, BSN HESI 266 MED SURG EXAM with Questions and
Answers/Plus a Rationale Updated 2026 A+/Instant
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EXAM COVERAGE - 1. Cardiovascular Disorders - 2.
Respiratory Disorders - 3. Renal and Genitourinary Disorders
- 4. Endocrine Disorders - 5. Gastrointestinal and Hepatic
Disorders - 6. Neurological and Musculoskeletal Conditions -
7. Fluid, Electrolyte, and Acid-Base Imbalances - 8.
Perioperative Care and Patient Safety
1. A client who is 2 hours post-transurethral resection of the prostate (TURP) with continuous
bladder irrigation (CBI) reports a strong urge to urinate and lower abdominal cramping around
the catheter. What is the initial nursing action?
A. Administer a scheduled dose of IV morphine sulfate immediately.
B. Manually irrigate the catheter with 50 mL of sterile normal saline.
C. Check the patency of the drainage tubing and verify the flow rate of the irrigation.
D. Deflate the balloon slightly to relieve bladder pressure against the trigone.
CORRECT ANSWER : C
Rationale: The client's sensation of a strong urge to urinate and cramping typically indicates
bladder spasms caused by catheter blockage from blood clots or kinks in the tubing. The nurse
should first assess the drainage system for kinks, twists, or blood clot obstructions before
attempting manual irrigation or administering analgesics. Manual irrigation (option B) is only
performed after confirming a mechanical obstruction in the tubing, whereas deflating the
balloon (option D) is contraindicated because it can cause hemorrhage and dislodge the
catheter.
2. A client with chronic kidney disease (CKD) has a serum potassium level of 6.8 mEq/L and
exhibits peaked T waves on the electrocardiogram (ECG). Which prescribed medication should
the nurse administer first?
, A. Sodium polystyrene sulfonate oral suspension
B. Calcium gluconate intravenous infusion
C. Regular insulin with 50 mL of 50% dextrose intravenous push
D. Furosemide intravenous bolus injection
CORRECT ANSWER : B
Rationale: A potassium level of 6.8 mEq/L combined with ECG changes (peaked T waves)
indicates severe hyperkalemia that places the client at immediate risk for lethal ventricular
dysrhythmias. Intravenous calcium gluconate must be administered first to stabilize the
myocardial cell membrane and protect the heart, even though it does not lower serum potassium
levels. Insulin and glucose (option C) or sodium polystyrene sulfonate (option A) are given
subsequently to shift potassium into cells or eliminate it from the body.
3. A client is admitted with a diagnosis of acute myocardial infarction (MI). Which assessment
finding warrants immediate notification of the healthcare provider?
A. Blood pressure of 118/76 mmHg and heart rate of 88 beats/minute
B. New onset of fine crackles bilaterally in the lung bases and an S3 heart sound
C. Mild, dull chest discomfort controlled with sublingual nitroglycerin
D. Serum troponin T level elevated at 4.5 ng/mL
CORRECT ANSWER : B
Rationale: The development of bilateral basal crackles and an S3 heart sound indicates acute
left ventricular failure leading to pulmonary congestion, which is a life-threatening complication
of myocardial infarction requiring immediate intervention. While elevated troponin (option D)
confirms myocardial injury and chest discomfort (option C) requires ongoing monitoring, acute
heart failure symptoms demand rapid intervention to prevent pulmonary edema and cardiogenic
shock. Stable hemodynamics (option A) are reassuring.
4. A nurse is caring for a client with type 1 diabetes mellitus who is brought to the emergency
department unresponsive, with deep, rapid respirations and a fruity odor to the breath.
Laboratory results reveal blood glucose of 480 mg/dL, pH 7.21, and serum bicarbonate of 12
mEq/L. Which intravenous fluid order should the nurse anticipate initiating first?
, A. 0.9% Sodium Chloride injection at 500 to 1000 mL/hour
B. 0.45% Sodium Chloride injection with 20 mEq potassium chloride
C. 5% Dextrose in 0.9% Sodium Chloride injection
D. 5% Dextrose in Water (D5W) at 50 mL/hour
CORRECT ANSWER : A
Rationale: Diabetic ketoacidosis (DKA) results in severe extracellular fluid volume depletion
due to osmotic diuresis. The primary initial goal of therapy is restoring intravascular volume
and tissue perfusion by administering isotonic 0.9% sodium chloride rapidly. Hypotonic
solutions (option B) or dextrose-containing fluids (options C and D) are introduced later once
blood glucose levels decline and hydration is partially restored.
5. A client with liver cirrhosis and massive ascites is scheduled for a paracentesis. Which nursing
intervention is essential prior to the procedure?
A. Administer a prescribed soap suds enema to clear the lower bowel.
B. Place the client in a strict prone position to pool peritoneal fluid.
C. Instruct the client to empty their urinary bladder completely.
D. Infuse 1000 mL of 5% Albumin rapidly to prevent hypertension.
CORRECT ANSWER : C
Rationale: To prevent accidental perforation of the urinary bladder during needle insertion for a
paracentesis, the client must empty the bladder immediately before the procedure. A semi-
Fowler's or upright position is preferred to pool fluid in the lower abdomen (ruling out prone
positioning). Albumin infusions (option D) are often given post-procedure for large-volume taps
to prevent circulatory collapse, not pre-procedure.
6. A nurse is evaluating a client receiving a unit of packed red blood cells (PRBCs) who develops
lower back pain, chills, and hypotension 15 minutes after the infusion starts. What is the nurse's
priority action?
A. Slow the blood infusion rate by half and notify the blood bank.
Answers/Plus a Rationale Updated 2026 A+/Instant
Download PDF
EXAM COVERAGE - 1. Cardiovascular Disorders - 2.
Respiratory Disorders - 3. Renal and Genitourinary Disorders
- 4. Endocrine Disorders - 5. Gastrointestinal and Hepatic
Disorders - 6. Neurological and Musculoskeletal Conditions -
7. Fluid, Electrolyte, and Acid-Base Imbalances - 8.
Perioperative Care and Patient Safety
1. A client who is 2 hours post-transurethral resection of the prostate (TURP) with continuous
bladder irrigation (CBI) reports a strong urge to urinate and lower abdominal cramping around
the catheter. What is the initial nursing action?
A. Administer a scheduled dose of IV morphine sulfate immediately.
B. Manually irrigate the catheter with 50 mL of sterile normal saline.
C. Check the patency of the drainage tubing and verify the flow rate of the irrigation.
D. Deflate the balloon slightly to relieve bladder pressure against the trigone.
CORRECT ANSWER : C
Rationale: The client's sensation of a strong urge to urinate and cramping typically indicates
bladder spasms caused by catheter blockage from blood clots or kinks in the tubing. The nurse
should first assess the drainage system for kinks, twists, or blood clot obstructions before
attempting manual irrigation or administering analgesics. Manual irrigation (option B) is only
performed after confirming a mechanical obstruction in the tubing, whereas deflating the
balloon (option D) is contraindicated because it can cause hemorrhage and dislodge the
catheter.
2. A client with chronic kidney disease (CKD) has a serum potassium level of 6.8 mEq/L and
exhibits peaked T waves on the electrocardiogram (ECG). Which prescribed medication should
the nurse administer first?
, A. Sodium polystyrene sulfonate oral suspension
B. Calcium gluconate intravenous infusion
C. Regular insulin with 50 mL of 50% dextrose intravenous push
D. Furosemide intravenous bolus injection
CORRECT ANSWER : B
Rationale: A potassium level of 6.8 mEq/L combined with ECG changes (peaked T waves)
indicates severe hyperkalemia that places the client at immediate risk for lethal ventricular
dysrhythmias. Intravenous calcium gluconate must be administered first to stabilize the
myocardial cell membrane and protect the heart, even though it does not lower serum potassium
levels. Insulin and glucose (option C) or sodium polystyrene sulfonate (option A) are given
subsequently to shift potassium into cells or eliminate it from the body.
3. A client is admitted with a diagnosis of acute myocardial infarction (MI). Which assessment
finding warrants immediate notification of the healthcare provider?
A. Blood pressure of 118/76 mmHg and heart rate of 88 beats/minute
B. New onset of fine crackles bilaterally in the lung bases and an S3 heart sound
C. Mild, dull chest discomfort controlled with sublingual nitroglycerin
D. Serum troponin T level elevated at 4.5 ng/mL
CORRECT ANSWER : B
Rationale: The development of bilateral basal crackles and an S3 heart sound indicates acute
left ventricular failure leading to pulmonary congestion, which is a life-threatening complication
of myocardial infarction requiring immediate intervention. While elevated troponin (option D)
confirms myocardial injury and chest discomfort (option C) requires ongoing monitoring, acute
heart failure symptoms demand rapid intervention to prevent pulmonary edema and cardiogenic
shock. Stable hemodynamics (option A) are reassuring.
4. A nurse is caring for a client with type 1 diabetes mellitus who is brought to the emergency
department unresponsive, with deep, rapid respirations and a fruity odor to the breath.
Laboratory results reveal blood glucose of 480 mg/dL, pH 7.21, and serum bicarbonate of 12
mEq/L. Which intravenous fluid order should the nurse anticipate initiating first?
, A. 0.9% Sodium Chloride injection at 500 to 1000 mL/hour
B. 0.45% Sodium Chloride injection with 20 mEq potassium chloride
C. 5% Dextrose in 0.9% Sodium Chloride injection
D. 5% Dextrose in Water (D5W) at 50 mL/hour
CORRECT ANSWER : A
Rationale: Diabetic ketoacidosis (DKA) results in severe extracellular fluid volume depletion
due to osmotic diuresis. The primary initial goal of therapy is restoring intravascular volume
and tissue perfusion by administering isotonic 0.9% sodium chloride rapidly. Hypotonic
solutions (option B) or dextrose-containing fluids (options C and D) are introduced later once
blood glucose levels decline and hydration is partially restored.
5. A client with liver cirrhosis and massive ascites is scheduled for a paracentesis. Which nursing
intervention is essential prior to the procedure?
A. Administer a prescribed soap suds enema to clear the lower bowel.
B. Place the client in a strict prone position to pool peritoneal fluid.
C. Instruct the client to empty their urinary bladder completely.
D. Infuse 1000 mL of 5% Albumin rapidly to prevent hypertension.
CORRECT ANSWER : C
Rationale: To prevent accidental perforation of the urinary bladder during needle insertion for a
paracentesis, the client must empty the bladder immediately before the procedure. A semi-
Fowler's or upright position is preferred to pool fluid in the lower abdomen (ruling out prone
positioning). Albumin infusions (option D) are often given post-procedure for large-volume taps
to prevent circulatory collapse, not pre-procedure.
6. A nurse is evaluating a client receiving a unit of packed red blood cells (PRBCs) who develops
lower back pain, chills, and hypotension 15 minutes after the infusion starts. What is the nurse's
priority action?
A. Slow the blood infusion rate by half and notify the blood bank.
