BSN HESI 266 Med Surg Exam – -
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,───────────────────────────────────────────────────────
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The nurse is caring for a client with a new diagnosis of heart failure.
Which assessment finding indicates the client is experiencing left-
sided heart failure?
A) Dependent edema
B) Jugular vein distension
C) Crackles in the lung bases
D) Hepatomegaly
Answer: C Rationale: Left-sided heart failure causes fluid to back up
into the pulmonary system, resulting in crackles in the lungs. Right-
sided heart failure causes systemic backup, leading to edema, JVD,
and hepatomegaly.
A client is admitted with chest pain. Which cardiac enzyme is the
most specific and reliable early indicator of a myocardial infarction?
A) Creatine kinase (CK)
B) CK-MB
C) Lactate dehydrogenase (LDH)
D) Troponin I
Answer: D Rationale: Troponin I is highly specific to cardiac muscle
and rises within 3-4 hours after an MI, making it the most reliable
early indicator. CK-MB is also specific but rises later (4-6 hours).
A client with atrial fibrillation is prescribed warfarin. The nurse
notes the client’s INR is 3.5. What is the most appropriate action?
A) Administer vitamin K
B) Hold the next dose of warfarin
C) Increase the warfarin dose
D) Administer heparin
Answer: B Rationale: The therapeutic INR for a client with atrial
fibrillation is 2.0-3.0. An INR of 3.5 is elevated, indicating a risk for
,bleeding. The nurse should hold the dose and notify the provider.
Vitamin K is an antidote used for severe bleeding or extremely high
INR.
The nurse is assessing a client with a peripheral intravenous
infusion. The site is edematous, cool, and tender. What is the
priority nursing action?
A) Apply a warm compress
B) Slow the infusion rate
C) Discontinue the IV
D) Elevate the extremity
Answer: C Rationale: These signs indicate infiltration. The priority
action is to discontinue the IV to prevent further fluid leakage into
the tissue, then apply a warm/cold compress and elevate the
extremity based on fluid type.
A client is receiving a blood transfusion. Fifteen minutes after the
infusion starts, the client reports chills and back pain. What is the
nurse's first action?
A) Check the client's vital signs
B) Stop the blood transfusion
C) Notify the healthcare provider
D) Administer diphenhydramine
Answer: B Rationale: Chills and back pain are signs of an acute
hemolytic transfusion reaction. The very first action is to stop the
transfusion to prevent further infusion of incompatible blood.
A client is admitted with a severe asthma attack. Which arterial
blood gas (ABG) result is consistent with this client's condition?
A) pH 7.32, PaCO2 48, PaO2 80, HCO3 24
B) pH 7.50, PaCO2 30, PaO2 90, HCO3 26
C) pH 7.35, PaCO2 40, PaO2 95, HCO3 24
D) pH 7.25, PaCO2 55, PaO2 60, HCO3 28
, Answer: A Rationale: An acute asthma attack causes
bronchoconstriction, leading to CO2 retention (respiratory acidosis:
pH low, PaCO2 high). Early asthma may show respiratory alkalosis
from hyperventilation, but severe asthma leads to acidosis.
A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen via nasal cannula at 2 L/min. The nurse finds the
client dyspneic and increases the oxygen to 5 L/min. What is the
potential complication of this action?
A) Oxygen toxicity
B) Cor pulmonale
C) Hypoventilation and respiratory arrest
D) Pulmonary embolism
Answer: C Rationale: Clients with COPD rely on a hypoxic drive to
breathe. High oxygen levels can eliminate this drive, leading to CO2
retention, hypoventilation, and potentially respiratory arrest.
The nurse is caring for a client with a chest tube. The client's
nursing assistant reports the chest tube was accidentally pulled out.
What is the nurse's first action?
A) Call the healthcare provider
B) Reinsert the chest tube
C) Cover the site with a sterile occlusive dressing
D) Clamp the chest tube
Answer: C Rationale: If a chest tube is dislodged, the priority is to
prevent air from entering the pleural space (pneumothorax). The
nurse should immediately cover the site with a sterile occlusive
dressing (like Vaseline gauze) taped on three sides.
Nightingale Questions and Verified
Answers
With rationales 2026\2027 update
This Exam contains:
Guarantee passing score
Questions and Ansẉers
format set of multiple-choice
Expert-Verified rationales
Verified ẉith trusted textbooks
,───────────────────────────────────────────────────────
─
The nurse is caring for a client with a new diagnosis of heart failure.
Which assessment finding indicates the client is experiencing left-
sided heart failure?
A) Dependent edema
B) Jugular vein distension
C) Crackles in the lung bases
D) Hepatomegaly
Answer: C Rationale: Left-sided heart failure causes fluid to back up
into the pulmonary system, resulting in crackles in the lungs. Right-
sided heart failure causes systemic backup, leading to edema, JVD,
and hepatomegaly.
A client is admitted with chest pain. Which cardiac enzyme is the
most specific and reliable early indicator of a myocardial infarction?
A) Creatine kinase (CK)
B) CK-MB
C) Lactate dehydrogenase (LDH)
D) Troponin I
Answer: D Rationale: Troponin I is highly specific to cardiac muscle
and rises within 3-4 hours after an MI, making it the most reliable
early indicator. CK-MB is also specific but rises later (4-6 hours).
A client with atrial fibrillation is prescribed warfarin. The nurse
notes the client’s INR is 3.5. What is the most appropriate action?
A) Administer vitamin K
B) Hold the next dose of warfarin
C) Increase the warfarin dose
D) Administer heparin
Answer: B Rationale: The therapeutic INR for a client with atrial
fibrillation is 2.0-3.0. An INR of 3.5 is elevated, indicating a risk for
,bleeding. The nurse should hold the dose and notify the provider.
Vitamin K is an antidote used for severe bleeding or extremely high
INR.
The nurse is assessing a client with a peripheral intravenous
infusion. The site is edematous, cool, and tender. What is the
priority nursing action?
A) Apply a warm compress
B) Slow the infusion rate
C) Discontinue the IV
D) Elevate the extremity
Answer: C Rationale: These signs indicate infiltration. The priority
action is to discontinue the IV to prevent further fluid leakage into
the tissue, then apply a warm/cold compress and elevate the
extremity based on fluid type.
A client is receiving a blood transfusion. Fifteen minutes after the
infusion starts, the client reports chills and back pain. What is the
nurse's first action?
A) Check the client's vital signs
B) Stop the blood transfusion
C) Notify the healthcare provider
D) Administer diphenhydramine
Answer: B Rationale: Chills and back pain are signs of an acute
hemolytic transfusion reaction. The very first action is to stop the
transfusion to prevent further infusion of incompatible blood.
A client is admitted with a severe asthma attack. Which arterial
blood gas (ABG) result is consistent with this client's condition?
A) pH 7.32, PaCO2 48, PaO2 80, HCO3 24
B) pH 7.50, PaCO2 30, PaO2 90, HCO3 26
C) pH 7.35, PaCO2 40, PaO2 95, HCO3 24
D) pH 7.25, PaCO2 55, PaO2 60, HCO3 28
, Answer: A Rationale: An acute asthma attack causes
bronchoconstriction, leading to CO2 retention (respiratory acidosis:
pH low, PaCO2 high). Early asthma may show respiratory alkalosis
from hyperventilation, but severe asthma leads to acidosis.
A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen via nasal cannula at 2 L/min. The nurse finds the
client dyspneic and increases the oxygen to 5 L/min. What is the
potential complication of this action?
A) Oxygen toxicity
B) Cor pulmonale
C) Hypoventilation and respiratory arrest
D) Pulmonary embolism
Answer: C Rationale: Clients with COPD rely on a hypoxic drive to
breathe. High oxygen levels can eliminate this drive, leading to CO2
retention, hypoventilation, and potentially respiratory arrest.
The nurse is caring for a client with a chest tube. The client's
nursing assistant reports the chest tube was accidentally pulled out.
What is the nurse's first action?
A) Call the healthcare provider
B) Reinsert the chest tube
C) Cover the site with a sterile occlusive dressing
D) Clamp the chest tube
Answer: C Rationale: If a chest tube is dislodged, the priority is to
prevent air from entering the pleural space (pneumothorax). The
nurse should immediately cover the site with a sterile occlusive
dressing (like Vaseline gauze) taped on three sides.
