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BSN HESI 266 Medical-Surgical
Nursing Comprehensive Exam
Questions With Verified Solutions -
Nightingale College
Question 1
A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with a blood pressure of 138/88 mm Hg who reports a headache
B. A client with a heart rate of 110/min who is anxious about an upcoming
procedure
C. A client with a respiratory rate of 28/min and SpO₂ of 88% on room air
D. A client with a temperature of 38.2°C (100.8°F) who has a surgical incision
Correct Answer: C
Rationale: According to the ABCs (Airway, Breathing, Circulation) priority
framework, the client with compromised oxygenation requires immediate
assessment and intervention. This represents a life-threatening situation.
Question 2
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A client admitted with acute decompensated heart failure has bibasilar crackles,
JVD, orthopnea, and a 6-pound weight gain over 3 days. Which pathophysiologic
mechanism best explains these findings?
A. Increased left ventricular afterload causing backward flow into the aorta
B. Left ventricular pumping failure causing pulmonary venous congestion
C. Right ventricular failure causing systemic venous congestion alone
D. Decreased preload causing decreased pulmonary capillary pressure
Correct Answer: B
Rationale: Left-sided heart failure impairs the left ventricle's ability to eject blood,
so pressure backs up into the left atrium and pulmonary veins, producing crackles,
orthopnea, dyspnea, and pulmonary edema; fluid retention then causes rapid
weight gain.
Question 3
A client receiving digoxin 0.25 mg daily has a digoxin level of 2.8 ng/mL and a
serum potassium of 3.1 mEq/L. The apical pulse is 58 and irregular. Which
interpretation by the nurse is correct?
A. The digoxin level is therapeutic and no action is needed
B. The client should receive an additional dose because the heart rate is below 60
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C. The potassium level indicates hyperkalemia, which protects against toxicity
D. The client has digoxin toxicity potentiated by hypokalemia and the next dose
should be withheld
Correct Answer: D
Rationale: The therapeutic digoxin range is 0.5 to 2.0 ng/mL, so a level of 2.8
ng/mL indicates toxicity, and the apical pulse below 60 confirms the need to
withhold the dose and notify the health care provider. Hypokalemia potentiates
digoxin toxicity.
Question 4
After checking the urinary drainage system for kinks in the tubing, the nurse
determines that a client who has returned from the post-anesthesia care unit has
a dark, concentrated urinary output of 54 mL for the last 2 hours. What priority
nursing action should be implemented?
A. Report the findings to the surgeon
B. Irrigate the indwelling urinary catheter
C. Apply manual pressure to the bladder
D. Increase the IV flow rate for 15 minutes
Correct Answer: A
BSN HESI 266 Medical-Surgical
Nursing Comprehensive Exam
Questions With Verified Solutions -
Nightingale College
Question 1
A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with a blood pressure of 138/88 mm Hg who reports a headache
B. A client with a heart rate of 110/min who is anxious about an upcoming
procedure
C. A client with a respiratory rate of 28/min and SpO₂ of 88% on room air
D. A client with a temperature of 38.2°C (100.8°F) who has a surgical incision
Correct Answer: C
Rationale: According to the ABCs (Airway, Breathing, Circulation) priority
framework, the client with compromised oxygenation requires immediate
assessment and intervention. This represents a life-threatening situation.
Question 2
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A client admitted with acute decompensated heart failure has bibasilar crackles,
JVD, orthopnea, and a 6-pound weight gain over 3 days. Which pathophysiologic
mechanism best explains these findings?
A. Increased left ventricular afterload causing backward flow into the aorta
B. Left ventricular pumping failure causing pulmonary venous congestion
C. Right ventricular failure causing systemic venous congestion alone
D. Decreased preload causing decreased pulmonary capillary pressure
Correct Answer: B
Rationale: Left-sided heart failure impairs the left ventricle's ability to eject blood,
so pressure backs up into the left atrium and pulmonary veins, producing crackles,
orthopnea, dyspnea, and pulmonary edema; fluid retention then causes rapid
weight gain.
Question 3
A client receiving digoxin 0.25 mg daily has a digoxin level of 2.8 ng/mL and a
serum potassium of 3.1 mEq/L. The apical pulse is 58 and irregular. Which
interpretation by the nurse is correct?
A. The digoxin level is therapeutic and no action is needed
B. The client should receive an additional dose because the heart rate is below 60
, 3|Page
C. The potassium level indicates hyperkalemia, which protects against toxicity
D. The client has digoxin toxicity potentiated by hypokalemia and the next dose
should be withheld
Correct Answer: D
Rationale: The therapeutic digoxin range is 0.5 to 2.0 ng/mL, so a level of 2.8
ng/mL indicates toxicity, and the apical pulse below 60 confirms the need to
withhold the dose and notify the health care provider. Hypokalemia potentiates
digoxin toxicity.
Question 4
After checking the urinary drainage system for kinks in the tubing, the nurse
determines that a client who has returned from the post-anesthesia care unit has
a dark, concentrated urinary output of 54 mL for the last 2 hours. What priority
nursing action should be implemented?
A. Report the findings to the surgeon
B. Irrigate the indwelling urinary catheter
C. Apply manual pressure to the bladder
D. Increase the IV flow rate for 15 minutes
Correct Answer: A
