BSN 266 HESI V2 Comprehensive Exam |Real
Questions and Explained Answers with
Complete Solutions UPDATED!!!
Question 1
A client with type 2 diabetes mellitus reports episodes of weakness and palpitations. Which assessment finding
should the nurse prioritize?
A) Blood glucose level
B) Serum potassium level
C) Heart rate and rhythm
D) Blood pressure
Answer: A
Weakness and palpitations in a client with diabetes are classic symptoms of hypoglycemia. The nurse should
prioritize checking the blood glucose level to confirm or rule out hypoglycemia before initiating any
intervention.
Question 2
A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition should the nurse
recognize as a contraindication for peritoneal dialysis?
A) Peritoneal adhesions
B) Hypertension
C) Diabetes mellitus
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,D) Hyperlipidemia
Answer: A
Peritoneal adhesions or abdominal surgeries that compromise the peritoneal membrane are contraindications
for peritoneal dialysis because they reduce the surface area available for dialysis and increase the risk of
complications.
Question 3
The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral neuropathy. Which
information should the nurse provide?
A) Inspect feet daily for blisters or sores
B) Soak feet in warm water daily
C) Walk barefoot to improve circulation
D) Apply heating pads to numb feet
Answer: A
Clients with peripheral neuropathy have decreased sensation and are at high risk for foot ulcers. Daily foot
inspection is essential to detect injuries early. Clients should not walk barefoot or use heating pads due to burn
risk.
Question 4
Which nursing measure is essential to the nursing care of a client with a pressure injury?
A) Massage any reddened areas for at least five minutes
B) Reposition the client every 2 hours
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,C) Apply heat to promote circulation
D) Keep the wound open to air
Answer: B
Repositioning every 2 hours relieves pressure on bony prominences and is essential for preventing further tissue
damage. Massaging reddened areas can damage underlying capillaries.
Question 5
The nurse is assessing a client with a history of heart failure. Which finding indicates worsening of the condition?
A) Weight gain of 2 pounds in 24 hours
B) Decreased jugular venous distention
C) Clear breath sounds
D) Increased urine output
Answer: A
A weight gain of 2 pounds in 24 hours indicates fluid retention, which is a sign of worsening heart failure. Daily
weight monitoring is essential for early detection of fluid overload.
Question 6
A client with pneumonia has a temperature of 102.5°F, productive cough with green sputum, and decreased
breath sounds in the right lower lobe. Which intervention should the nurse implement first?
A) Administer prescribed antibiotics
B) Encourage deep breathing and coughing
C) Administer antipyretic medication
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, D) Obtain a sputum culture
Answer: D
A sputum culture should be obtained before initiating antibiotics to identify the causative organism and guide
appropriate antibiotic therapy. Antibiotics should be started after the culture is obtained.
Question 7
The nurse is caring for a client with a nasogastric tube to suction following a total gastrectomy. Which finding
requires immediate intervention?
A) The client reports nausea
B) The nasogastric tube is draining bright red blood
C) The client's bowel sounds are hypoactive
D) The nasogastric tube output is 200 mL in 4 hours
Answer: B
Bright red blood draining from the nasogastric tube indicates active bleeding, which is a complication of gastric
surgery and requires immediate notification of the healthcare provider.
Question 8
A client with chronic obstructive pulmonary disease (COPD) has an oxygen saturation of 88% on room air. Which
action should the nurse take?
A) Administer oxygen at 2 L/min via nasal cannula
B) Administer oxygen at 6 L/min via nasal cannula
C) Encourage the client to take deep breaths
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Questions and Explained Answers with
Complete Solutions UPDATED!!!
Question 1
A client with type 2 diabetes mellitus reports episodes of weakness and palpitations. Which assessment finding
should the nurse prioritize?
A) Blood glucose level
B) Serum potassium level
C) Heart rate and rhythm
D) Blood pressure
Answer: A
Weakness and palpitations in a client with diabetes are classic symptoms of hypoglycemia. The nurse should
prioritize checking the blood glucose level to confirm or rule out hypoglycemia before initiating any
intervention.
Question 2
A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition should the nurse
recognize as a contraindication for peritoneal dialysis?
A) Peritoneal adhesions
B) Hypertension
C) Diabetes mellitus
Page 1 of 77
,D) Hyperlipidemia
Answer: A
Peritoneal adhesions or abdominal surgeries that compromise the peritoneal membrane are contraindications
for peritoneal dialysis because they reduce the surface area available for dialysis and increase the risk of
complications.
Question 3
The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral neuropathy. Which
information should the nurse provide?
A) Inspect feet daily for blisters or sores
B) Soak feet in warm water daily
C) Walk barefoot to improve circulation
D) Apply heating pads to numb feet
Answer: A
Clients with peripheral neuropathy have decreased sensation and are at high risk for foot ulcers. Daily foot
inspection is essential to detect injuries early. Clients should not walk barefoot or use heating pads due to burn
risk.
Question 4
Which nursing measure is essential to the nursing care of a client with a pressure injury?
A) Massage any reddened areas for at least five minutes
B) Reposition the client every 2 hours
Page 2 of 77
,C) Apply heat to promote circulation
D) Keep the wound open to air
Answer: B
Repositioning every 2 hours relieves pressure on bony prominences and is essential for preventing further tissue
damage. Massaging reddened areas can damage underlying capillaries.
Question 5
The nurse is assessing a client with a history of heart failure. Which finding indicates worsening of the condition?
A) Weight gain of 2 pounds in 24 hours
B) Decreased jugular venous distention
C) Clear breath sounds
D) Increased urine output
Answer: A
A weight gain of 2 pounds in 24 hours indicates fluid retention, which is a sign of worsening heart failure. Daily
weight monitoring is essential for early detection of fluid overload.
Question 6
A client with pneumonia has a temperature of 102.5°F, productive cough with green sputum, and decreased
breath sounds in the right lower lobe. Which intervention should the nurse implement first?
A) Administer prescribed antibiotics
B) Encourage deep breathing and coughing
C) Administer antipyretic medication
Page 3 of 77
, D) Obtain a sputum culture
Answer: D
A sputum culture should be obtained before initiating antibiotics to identify the causative organism and guide
appropriate antibiotic therapy. Antibiotics should be started after the culture is obtained.
Question 7
The nurse is caring for a client with a nasogastric tube to suction following a total gastrectomy. Which finding
requires immediate intervention?
A) The client reports nausea
B) The nasogastric tube is draining bright red blood
C) The client's bowel sounds are hypoactive
D) The nasogastric tube output is 200 mL in 4 hours
Answer: B
Bright red blood draining from the nasogastric tube indicates active bleeding, which is a complication of gastric
surgery and requires immediate notification of the healthcare provider.
Question 8
A client with chronic obstructive pulmonary disease (COPD) has an oxygen saturation of 88% on room air. Which
action should the nurse take?
A) Administer oxygen at 2 L/min via nasal cannula
B) Administer oxygen at 6 L/min via nasal cannula
C) Encourage the client to take deep breaths
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