BSN HESI 266 MED SURG EXAM SCRIPT
2026 COMPREHENSIVE QUESTIONS WITH
VERIFIED SOLUTIONS
◉ The nurse is caring for a client with a continuous feeding through
a percutaneous endoscopic gastrostomy (PEG) tube. Which
intervention should the nurse include in the plan of care?
A. Flush the tube with 50 ml of water q 8 hours.
B. Check for tube placement and residual volume q4 hours.
C. Obtain a daily x- ray to verify tube placement.
D. Position on left side with head of bed elevated 45 degrees.
Answer: B. Check for tube placement and residual volume q4 hours.
Rationale
Tube placement and residual volume should be checked every four
hours for clients on continuous feeding. If the gastric residual is
more than 200mL for an adult client; stop the feeding and re-check
the gastric residual one hour later. If the residual still remains more
than 200mL; continue to keep the feeding on hold and contact the
client's health care provider.
◉ Which assessment finding by the nurse during a client's clinical
breast examination requires follow-up?
A. Newly retracted nipple.
,B. A thickened area where the skin folds under the breast.
C. Whitish nipple discharge.
D. Tender lumpiness noted bilaterally throughout the breasts.
Answer: A. Newly retracted nipple.
Rationale
A newly retracted nipple, compared to a life-long finding, may be an
indication of breast cancer and requires additional follow-up.
◉ A client has been taking oral corticosteroids for the past five days
because of seasonal allergies. Which assessment finding is of most
concern to the nurse?
A. White blood count of 10,000 mm3.
B. Serum glucose of 115 mg/dl.
C. Purulent sputum.
D. Excessive hunger.
Answer: C. Purulent sputum.
Rationale
Steroids cause immunosuppression, and a purulent sputum is an
indication of infection, so this symptom is of greatest concern.
◉ The nurse is completing an admission interview and assessment
on a client with a history of Parkinson's disease. Which question
provides information relevant to the client's plan of care?
,A. "Have you ever experienced any paralysis of your arms or legs?"
B. "Have you ever sustained a severe head injury?"
C. "Have you ever been 'frozen' in one spot, unable to move?"
D. "Do you have headaches, especially ones with throbbing pain?"
Answer: C. "Have you ever been 'frozen' in one spot, unable to
move?"
Rationale
Clients with Parkinson's disease frequently experience difficulty in
initiating, maintaining, and performing motor activities. They may
even experience being rooted to a spot and unable to move, refer to
as being "frozen" in one spot.
◉ The nurse working on a telemetry unit finds a client unconscious
and in pulseless ventricular tachycardia (VT). The client has an
implanted automatic defibrillator. What action should the nurse
implement?
A. Prepare the client for transcutaneous pacemaker.
B. Shock the client with 200 joules per hospital policy.
C. Use a magnet to deactivate the implanted pacemaker.
D. Observe the monitor until the onset of ventricular fibrillation.
Answer: B. Shock the client with 200 joules per hospital policy.
Rationale
, The client must be externally shocked 200 joules per hospital policy
to restore an effective cardiac rhythm. The automatic defibrillator is
obviously malfunctioning.
◉ In assessing a client diagnosed with primary hyperaldosteronism,
the nurse expects the laboratory test results to indicate a decreased
serum level of which substance?
A. Sodium.
B. Antidiuretic hormone.
C. Potassium.
D. Glucose.
Answer: C. Potassium.
Rationale
Clients with primary hyperaldosteronism exhibit a profound decline
in the serum levels of potassium (hypokalemia). Hypertension, along
with the hypokalemia are the most prominent and universal signs
for this condition. If both of these findings are present, there is 50%
likelihood the client to be diagnosed with hyperaldosteronism.
◉ The healthcare provider prescribes aluminum and magnesium
hydroxide (Maalox), 1 tablet PO PRN, for a client with chronic kidney
disease (CKD) who is complaining of indigestion. What intervention
should the nurse implement?
A. Administer 30 minutes before eating.
B. Evaluate the effectiveness 1 hour after administration.
2026 COMPREHENSIVE QUESTIONS WITH
VERIFIED SOLUTIONS
◉ The nurse is caring for a client with a continuous feeding through
a percutaneous endoscopic gastrostomy (PEG) tube. Which
intervention should the nurse include in the plan of care?
A. Flush the tube with 50 ml of water q 8 hours.
B. Check for tube placement and residual volume q4 hours.
C. Obtain a daily x- ray to verify tube placement.
D. Position on left side with head of bed elevated 45 degrees.
Answer: B. Check for tube placement and residual volume q4 hours.
Rationale
Tube placement and residual volume should be checked every four
hours for clients on continuous feeding. If the gastric residual is
more than 200mL for an adult client; stop the feeding and re-check
the gastric residual one hour later. If the residual still remains more
than 200mL; continue to keep the feeding on hold and contact the
client's health care provider.
◉ Which assessment finding by the nurse during a client's clinical
breast examination requires follow-up?
A. Newly retracted nipple.
,B. A thickened area where the skin folds under the breast.
C. Whitish nipple discharge.
D. Tender lumpiness noted bilaterally throughout the breasts.
Answer: A. Newly retracted nipple.
Rationale
A newly retracted nipple, compared to a life-long finding, may be an
indication of breast cancer and requires additional follow-up.
◉ A client has been taking oral corticosteroids for the past five days
because of seasonal allergies. Which assessment finding is of most
concern to the nurse?
A. White blood count of 10,000 mm3.
B. Serum glucose of 115 mg/dl.
C. Purulent sputum.
D. Excessive hunger.
Answer: C. Purulent sputum.
Rationale
Steroids cause immunosuppression, and a purulent sputum is an
indication of infection, so this symptom is of greatest concern.
◉ The nurse is completing an admission interview and assessment
on a client with a history of Parkinson's disease. Which question
provides information relevant to the client's plan of care?
,A. "Have you ever experienced any paralysis of your arms or legs?"
B. "Have you ever sustained a severe head injury?"
C. "Have you ever been 'frozen' in one spot, unable to move?"
D. "Do you have headaches, especially ones with throbbing pain?"
Answer: C. "Have you ever been 'frozen' in one spot, unable to
move?"
Rationale
Clients with Parkinson's disease frequently experience difficulty in
initiating, maintaining, and performing motor activities. They may
even experience being rooted to a spot and unable to move, refer to
as being "frozen" in one spot.
◉ The nurse working on a telemetry unit finds a client unconscious
and in pulseless ventricular tachycardia (VT). The client has an
implanted automatic defibrillator. What action should the nurse
implement?
A. Prepare the client for transcutaneous pacemaker.
B. Shock the client with 200 joules per hospital policy.
C. Use a magnet to deactivate the implanted pacemaker.
D. Observe the monitor until the onset of ventricular fibrillation.
Answer: B. Shock the client with 200 joules per hospital policy.
Rationale
, The client must be externally shocked 200 joules per hospital policy
to restore an effective cardiac rhythm. The automatic defibrillator is
obviously malfunctioning.
◉ In assessing a client diagnosed with primary hyperaldosteronism,
the nurse expects the laboratory test results to indicate a decreased
serum level of which substance?
A. Sodium.
B. Antidiuretic hormone.
C. Potassium.
D. Glucose.
Answer: C. Potassium.
Rationale
Clients with primary hyperaldosteronism exhibit a profound decline
in the serum levels of potassium (hypokalemia). Hypertension, along
with the hypokalemia are the most prominent and universal signs
for this condition. If both of these findings are present, there is 50%
likelihood the client to be diagnosed with hyperaldosteronism.
◉ The healthcare provider prescribes aluminum and magnesium
hydroxide (Maalox), 1 tablet PO PRN, for a client with chronic kidney
disease (CKD) who is complaining of indigestion. What intervention
should the nurse implement?
A. Administer 30 minutes before eating.
B. Evaluate the effectiveness 1 hour after administration.
