal girth increase and hepatomegaly.
D. Crackles heard upon auscultation of the lungs.
Answer: D
,Explanation: Left-sided heart failure results in pulmonary congestion, leading to
symptoms like crackles, dyspnea, and orthopnea.
3. A patient with COPD is receiving oxygen therapy. What is the primary reason
the nurse maintains a low oxygen flow rate (1-2 L/min)?
A. Patients with COPD rely on a hypoxic drive to breathe.
B. High levels of oxygen can cause rupture of pulmonary blebs.
C. To prevent oxygen toxicity to the lung tissues.
D. High flow rates cause excessive drying of the nasal mucosa.
Answer: A
Explanation: In chronic CO2 retainers, high oxygen levels can suppress the hypoxic drive,
which is their primary stimulus for respiration.
4. An arterial blood gas (ABG) result shows: pH 7.48, PaCO2 30 mmHg, and
HCO3 24 mEq/L. How should the nurse interpret these findings?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Metabolic Acidosis
Answer: B
Explanation: A pH > 7.45 indicates alkalosis, and a PaCO2 < 35 mmHg indicates a
respiratory cause. The normal HCO3 suggests it is uncompensated.
,5. Which food choice indicates that a patient with Celiac disease understands
their dietary restrictions?
A. Whole wheat toast with butter.
B. Spaghetti with meat sauce.
C. Grilled chicken with steamed white rice.
D. Cream of mushroom soup with barley.
Answer: C
Explanation: Celiac disease requires a gluten-free diet. Rice and chicken are gluten-free,
whereas wheat, barley, and rye contain gluten.
6. A nurse enters the room of a patient who is having a tonic-clonic seizure.
What is the nurse’s priority action?
A. Turn the patient to a side-lying position.
B. Restrain the patient’s limbs to prevent injury.
C. Insert a tongue blade into the patient’s mouth.
D. Administer oral diazepam immediately.
Answer: A
Explanation: The priority is maintaining a patent airway and preventing aspiration by
turning the patient to the side. Never insert anything into the mouth.
, 7. A patient is being treated for Deep Vein Thrombosis (DVT) with a Heparin
infusion. Which laboratory value should the nurse monitor?
A. Prothrombin Time (PT)
B. International Normalized Ratio (INR)
C. Activated Partial Thromboplastin Time (aPTT)
D. Platelet count only
Answer: C
Explanation: aPTT is used to monitor the effectiveness of Heparin therapy, whereas
PT/INR is used for Warfarin.
8. What is the first sign of hypovolemic shock that a nurse should monitor for in
a post-operative patient?
A. Decreased urine output
B. Hypotension
C. Tachycardia
D. Bradypnea
Answer: C
Explanation: Tachycardia is an early compensatory mechanism for decreased blood
volume as the heart tries to maintain cardiac output.
