BSN HESI 266 MED SURG EXAM – NIGHTINGALE – 2025
EDITION
Actual Questions and Answers
Expert-Verified Explanation
This Exam contains:
✪ Multiple-choice and True/False Format
✪ Expert-Verified Explanations
✪ Verified with Trusted Textbooks
1. Client is recovering from a transurethral prostatectomy. Which activity should be limited
until after the first postoperative visit with the healthcare provider?
A. Drinking 3L of fluids
B. Walking short distances
C. Lifting heavy objects
D. Sitting for prolonged periods
Answer: A
EXPLANATION: After a transurethral prostatectomy, excessive fluid intake such as drinking 3
liters can increase bladder irritation and risk of bleeding. The healthcare provider advises on safe
fluid intake at the first postoperative visit.
2. A client with stage IV bone cancer is admitted with pain rated 8 on a 1–10 scale. Which
intervention should the nurse implement?
A. Administer opioid medications only
B. Administer non-opioid medications only
C. Administer opioid and non-opioid medications simultaneously
D. Delay medication until lab results are reviewed
Answer: C
EXPLANATION: Combining opioid and non-opioid analgesics can improve pain control by
targeting different pain pathways, maximizing relief while minimizing side effects.
3. A client experiences an ABO incompatibility reaction after multiple blood transfusions.
Which finding should the nurse report immediately to the healthcare provider?
A. Low back pain and hypotension
B. Rhinitis and nasal stuffiness
, C. Delayed painful rash with urticarial
D. Arthritic joint changes and chronic pain
Answer: A
EXPLANATION: Low back pain and hypotension are signs of an acute hemolytic transfusion
reaction, which is life-threatening and requires immediate intervention.
4. When conducting discharge teaching for a client diagnosed with diverticulosis, which
diet instruction should the nurse include?
A. Have small frequent meals and sit up for at least two hours after meals
B. Eat a bland diet and avoid spicy foods
C. Eat a high fiber diet and increase fluid intake
D. Eat a soft diet with increased intake of milk and milk products
Answer: C
EXPLANATION: High fiber intake and increased fluids help prevent constipation and reduce
the risk of diverticulitis flare-ups.
5. The nurse observes increased blood clots in the drainage tubing of a client with
continuous bladder irrigation following transurethral resection of the prostate (TURP).
What is the best initial nursing action?
A. Provide additional oral fluids
B. Measure intake and output
C. Increase the flow of bladder irrigation
D. Administer a PRN antispasmodic agent
Answer: C
EXPLANATION: Increasing bladder irrigation flow helps flush out clots and prevents catheter
blockage, which can cause bladder distension and bleeding.
6. A client with lung cancer wearing a subcutaneous morphine sulfate patch for pain is short
of breath and difficult to arouse. The nurse discovers four analgesic patches on the client.
What is the best action?
A. Leave all patches in place and notify the healthcare provider
B. Remove all morphine patches immediately
C. Remove only one patch and monitor vital signs
D. Administer naloxone before removing patches
,Answer: B
EXPLANATION: Multiple morphine patches can cause overdose and respiratory depression;
removing all patches immediately reduces opioid toxicity risk.
7. A client falls down basement steps and is brought to the ER with a cast on the leg. Which
assessment finding warrants immediate intervention?
A. Right foot pale with sluggish capillary refill
B. Pain managed with oral analgesics
C. Swelling around the cast edges
D. Mild itching under the cast
Answer: A
EXPLANATION: Pale foot and sluggish capillary refill indicate compromised circulation and
possible compartment syndrome requiring urgent care.
8. An overweight young adult newly diagnosed with type 2 diabetes is admitted for hernia
repair. He reports feeling weak and jittery. Which actions should the nurse implement?
(Select all that apply.)
A. Check finger stick glucose
B. Assess skin temperature and moisture
C. Measure pulse and blood pressure
D. Administer insulin immediately
Answer: A, B, C
EXPLANATION: Weakness and jitteriness may indicate hypoglycemia. Checking glucose, skin
condition, and vital signs helps assess and manage the situation promptly. Insulin administration
without confirming glucose level could worsen hypoglycemia.
9. A client who underwent cardiac stent placement 4 days ago reports sudden chest pressure
and shortness of breath. What should the nurse do next?
A. Listen for extra heart sounds and murmurs
B. Evaluate extremities for perfusion and edema
C. Verify scheduled troponin level assessments
D. Obtain a 12-lead ECG and begin continuous cardiac monitoring
Answer: D
EXPLANATION: Sudden chest pressure and dyspnea may indicate acute coronary syndrome or
stent thrombosis; immediate ECG and monitoring are critical.
, 10. While assessing a client with migraines, the nurse notes bilateral hand grip weakness and
joint pain. What should the nurse do?
A. Implement fall precautions
B. Explain migraine relief will fix symptoms
C. Gather additional data about pain and weakness
D. Consult occupational therapy for functional assessment
Answer: C
EXPLANATION: Weakness and joint pain are not typical migraine symptoms and require
further assessment to identify underlying causes.
11. The nurse is caring for a client with psoriasis vulgaris receiving PUVA therapy. Which
finding indicates overexposure?
A. Thick plaques with silvery scales
B. Tenderness and generalized erythema
C. Brown, wart-like papules on face
D. Needs sunglasses because sunlight hurts eyes
Answer: B
EXPLANATION: Tenderness and erythema indicate phototoxicity or overexposure to PUVA,
requiring treatment adjustment.
12. A client with congestive heart failure complains of increased swelling in legs. Which is
the priority nursing action?
A. Elevate legs and monitor edema
B. Administer prescribed diuretics
C. Assess respiratory status and oxygen saturation
D. Check blood pressure
Answer: C
EXPLANATION: Respiratory assessment is crucial because worsening heart failure can lead to
pulmonary edema, which is life-threatening.
13. A client is prescribed warfarin. Which laboratory test should the nurse monitor?
A. Prothrombin time (PT) and INR
B. Partial thromboplastin time (PTT)
C. Platelet count
D. Bleeding time
EDITION
Actual Questions and Answers
Expert-Verified Explanation
This Exam contains:
✪ Multiple-choice and True/False Format
✪ Expert-Verified Explanations
✪ Verified with Trusted Textbooks
1. Client is recovering from a transurethral prostatectomy. Which activity should be limited
until after the first postoperative visit with the healthcare provider?
A. Drinking 3L of fluids
B. Walking short distances
C. Lifting heavy objects
D. Sitting for prolonged periods
Answer: A
EXPLANATION: After a transurethral prostatectomy, excessive fluid intake such as drinking 3
liters can increase bladder irritation and risk of bleeding. The healthcare provider advises on safe
fluid intake at the first postoperative visit.
2. A client with stage IV bone cancer is admitted with pain rated 8 on a 1–10 scale. Which
intervention should the nurse implement?
A. Administer opioid medications only
B. Administer non-opioid medications only
C. Administer opioid and non-opioid medications simultaneously
D. Delay medication until lab results are reviewed
Answer: C
EXPLANATION: Combining opioid and non-opioid analgesics can improve pain control by
targeting different pain pathways, maximizing relief while minimizing side effects.
3. A client experiences an ABO incompatibility reaction after multiple blood transfusions.
Which finding should the nurse report immediately to the healthcare provider?
A. Low back pain and hypotension
B. Rhinitis and nasal stuffiness
, C. Delayed painful rash with urticarial
D. Arthritic joint changes and chronic pain
Answer: A
EXPLANATION: Low back pain and hypotension are signs of an acute hemolytic transfusion
reaction, which is life-threatening and requires immediate intervention.
4. When conducting discharge teaching for a client diagnosed with diverticulosis, which
diet instruction should the nurse include?
A. Have small frequent meals and sit up for at least two hours after meals
B. Eat a bland diet and avoid spicy foods
C. Eat a high fiber diet and increase fluid intake
D. Eat a soft diet with increased intake of milk and milk products
Answer: C
EXPLANATION: High fiber intake and increased fluids help prevent constipation and reduce
the risk of diverticulitis flare-ups.
5. The nurse observes increased blood clots in the drainage tubing of a client with
continuous bladder irrigation following transurethral resection of the prostate (TURP).
What is the best initial nursing action?
A. Provide additional oral fluids
B. Measure intake and output
C. Increase the flow of bladder irrigation
D. Administer a PRN antispasmodic agent
Answer: C
EXPLANATION: Increasing bladder irrigation flow helps flush out clots and prevents catheter
blockage, which can cause bladder distension and bleeding.
6. A client with lung cancer wearing a subcutaneous morphine sulfate patch for pain is short
of breath and difficult to arouse. The nurse discovers four analgesic patches on the client.
What is the best action?
A. Leave all patches in place and notify the healthcare provider
B. Remove all morphine patches immediately
C. Remove only one patch and monitor vital signs
D. Administer naloxone before removing patches
,Answer: B
EXPLANATION: Multiple morphine patches can cause overdose and respiratory depression;
removing all patches immediately reduces opioid toxicity risk.
7. A client falls down basement steps and is brought to the ER with a cast on the leg. Which
assessment finding warrants immediate intervention?
A. Right foot pale with sluggish capillary refill
B. Pain managed with oral analgesics
C. Swelling around the cast edges
D. Mild itching under the cast
Answer: A
EXPLANATION: Pale foot and sluggish capillary refill indicate compromised circulation and
possible compartment syndrome requiring urgent care.
8. An overweight young adult newly diagnosed with type 2 diabetes is admitted for hernia
repair. He reports feeling weak and jittery. Which actions should the nurse implement?
(Select all that apply.)
A. Check finger stick glucose
B. Assess skin temperature and moisture
C. Measure pulse and blood pressure
D. Administer insulin immediately
Answer: A, B, C
EXPLANATION: Weakness and jitteriness may indicate hypoglycemia. Checking glucose, skin
condition, and vital signs helps assess and manage the situation promptly. Insulin administration
without confirming glucose level could worsen hypoglycemia.
9. A client who underwent cardiac stent placement 4 days ago reports sudden chest pressure
and shortness of breath. What should the nurse do next?
A. Listen for extra heart sounds and murmurs
B. Evaluate extremities for perfusion and edema
C. Verify scheduled troponin level assessments
D. Obtain a 12-lead ECG and begin continuous cardiac monitoring
Answer: D
EXPLANATION: Sudden chest pressure and dyspnea may indicate acute coronary syndrome or
stent thrombosis; immediate ECG and monitoring are critical.
, 10. While assessing a client with migraines, the nurse notes bilateral hand grip weakness and
joint pain. What should the nurse do?
A. Implement fall precautions
B. Explain migraine relief will fix symptoms
C. Gather additional data about pain and weakness
D. Consult occupational therapy for functional assessment
Answer: C
EXPLANATION: Weakness and joint pain are not typical migraine symptoms and require
further assessment to identify underlying causes.
11. The nurse is caring for a client with psoriasis vulgaris receiving PUVA therapy. Which
finding indicates overexposure?
A. Thick plaques with silvery scales
B. Tenderness and generalized erythema
C. Brown, wart-like papules on face
D. Needs sunglasses because sunlight hurts eyes
Answer: B
EXPLANATION: Tenderness and erythema indicate phototoxicity or overexposure to PUVA,
requiring treatment adjustment.
12. A client with congestive heart failure complains of increased swelling in legs. Which is
the priority nursing action?
A. Elevate legs and monitor edema
B. Administer prescribed diuretics
C. Assess respiratory status and oxygen saturation
D. Check blood pressure
Answer: C
EXPLANATION: Respiratory assessment is crucial because worsening heart failure can lead to
pulmonary edema, which is life-threatening.
13. A client is prescribed warfarin. Which laboratory test should the nurse monitor?
A. Prothrombin time (PT) and INR
B. Partial thromboplastin time (PTT)
C. Platelet count
D. Bleeding time
