BSN HESI 266 Medical Surgical Exam
Questions with Correct Answers
Question 1
The nurse is completing the health assessment of a 79-year-old male client who
denies any significant health problems. Which finding requires the most
immediate follow-up assessment?
A. Kyphosis with a reduction in height.
B. Dilated superficial veins on both legs.
C. External hemorrhoids with itching.
D. Yellowish discoloration of the sclerae.
Correct Answer
D
Rationale
In a geriatric client, a yellowish discoloration (jaundice) of the sclerae is not a
normal finding and may indicate liver damage and requires further assessment
Page 1 of 94
,Question 2
A client is admitted for complaints of chest pain and aching for the past 4 days.
The results for serum creatine kinase-MB (CK-MB) and troponin levels are
obtained. What rationale should the nurse use to evaluate the laboratory
findings?
A. Serum myoglobin levels are needed to confirm myocardial damage.
B. The most reliable indicator of myocardial necrosis is serum CK-MB.
C. Serum cardiac markers are inconclusive in determining myocardial injury after
waiting several days.
D. Myocardial damage that occurred several days earlier is best validated by serum
troponin levels.
Correct Answer
D
Rationale
An elevated serum troponin has become the cardiac marker of choice for
diagnosing an acute MI, according the American College of Cardiology (ACC)
guidelines (2017) for NSTEMI. An elevated troponin will become evident
within 2-3 hours of an MI in comparison to the CK-MB and other cardiac
enzymes that can take up to 6-9 hours after the MI occurrence
Page 2 of 94
,Question 3
What instruction should the nurse include in the discharge teaching for a client
who needs to perform self-catheterization technique at home?
A. Catheterize every 3 to 4 hours.
B. Maintain sterile technique.
C. Use the Cred maneuver before catheterization.
D. Drink 500 ml of fluid within 2 hours of catheterization.
Correct Answer
A
Rationale
The average interval between catheterizations for adults is every 3 to 4 hours.
Although sterile technique is indicated in healthcare facilities, clean technique
is often followed by the client when performing self-catheterization at home
Page 3 of 94
, Question 4
A Korean-American client, who speaks very little English, is being discharged
following surgery. Which nurse should the nurse manager assign to provide the
discharge instructions for the client?
A. A graduate registered nurse (RN) with three weeks of experience.
B. The registered nurse (RN) case manager for the unit with 1 year's experience.
C. A "floating" registered nurse (RN) with five years of nursing experience.
A Korean-American practical nurse (PN) with six years of nursing experience
Correct Answer
B
Rationale
The RN case manager is the best-qualified nurse to assess and provide
discharge educational needs, obtain resources for the client, enhance
coordination of care, and prevent fragmentation of care.
Page 4 of 94
Questions with Correct Answers
Question 1
The nurse is completing the health assessment of a 79-year-old male client who
denies any significant health problems. Which finding requires the most
immediate follow-up assessment?
A. Kyphosis with a reduction in height.
B. Dilated superficial veins on both legs.
C. External hemorrhoids with itching.
D. Yellowish discoloration of the sclerae.
Correct Answer
D
Rationale
In a geriatric client, a yellowish discoloration (jaundice) of the sclerae is not a
normal finding and may indicate liver damage and requires further assessment
Page 1 of 94
,Question 2
A client is admitted for complaints of chest pain and aching for the past 4 days.
The results for serum creatine kinase-MB (CK-MB) and troponin levels are
obtained. What rationale should the nurse use to evaluate the laboratory
findings?
A. Serum myoglobin levels are needed to confirm myocardial damage.
B. The most reliable indicator of myocardial necrosis is serum CK-MB.
C. Serum cardiac markers are inconclusive in determining myocardial injury after
waiting several days.
D. Myocardial damage that occurred several days earlier is best validated by serum
troponin levels.
Correct Answer
D
Rationale
An elevated serum troponin has become the cardiac marker of choice for
diagnosing an acute MI, according the American College of Cardiology (ACC)
guidelines (2017) for NSTEMI. An elevated troponin will become evident
within 2-3 hours of an MI in comparison to the CK-MB and other cardiac
enzymes that can take up to 6-9 hours after the MI occurrence
Page 2 of 94
,Question 3
What instruction should the nurse include in the discharge teaching for a client
who needs to perform self-catheterization technique at home?
A. Catheterize every 3 to 4 hours.
B. Maintain sterile technique.
C. Use the Cred maneuver before catheterization.
D. Drink 500 ml of fluid within 2 hours of catheterization.
Correct Answer
A
Rationale
The average interval between catheterizations for adults is every 3 to 4 hours.
Although sterile technique is indicated in healthcare facilities, clean technique
is often followed by the client when performing self-catheterization at home
Page 3 of 94
, Question 4
A Korean-American client, who speaks very little English, is being discharged
following surgery. Which nurse should the nurse manager assign to provide the
discharge instructions for the client?
A. A graduate registered nurse (RN) with three weeks of experience.
B. The registered nurse (RN) case manager for the unit with 1 year's experience.
C. A "floating" registered nurse (RN) with five years of nursing experience.
A Korean-American practical nurse (PN) with six years of nursing experience
Correct Answer
B
Rationale
The RN case manager is the best-qualified nurse to assess and provide
discharge educational needs, obtain resources for the client, enhance
coordination of care, and prevent fragmentation of care.
Page 4 of 94
