BSN 266 MED SURG HESI EXAM 2025
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES/ HESI MED SURG BSN 266 LATEST
EXAM/HESI MED SURG BSN 266(NEW)
a nurse is planning care to prevent complications for a client with multiple
myeloma. Which intervention is most important for the nurse to include? -
ANSWER-maintain a fluid intake of 3-4 l per day
How should the nurse position the electrodes for modified chest lead one (MCL I)
telemetry monitoring?
A) Positive polarity right shoulder, negative polarity left shoulder, ground left chest
nipple line.
B) Positive polarity left shoulder, negative polarity right chest nipple line, ground
left chest nipple line.
C) Positive polarity right chest nipple line, negative polarity left chest nipple line,
ground left shoulder.
D) Negative polarity left shoulder, positive polarity right chest nipple line, ground
left chest nipple line. - ANSWER-Negative polarity left shoulder, positive polarity
right chest nipple line, ground left chest nipple line.
the nurse is caring for a client with a stroke resulting in right-sided paresis and
aphasia. The client attempts to use the left hand for feeding and other self care
activites. The spouse becomes frustrated and insists on doing everything for the
client. based on this data, which nursing diagnosis should the nurse document for
this client? - ANSWER-disabled family coping related to dissonant comping style
of significant person
HESI MED SURG BSN 266(NEW)
,A 77 yr old female is admitted to the hospital. She is confused, has no appetite, is
nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43
bpm. Which question is priority for the nurse to ask this pt or her family on
admission? - ANSWER-Does the pt take digitalis?
It is important to obtain a complete medication history, the symptoms described are
classic for digitalis toxicity and assessment of this problem should be made
promptly.
The nurse is working with a 71 yr old obese pt with bilateral osteoarthritis of the
hips. What recommendation should the nurse make that is most beneficial in
protecting the pt joints? - ANSWER-Initiate a weight-reduction diet to achieve a
healthy body weight.
Achieving a healthy weight is critical to protect the joints of pt with OA. Weight
loss will take off the excess pressure that joints are exposed to
An elderly male pt comes to the geriatric screening clinic complaining of pain in
his left calf. The nurse notices a reddened area on the calf of his right leg which is
warm to the touch and suspects it might be thrombophlebitis. Which type of pain
would further confirm this suspicion? - ANSWER-Pain in the calf upon exertion
which is relieved by rest and elevating the extremity.
In preparing to administer intravenous albumin to a client following surgery, what
is the priority nursing intervention? (Select all that apply.)
A) Set the infusion pump to infuse the albumin within four hours.
B) Compare the client's blood type with the label on the albumin.
C) Assign a UAP to monitor blood pressure q15 minutes.
D) Administer through a large gauge catheter.
E) Monitor hemoglobin and hematocrit levels.
HESI MED SURG BSN 266(NEW)
,F) Assess for increased bleeding after administration. - ANSWER-A,d, e, f
A male client receives a local anesthetic during surgery. During the post-operative
assessment, the nurse notices the client is slurring his speech. Which action should
the nurse take?
A) Determine the client is anxious and allow him to sleep.
B) Evaluate his blood pressure, pulse, and respiratory status.
C) Review the client's pre-operative history for alcohol abuse.
D) Continue to monitor the client for reactivity to anesthesia. - ANSWER-Evaluate
his BP, pulse, and respiratory status
Slurred speech in the post operative client who received a local anesthesia is an
atypical finding and may indicate neurological deficits that require further
assessment.
Which symptoms should the nurse expect a client to exhibit who is diagnosed with
a pheochromocytoma? - ANSWER-Headache, diaphoresis, and palpitations
A client with diabetes mellitus is experiencing polyphagia. Which outcome
statement is the priority for this client?
A) Fluid and electrolyte balance.
B) Prevention of water toxicity.
C) Reduced glucose in the urine.
D) Adequate cellular nourishment. - ANSWER-Adequate cellular nourishment
The nurse is teaching a female client about the best time to plan intercourse in
order to conceive. Which information should the nurse provide? - ANSWER-Two
weeks before menstruation
HESI MED SURG BSN 266(NEW)
, Which intervention should the nurse plan to implement when caring for a client
who has just undergone a right above-the-knee amputation?
A) Maintain the residual limb on three pillows at all times.
B) Place a large tourniquet at the client's bedside.
C) Apply constant, direct pressure to the residual limb.
D) Do not allow the client to lie in the prone position. - ANSWER-B) Place a large
tourniquet at the client's bedside.
A large tourniquet should be placed in plain sight at the client's bedside (B). If
severe bleeding occurs, the tourniquet should be readily available and applied to
the residual limb to control hemorrhage.
The nurse is preparing a client for orthopedic surgery on the left leg and
completing a safety checklist before transport to the operating room. Which items
should the nurse remove from the client? - ANSWER-Nail polish - provides more
accurate pulse oximetry
Hearing aids, contact lenses, partial dentures - removed to prevent damage, loss or
misplacement, or injury during surgery
What instruction should the nurse include in the discharge teaching for a client
who needs to preform self-catherization technique at home? - ANSWER-
Catheterize every 3-4 hours
The nurse assesses a long-term resident of a nursing home and finds the client has
a fungal infection beneath both breasts. To prevent nosocomial infection, which
protocol should the nurse review with the rest of the staff? - ANSWER-Wash hands
after caring for the client
HESI MED SURG BSN 266(NEW)
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES/ HESI MED SURG BSN 266 LATEST
EXAM/HESI MED SURG BSN 266(NEW)
a nurse is planning care to prevent complications for a client with multiple
myeloma. Which intervention is most important for the nurse to include? -
ANSWER-maintain a fluid intake of 3-4 l per day
How should the nurse position the electrodes for modified chest lead one (MCL I)
telemetry monitoring?
A) Positive polarity right shoulder, negative polarity left shoulder, ground left chest
nipple line.
B) Positive polarity left shoulder, negative polarity right chest nipple line, ground
left chest nipple line.
C) Positive polarity right chest nipple line, negative polarity left chest nipple line,
ground left shoulder.
D) Negative polarity left shoulder, positive polarity right chest nipple line, ground
left chest nipple line. - ANSWER-Negative polarity left shoulder, positive polarity
right chest nipple line, ground left chest nipple line.
the nurse is caring for a client with a stroke resulting in right-sided paresis and
aphasia. The client attempts to use the left hand for feeding and other self care
activites. The spouse becomes frustrated and insists on doing everything for the
client. based on this data, which nursing diagnosis should the nurse document for
this client? - ANSWER-disabled family coping related to dissonant comping style
of significant person
HESI MED SURG BSN 266(NEW)
,A 77 yr old female is admitted to the hospital. She is confused, has no appetite, is
nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43
bpm. Which question is priority for the nurse to ask this pt or her family on
admission? - ANSWER-Does the pt take digitalis?
It is important to obtain a complete medication history, the symptoms described are
classic for digitalis toxicity and assessment of this problem should be made
promptly.
The nurse is working with a 71 yr old obese pt with bilateral osteoarthritis of the
hips. What recommendation should the nurse make that is most beneficial in
protecting the pt joints? - ANSWER-Initiate a weight-reduction diet to achieve a
healthy body weight.
Achieving a healthy weight is critical to protect the joints of pt with OA. Weight
loss will take off the excess pressure that joints are exposed to
An elderly male pt comes to the geriatric screening clinic complaining of pain in
his left calf. The nurse notices a reddened area on the calf of his right leg which is
warm to the touch and suspects it might be thrombophlebitis. Which type of pain
would further confirm this suspicion? - ANSWER-Pain in the calf upon exertion
which is relieved by rest and elevating the extremity.
In preparing to administer intravenous albumin to a client following surgery, what
is the priority nursing intervention? (Select all that apply.)
A) Set the infusion pump to infuse the albumin within four hours.
B) Compare the client's blood type with the label on the albumin.
C) Assign a UAP to monitor blood pressure q15 minutes.
D) Administer through a large gauge catheter.
E) Monitor hemoglobin and hematocrit levels.
HESI MED SURG BSN 266(NEW)
,F) Assess for increased bleeding after administration. - ANSWER-A,d, e, f
A male client receives a local anesthetic during surgery. During the post-operative
assessment, the nurse notices the client is slurring his speech. Which action should
the nurse take?
A) Determine the client is anxious and allow him to sleep.
B) Evaluate his blood pressure, pulse, and respiratory status.
C) Review the client's pre-operative history for alcohol abuse.
D) Continue to monitor the client for reactivity to anesthesia. - ANSWER-Evaluate
his BP, pulse, and respiratory status
Slurred speech in the post operative client who received a local anesthesia is an
atypical finding and may indicate neurological deficits that require further
assessment.
Which symptoms should the nurse expect a client to exhibit who is diagnosed with
a pheochromocytoma? - ANSWER-Headache, diaphoresis, and palpitations
A client with diabetes mellitus is experiencing polyphagia. Which outcome
statement is the priority for this client?
A) Fluid and electrolyte balance.
B) Prevention of water toxicity.
C) Reduced glucose in the urine.
D) Adequate cellular nourishment. - ANSWER-Adequate cellular nourishment
The nurse is teaching a female client about the best time to plan intercourse in
order to conceive. Which information should the nurse provide? - ANSWER-Two
weeks before menstruation
HESI MED SURG BSN 266(NEW)
, Which intervention should the nurse plan to implement when caring for a client
who has just undergone a right above-the-knee amputation?
A) Maintain the residual limb on three pillows at all times.
B) Place a large tourniquet at the client's bedside.
C) Apply constant, direct pressure to the residual limb.
D) Do not allow the client to lie in the prone position. - ANSWER-B) Place a large
tourniquet at the client's bedside.
A large tourniquet should be placed in plain sight at the client's bedside (B). If
severe bleeding occurs, the tourniquet should be readily available and applied to
the residual limb to control hemorrhage.
The nurse is preparing a client for orthopedic surgery on the left leg and
completing a safety checklist before transport to the operating room. Which items
should the nurse remove from the client? - ANSWER-Nail polish - provides more
accurate pulse oximetry
Hearing aids, contact lenses, partial dentures - removed to prevent damage, loss or
misplacement, or injury during surgery
What instruction should the nurse include in the discharge teaching for a client
who needs to preform self-catherization technique at home? - ANSWER-
Catheterize every 3-4 hours
The nurse assesses a long-term resident of a nursing home and finds the client has
a fungal infection beneath both breasts. To prevent nosocomial infection, which
protocol should the nurse review with the rest of the staff? - ANSWER-Wash hands
after caring for the client
HESI MED SURG BSN 266(NEW)
