BSN 266 HESI V1 QUESTIONS AND ANSWERS ALREADY GRADED A+. 100% Verified Solutions | Updated Per
Latest Guidelines | Graded A+ Nightingale.
Core Domains
Medical-Surgical Nursing: Cardiovascular and Respiratory Disorders
Medical-Surgical Nursing: Gastrointestinal, Renal, and Endocrine Disorders
Medical-Surgical Nursing: Neurological and Musculoskeletal Disorders
Pharmacology and Medication Administration
Fluid, Electrolyte, and Acid-Base Balance
Perioperative and Postoperative Nursing Care
Infection Control and Safety
Nursing Leadership, Delegation, and Prioritization
This comprehensive assessment evaluates critical nursing knowledge and clinical decision-making skills essential
for safe, effective medical-surgical nursing practice. The exam assesses mastery of foundational theory, applied
professional knowledge, regulatory compliance, ethics, and professional standards through multiple-choice and
scenario-based questions. Skills and knowledge assessed include pathophysiology recognition, pharmacological
interventions, patient monitoring, emergency response, and therapeutic communication. Questions emphasize
real-world application requiring critical thinking, prioritization, and evidence-based decision-making in diverse
,clinical scenarios. The exam structure presents 100 multiple-choice questions with four options each, simulating
actual healthcare environments. Each question includes verified correct answers with detailed rationales explaining
clinical reasoning. This format prepares nurses for professional certification, licensure, and clinical competency
validation.
SECTION ONE
Questions 1–100
Question 1
A client who underwent cardiac stent placement four days ago arrives at the emergency department reporting a
sudden onset of chest pressure and shortness of breath. Which action should the nurse take next?
A. Listen for extra heart sounds, murmurs, and rhythm with the bell of the stethoscope.
B. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema.
C. Verify troponin level assessments are scheduled every 3-6 hours for a series of three.
D. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring.
🟢 Correct Answer:
D. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring.
,🔴 RATIONALE:
Sudden chest pressure and shortness of breath after stent placement suggest possible stent thrombosis or
acute myocardial infarction. The priority is to obtain a 12-lead ECG and initiate continuous cardiac monitoring
to assess for ischemic changes and guide immediate intervention. While auscultation, perfusion assessment,
and troponin monitoring are important components of cardiac assessment, they should follow the immediate
ECG to rapidly identify life-threatening changes.
Question 2
A client with chronic heart failure reports a weight gain of 3 pounds in 24 hours and increased dyspnea. Which
action should the nurse take first?
A. Encourage the client to restrict oral fluids to 1 liter per day.
B. Auscultate lung sounds for crackles or wheezes.
C. Assess for jugular vein distention and peripheral edema.
D. Administer a prescribed PRN dose of furosemide.
🟢 Correct Answer:
C. Assess for jugular vein distention and peripheral edema.
🔴 RATIONALE:
, The nurse should first assess for signs of fluid overload, including jugular vein distention and peripheral edema,
to confirm worsening heart failure before implementing interventions such as diuretic administration or fluid
restriction. While lung auscultation is also important, assessing for JVD and edema provides more direct
evidence of fluid volume status. Assessment must precede intervention to ensure appropriate action.
Question 3
A client with type 2 diabetes mellitus arrives at the clinic reporting episodes of weakness and palpitations.
Which finding should the nurse recognize as a possible complication?
A. Anxiety and sighing
B. Myalgia in wrists and hands
C. Hyperactive bowel sounds
D. Dark yellow urine
🟢 Correct Answer:
D. Dark yellow urine
🔴 RATIONALE:
Dark yellow urine may indicate dehydration, which is a common complication in clients with diabetes mellitus
due to hyperglycemia-induced osmotic diuresis. Weakness and palpitations can be related to electrolyte
imbalances from dehydration. The other options are not directly associated with diabetes-related complications
and would require further assessment to determine significance.
Latest Guidelines | Graded A+ Nightingale.
Core Domains
Medical-Surgical Nursing: Cardiovascular and Respiratory Disorders
Medical-Surgical Nursing: Gastrointestinal, Renal, and Endocrine Disorders
Medical-Surgical Nursing: Neurological and Musculoskeletal Disorders
Pharmacology and Medication Administration
Fluid, Electrolyte, and Acid-Base Balance
Perioperative and Postoperative Nursing Care
Infection Control and Safety
Nursing Leadership, Delegation, and Prioritization
This comprehensive assessment evaluates critical nursing knowledge and clinical decision-making skills essential
for safe, effective medical-surgical nursing practice. The exam assesses mastery of foundational theory, applied
professional knowledge, regulatory compliance, ethics, and professional standards through multiple-choice and
scenario-based questions. Skills and knowledge assessed include pathophysiology recognition, pharmacological
interventions, patient monitoring, emergency response, and therapeutic communication. Questions emphasize
real-world application requiring critical thinking, prioritization, and evidence-based decision-making in diverse
,clinical scenarios. The exam structure presents 100 multiple-choice questions with four options each, simulating
actual healthcare environments. Each question includes verified correct answers with detailed rationales explaining
clinical reasoning. This format prepares nurses for professional certification, licensure, and clinical competency
validation.
SECTION ONE
Questions 1–100
Question 1
A client who underwent cardiac stent placement four days ago arrives at the emergency department reporting a
sudden onset of chest pressure and shortness of breath. Which action should the nurse take next?
A. Listen for extra heart sounds, murmurs, and rhythm with the bell of the stethoscope.
B. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema.
C. Verify troponin level assessments are scheduled every 3-6 hours for a series of three.
D. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring.
🟢 Correct Answer:
D. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring.
,🔴 RATIONALE:
Sudden chest pressure and shortness of breath after stent placement suggest possible stent thrombosis or
acute myocardial infarction. The priority is to obtain a 12-lead ECG and initiate continuous cardiac monitoring
to assess for ischemic changes and guide immediate intervention. While auscultation, perfusion assessment,
and troponin monitoring are important components of cardiac assessment, they should follow the immediate
ECG to rapidly identify life-threatening changes.
Question 2
A client with chronic heart failure reports a weight gain of 3 pounds in 24 hours and increased dyspnea. Which
action should the nurse take first?
A. Encourage the client to restrict oral fluids to 1 liter per day.
B. Auscultate lung sounds for crackles or wheezes.
C. Assess for jugular vein distention and peripheral edema.
D. Administer a prescribed PRN dose of furosemide.
🟢 Correct Answer:
C. Assess for jugular vein distention and peripheral edema.
🔴 RATIONALE:
, The nurse should first assess for signs of fluid overload, including jugular vein distention and peripheral edema,
to confirm worsening heart failure before implementing interventions such as diuretic administration or fluid
restriction. While lung auscultation is also important, assessing for JVD and edema provides more direct
evidence of fluid volume status. Assessment must precede intervention to ensure appropriate action.
Question 3
A client with type 2 diabetes mellitus arrives at the clinic reporting episodes of weakness and palpitations.
Which finding should the nurse recognize as a possible complication?
A. Anxiety and sighing
B. Myalgia in wrists and hands
C. Hyperactive bowel sounds
D. Dark yellow urine
🟢 Correct Answer:
D. Dark yellow urine
🔴 RATIONALE:
Dark yellow urine may indicate dehydration, which is a common complication in clients with diabetes mellitus
due to hyperglycemia-induced osmotic diuresis. Weakness and palpitations can be related to electrolyte
imbalances from dehydration. The other options are not directly associated with diabetes-related complications
and would require further assessment to determine significance.
