BSN 266 HESI MED SURG FINAL EXAM
PREP QUESTIONS AND ANSWERS
1. A patient with a spinal cord injury at the T4 level reports a sudden, severe headache and
nasal congestion. The nurse notes the patient is diaphoretic and has a blood pressure of
190/100 mmHg. What is the priority nursing action?
A. Administer an antihypertensive medication as ordered.
B. Place the patient in a high-Fowler’s position.
C. Check the patient’s urinary catheter for kinks or obstruction.
D. Perform a digital rectal exam to check for fecal impaction.
Answer: B
Conceptual Explanation: The patient is exhibiting signs of autonomic dysreflexia. The
immediate priority is to elevate the head of the bed (High-Fowler’s) to help lower blood
pressure through orthostatic changes before addressing the underlying cause.
,2. A nurse is caring for a patient who is 2 hours post-operative following an abdominal
hysterectomy. The patient suddenly reports feeling a ‘pop’ and the nurse observes a loop of
bowel protruding through the incision. Which action should the nurse take first?
A. Apply a sterile dressing moistened with warm sterile normal saline.
B. Notify the surgeon immediately.
C. Instruct the patient to remain still and not to cough.
D. Attempt to gently push the bowel back into the abdominal cavity.
Answer: A
Conceptual Explanation: Evisceration is a medical emergency. The first priority is to
protect the exposed organs by covering them with sterile dressings soaked in sterile
normal saline to prevent drying and infection.
3. A patient is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). The nurse notes a
blood glucose of 550 mg/dL and a serum potassium of 3.6 mEq/L. The physician orders an
intravenous insulin drip. What is the most important action for the nurse to take regarding
the potassium?
A. Consult the provider about adding potassium to the IV fluids before starting insulin.
B. Wait for the potassium to drop below 3.5 mEq/L before starting replacement.
C. Administer insulin immediately and recheck potassium in 4 hours.
D. Check for peaked T-waves on the EKG before administering potassium.
, Answer: A
Conceptual Explanation: Insulin shifts potassium into the cells, which will further lower
the serum potassium level. Since the patient’s potassium is already near the low end of
normal (3.6), starting insulin without potassium replacement could lead to life-threatening
hypokalemia.
4. A patient who underwent a subtotal thyroidectomy 12 hours ago complains of numbness
and tingling in their fingertips and around the mouth. Which assessment should the nurse
perform next?
A. Assess for Chvostek’s sign by tapping the facial nerve.
B. Check the patient’s blood pressure for hypotension.
C. Examine the surgical dressing for increased drainage.
D. Evaluate the patient’s range of motion in the neck.
Answer: A
Conceptual Explanation: These symptoms are signs of hypocalcemia, a common
complication of thyroid surgery due to accidental damage or removal of the parathyroid
glands. Assessing for Chvostek’s or Trousseau’s sign confirms neuromuscular irritability.
5. The nurse is monitoring a patient with a chest tube following a lobectomy. The nurse
notices constant, vigorous bubbling in the water seal chamber. How should the nurse
interpret this finding?
A. The system is functioning normally for a post-lobectomy patient.
PREP QUESTIONS AND ANSWERS
1. A patient with a spinal cord injury at the T4 level reports a sudden, severe headache and
nasal congestion. The nurse notes the patient is diaphoretic and has a blood pressure of
190/100 mmHg. What is the priority nursing action?
A. Administer an antihypertensive medication as ordered.
B. Place the patient in a high-Fowler’s position.
C. Check the patient’s urinary catheter for kinks or obstruction.
D. Perform a digital rectal exam to check for fecal impaction.
Answer: B
Conceptual Explanation: The patient is exhibiting signs of autonomic dysreflexia. The
immediate priority is to elevate the head of the bed (High-Fowler’s) to help lower blood
pressure through orthostatic changes before addressing the underlying cause.
,2. A nurse is caring for a patient who is 2 hours post-operative following an abdominal
hysterectomy. The patient suddenly reports feeling a ‘pop’ and the nurse observes a loop of
bowel protruding through the incision. Which action should the nurse take first?
A. Apply a sterile dressing moistened with warm sterile normal saline.
B. Notify the surgeon immediately.
C. Instruct the patient to remain still and not to cough.
D. Attempt to gently push the bowel back into the abdominal cavity.
Answer: A
Conceptual Explanation: Evisceration is a medical emergency. The first priority is to
protect the exposed organs by covering them with sterile dressings soaked in sterile
normal saline to prevent drying and infection.
3. A patient is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). The nurse notes a
blood glucose of 550 mg/dL and a serum potassium of 3.6 mEq/L. The physician orders an
intravenous insulin drip. What is the most important action for the nurse to take regarding
the potassium?
A. Consult the provider about adding potassium to the IV fluids before starting insulin.
B. Wait for the potassium to drop below 3.5 mEq/L before starting replacement.
C. Administer insulin immediately and recheck potassium in 4 hours.
D. Check for peaked T-waves on the EKG before administering potassium.
, Answer: A
Conceptual Explanation: Insulin shifts potassium into the cells, which will further lower
the serum potassium level. Since the patient’s potassium is already near the low end of
normal (3.6), starting insulin without potassium replacement could lead to life-threatening
hypokalemia.
4. A patient who underwent a subtotal thyroidectomy 12 hours ago complains of numbness
and tingling in their fingertips and around the mouth. Which assessment should the nurse
perform next?
A. Assess for Chvostek’s sign by tapping the facial nerve.
B. Check the patient’s blood pressure for hypotension.
C. Examine the surgical dressing for increased drainage.
D. Evaluate the patient’s range of motion in the neck.
Answer: A
Conceptual Explanation: These symptoms are signs of hypocalcemia, a common
complication of thyroid surgery due to accidental damage or removal of the parathyroid
glands. Assessing for Chvostek’s or Trousseau’s sign confirms neuromuscular irritability.
5. The nurse is monitoring a patient with a chest tube following a lobectomy. The nurse
notices constant, vigorous bubbling in the water seal chamber. How should the nurse
interpret this finding?
A. The system is functioning normally for a post-lobectomy patient.
