BSN HESI 266 Med Surg Exam Questions and Answers and Explanations | Latest For Nightingale V4

BSN HESI 266 Med Surg Exam Questions
and Answers and Explanations | Latest For
Nightingale V4
BSN HESI 266 Med-Surg Exam
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Instructions: Select the best answer for each question. cx cx cx cx cx cx cx




1. A client with heart failure is prescribed furosemide (Lasix) 40 mg IV push. Which assessment finding
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indicates the medication is having the desired effect?
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A. Increased heart rate
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B. Decreased peripheral edema
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C. Elevated blood pressure
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D. Increased jugular venous distension
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Correct Answer: B. Decreased peripheral edema
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Rationale: Furosemide is a loop diuretic that reduces fluid overload by promoting diuresis. A decrease in
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xperipheral edema indicates reduced fluid volume, which is the desired therapeutic effect in heart failure
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. Increased heart rate and elevated blood pressure are not direct desired effects, and increased JVD wou
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ld indicate worsening fluid overload.
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2. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who has an oxyg
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en saturation of 88% on room air. Which action should the nurse take first?
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A. Increase oxygen flow to 4 L/min via nasal cannula
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B. Place the client in a high-Fowler’s position
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C. Administer a bronchodilator nebulizer treatment
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D. Notify the healthcare provider
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Correct Answer: B. Place the client in a high-Fowler’s position
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Rationale: High-Fowler’s position maximizes lung expansion and improves ventilation-
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perfusion matching. While oxygen and bronchodilators are important, positioning is the first, immediate
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, non-invasive intervention to improve oxygenation. COPD clients are sensitive to high-
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flow oxygen, which can suppress their hypoxic drive.
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3. A client post-
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gastrectomy reports dizziness, sweating, and palpitations 30 minutes after eating. The nurse suspects:
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A. Hyperglycemia
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B. Dumping syndrome
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,C. Peritonitis
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D. Anastomotic leak
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Correct Answer: B. Dumping syndrome
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Rationale: Dumping syndrome occurs when hypertonic food rapidly enters the small intestine, causing fl
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uid shift, vasomotor symptoms (dizziness, sweating, palpitations), and GI distress. It typically occurs 15–
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30 minutes after meals in post-gastrectomy clients.
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4. Which laboratory value should the nurse monitor closely for a client receiving heparin therapy?
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A. Serum potassium
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B. aPTT (activated partial thromboplastin time)
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C. Serum creatinine
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D. Platelet count
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Correct Answer: B. aPTT cx cx cx



Rationale: Heparin is monitored using aPTT, with therapeutic range typically 1.5–
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2.5 times the control value. Platelet count is also monitored for heparin-
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induced thrombocytopenia (HIT), but aPTT is the primary lab for therapeutic monitoring.
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5. A client with cirrhosis presents with ascites and jaundice. Which dietary modification is most appro
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priate?
A. High-protein, high-sodium diet
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B. Low-sodium, low-protein diet
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C. High-calorie, low-sodium diet
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D. Low-calorie, high-protein diet
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Correct Answer: C. High-calorie, low-sodium diet
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Rationale: Cirrhosis clients need high- cx cx cx cx



calorie intake to prevent catabolism and low sodium to reduce fluid retention and ascites. Protein restri
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ction is not typically recommended unless hepatic encephalopathy is present.
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6. The nurse is assessing a client with diabetic ketoacidosis (DKA). Which finding requires immediate i
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ntervention?
A. Blood glucose 350 mg/dL
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B. Serum potassium 5.5 mEq/L
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C. Deep, rapid respirations
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D. Fruity odor to breath
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Correct Answer: B. Serum potassium 5.5 mEq/L
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Rationale: Hyperkalemia in DKA can lead to fatal cardiac dysrhythmias. While all other findings are consi
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stent with DKA, elevated potassium is a life-
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threatening electrolyte imbalance that requires immediate intervention.
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,7. A client is 24 hours post-
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hip replacement surgery. Which nursing intervention is most important to prevent venous thromboe
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mbolism (VTE)? cx



A. Administer enoxaparin as prescribed
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B. Apply sequential compression devices (SCDs)
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C. Encourage active range-of-motion exercises
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D. Elevate the affected leg
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Correct Answer: A. Administer enoxaparin as prescribed
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Rationale: Pharmacological prophylaxis (anticoagulants) is the most effective intervention for VTE preve
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ntion in post- cx cx



surgical clients, especially after major orthopedic surgery. Mechanical measures (SCDs, exercises) are ad
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junctive.



8. The nurse is caring for a client with acute pancreatitis. Which assessment finding indicates a compli
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cation?
A. Epigastric pain radiating to the back
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B. Nausea and vomiting
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C. Grey-Turner’s sign (flank ecchymosis)
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D. Hypotension
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Correct Answer: C. Grey-Turner’s sign
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Rationale: Grey- cx



Turner’s sign indicates retroperitoneal bleeding and is associated with severe necrotizing pancreatitis, a
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serious complication. Epigastric pain, nausea, and hypotension are common but not necessarily indicato
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rs of a complication.
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9. A client with chronic kidney disease (CKD) has a serum phosphorus level of 6.2 mg/dL. Which medic
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ation should the nurse anticipate administering?
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A. Calcium acetate (PhosLo)
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B. Potassium chloride
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C. Sodium bicarbonate
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D. Ferrous sulfate
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Correct Answer: A. Calcium acetate
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Rationale: Calcium acetate is a phosphate binder used to lower serum phosphorus in CKD clients by bin
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ding dietary phosphate in the GI tract. Elevated phosphorus contributes to renal osteodystrophy.
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10. The nurse is teaching a client with asthma about using a peak flow meter. Which statement indica
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tes understanding?
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A. "I will use the meter after taking my rescue inhaler."
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, B. "I should measure my peak flow before taking my morning medications."
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C. "I will record the lowest of three readings."
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D. "The green zone means I need to call my doctor."
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Correct Answer: B. "I should measure my peak flow before taking my morning medications."
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Rationale: Peak flow should be measured before medications to assess baseline lung function. The highe
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st of three readings is recorded, and green zone indicates good control.
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11. A client with myocardial infarction is prescribed aspirin. The nurse understands that aspirin is give
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n for which primary reason?
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A. Pain reliefcx cx



B. Fever reduction
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C. Antiplatelet aggregation
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D. Anti-inflammatory effect
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Correct Answer: C. Antiplatelet aggregation cx cx cx cx



Rationale: Aspirin inhibits platelet aggregation, reducing the risk of further thrombus formation in acute
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coronary syndrome. Pain and fever relief are secondary effects.
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12. The nurse is assessing a client with a head injury and notes a Glasgow Coma Scale (GCS) score of 8
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. Which intervention is most important?
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A. Prepare for intubation
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B. Administer mannitol
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C. Perform a neurological exam
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D. Position the client flat
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Correct Answer: A. Prepare for intubation cx cx cx cx cx



Rationale: A GCS of ≤ 8 indicates severe brain injury and the need for airway protection via intubation d
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ue to impaired gag and cough reflexes.
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13. A client with tuberculosis (TB) is started on a four-
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drug regimen. Which finding indicates the treatment is effective?
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A. Resolution of cough within 48 hours
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B. Negative sputum cultures after 2–3 weeks
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C. Negative tuberculin skin test
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D. Normal chest X-ray after 1 week
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Correct Answer: B. Negative sputum cultures after 2–3 weeks
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Rationale: Sputum culture conversion is the most reliable indicator of treatment response in TB. Clinical
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symptoms improve slowly over weeks. cx cx cx cx