1
BSN 266 Med Surg HESI Exam 2025 –
Actual Test Bank with 100% Verified
Questions & Rationales | Nightingale |
Updated & Graded A
1. A client with a history of heart failure is admitted with dyspnea and bilateral
crackles. Which nursing action is the priority?
A. Administer oxygen at 2 L/min via nasal cannula
B. Place the client in a supine position
C. Encourage deep breathing exercises
D. Administer a bronchodilator
Correct Answer: A (Administer oxygen at 2 L/min via nasal cannula)
Rationale: Dyspnea and bilateral crackles suggest pulmonary edema in heart failure,
requiring immediate oxygen administration to improve oxygenation. Supine positioning
may worsen breathing, and bronchodilators are not indicated for heart failure-related
dyspnea. Lewis, Medical-Surgical Nursing, Ch. 35.
2. A client post-myocardial infarction reports chest pain. The nurse should first:
A. Administer aspirin 325 mg orally
B. Assess vital signs and pain characteristics
C. Prepare for immediate surgery
D. Administer nitroglycerin sublingually
Correct Answer: B (Assess vital signs and pain characteristics)
Rationale: Chest pain post-MI requires immediate assessment to determine if it’s angina
or another MI. Vital signs and pain details guide further interventions like nitroglycerin
or notifying the provider. Lewis, Medical-Surgical Nursing, Ch. 34.
3. A client with type 1 diabetes mellitus has a blood glucose level of 350 mg/dL. Which
action is most appropriate?
A. Administer oral glucose tablets
B. Encourage the client to drink water
C. Administer insulin as prescribed
D. Restrict all carbohydrate intake
Correct Answer: C (Administer insulin as prescribed)
Rationale: A blood glucose level of 350 mg/dL indicates hyperglycemia, requiring
insulin to lower glucose levels. Oral glucose is for hypoglycemia, and restricting
carbohydrates is not immediate. Lewis, Medical-Surgical Nursing, Ch. 49.
4. A client with chronic obstructive pulmonary disease (COPD) is experiencing
dyspnea. Which position should the nurse place the client in?
A. Supine
, 2
B. Prone
C. High Fowler’s
D. Trendelenburg
Correct Answer: C (High Fowler’s)
Rationale: High Fowler’s position promotes lung expansion and eases breathing in
COPD clients. Supine and prone positions may worsen dyspnea, and Trendelenburg is
not indicated. Lewis, Medical-Surgical Nursing, Ch. 28.
5. A client with suspected appendicitis reports right lower quadrant pain. Which
assessment should the nurse perform first?
A. Palpate for rebound tenderness
B. Auscultate bowel sounds
C. Check for fever
D. Assess for psoas sign
Correct Answer: C (Check for fever)
Rationale: Fever is a key indicator of appendicitis and should be assessed first to guide
further evaluation. Palpation may cause pain, and auscultation is less urgent. Lewis,
Medical-Surgical Nursing, Ch. 43.
6. A client with a new colostomy is concerned about odor. What should the nurse
recommend?
A. Avoid all vegetables
B. Use a deodorizing pouch
C. Irrigate the colostomy twice daily
D. Apply petroleum jelly around the stoma
Correct Answer: B (Use a deodorizing pouch)
Rationale: Deodorizing pouches control odor effectively. Avoiding vegetables is
unnecessary, irrigation is not always required, and petroleum jelly may interfere with
appliance adhesion. Lewis, Medical-Surgical Nursing, Ch. 43.
7. A client with pneumonia has a temperature of 101.8°F. Which intervention is most
appropriate?
A. Administer antipyretics as prescribed
B. Apply a heating pad
C. Restrict fluid intake
D. Encourage bed rest without intervention
Correct Answer: A (Administer antipyretics as prescribed)
Rationale: Antipyretics reduce fever and improve comfort in pneumonia. Heating pads
may worsen fever, and fluids should be encouraged. Lewis, Medical-Surgical Nursing,
Ch. 27.
8. A client with a history of atrial fibrillation is prescribed warfarin. Which laboratory
value should the nurse monitor?
A. Platelet count
B. International Normalized Ratio (INR)
C. Hemoglobin A1c
D. Serum creatinine
Correct Answer: B (International Normalized Ratio (INR))
Rationale: INR monitors anticoagulation therapy effectiveness with warfarin, ensuring
therapeutic levels. Lewis, Medical-Surgical Nursing, Ch. 34.
, 3
9. A client with peptic ulcer disease reports epigastric pain. Which dietary
recommendation should the nurse provide?
A. Avoid spicy foods
B. Increase caffeine intake
C. Consume large meals
D. Eat immediately before bed
Correct Answer: A (Avoid spicy foods)
Rationale: Spicy foods can exacerbate ulcer pain. Small, frequent meals and avoiding
caffeine are recommended. Lewis, Medical-Surgical Nursing, Ch. 42.
10. A client with a fractured femur is in traction. Which nursing action is priority?
A. Check skin integrity under traction
B. Encourage active range of motion
C. Remove traction weights daily
D. Apply lotion to the affected leg
Correct Answer: A (Check skin integrity under traction)
Rationale: Traction can cause skin breakdown, making skin integrity checks critical to
prevent complications. Lewis, Medical-Surgical Nursing, Ch. 63.
11. A client with cirrhosis reports abdominal distension. Which assessment should the
nurse prioritize?
A. Measure abdominal girth
B. Palpate for rebound tenderness
C. Auscultate for bruits
D. Check for jaundice
Correct Answer: A (Measure abdominal girth)
Rationale: Abdominal distension in cirrhosis may indicate ascites, and measuring girth
monitors fluid accumulation. Lewis, Medical-Surgical Nursing, Ch. 44.
12. A client with acute pancreatitis has severe abdominal pain. Which position should
the nurse encourage?
A. Supine with legs elevated
B. Side-lying with knees flexed
C. Prone with head turned
D. Sitting upright
Correct Answer: B (Side-lying with knees flexed)
Rationale: Side-lying with knees flexed reduces pressure on the pancreas, alleviating
pain. Lewis, Medical-Surgical Nursing, Ch. 44.
13. A client with a history of stroke has dysphagia. Which nursing intervention is most
appropriate?
A. Offer thin liquids
B. Thicken liquids as prescribed
C. Encourage rapid eating
D. Provide a straw for all fluids
Correct Answer: B (Thicken liquids as prescribed)
Rationale: Thickened liquids reduce aspiration risk in clients with dysphagia. Lewis,
Medical-Surgical Nursing, Ch. 59.
14. A client with a new tracheostomy requires suctioning. Which action ensures safety?
A. Suction for 20 seconds continuously
, 4
B. Use a clean catheter for each pass
C. Apply suction while inserting the catheter
D. Suction for no more than 10 seconds per pass
Correct Answer: D (Suction for no more than 10 seconds per pass)
Rationale: Limiting suctioning to 10 seconds prevents hypoxia and mucosal damage.
Lewis, Medical-Surgical Nursing, Ch. 28.
15. A client with chronic kidney disease reports nausea. Which dietary restriction
should the nurse reinforce?
A. Low-sodium diet
B. High-protein diet
C. Low-potassium diet
D. High-carbohydrate diet
Correct Answer: C (Low-potassium diet)
Rationale: CKD causes potassium retention, and a low-potassium diet reduces
complications like hyperkalemia. Lewis, Medical-Surgical Nursing, Ch. 46.
16. A client with a history of hypertension is admitted with chest pain. Which diagnostic
test should the nurse expect?
A. Electrocardiogram (ECG)
B. Complete blood count (CBC)
C. Thyroid function tests
D. Blood glucose level
Correct Answer: A (Electrocardiogram (ECG))
Rationale: An ECG assesses for cardiac ischemia, a common cause of chest pain in
hypertensive clients. Lewis, Medical-Surgical Nursing, Ch. 34.
17. A client with a burn injury is at risk for infection. Which intervention is most
effective?
A. Apply lotion to intact skin
B. Use sterile technique for wound care
C. Encourage high-calorie snacks
D. Limit visitors to one per day
Correct Answer: B (Use sterile technique for wound care)
Rationale: Sterile technique prevents infection in burn wounds, which lack a protective
skin barrier. Lewis, Medical-Surgical Nursing, Ch. 25.
18. A client with a history of asthma reports wheezing. Which medication should the
nurse administer first?
A. Albuterol inhaler
B. Prednisone orally
C. Montelukast daily
D. Fluticasone inhaler
Correct Answer: A (Albuterol inhaler)
Rationale: Albuterol, a short-acting bronchodilator, provides rapid relief for acute
wheezing in asthma. Lewis, Medical-Surgical Nursing, Ch. 28.
19. A client with a spinal cord injury at T6 reports a severe headache. Which action
should the nurse take first?
A. Administer acetaminophen
B. Check blood pressure
BSN 266 Med Surg HESI Exam 2025 –
Actual Test Bank with 100% Verified
Questions & Rationales | Nightingale |
Updated & Graded A
1. A client with a history of heart failure is admitted with dyspnea and bilateral
crackles. Which nursing action is the priority?
A. Administer oxygen at 2 L/min via nasal cannula
B. Place the client in a supine position
C. Encourage deep breathing exercises
D. Administer a bronchodilator
Correct Answer: A (Administer oxygen at 2 L/min via nasal cannula)
Rationale: Dyspnea and bilateral crackles suggest pulmonary edema in heart failure,
requiring immediate oxygen administration to improve oxygenation. Supine positioning
may worsen breathing, and bronchodilators are not indicated for heart failure-related
dyspnea. Lewis, Medical-Surgical Nursing, Ch. 35.
2. A client post-myocardial infarction reports chest pain. The nurse should first:
A. Administer aspirin 325 mg orally
B. Assess vital signs and pain characteristics
C. Prepare for immediate surgery
D. Administer nitroglycerin sublingually
Correct Answer: B (Assess vital signs and pain characteristics)
Rationale: Chest pain post-MI requires immediate assessment to determine if it’s angina
or another MI. Vital signs and pain details guide further interventions like nitroglycerin
or notifying the provider. Lewis, Medical-Surgical Nursing, Ch. 34.
3. A client with type 1 diabetes mellitus has a blood glucose level of 350 mg/dL. Which
action is most appropriate?
A. Administer oral glucose tablets
B. Encourage the client to drink water
C. Administer insulin as prescribed
D. Restrict all carbohydrate intake
Correct Answer: C (Administer insulin as prescribed)
Rationale: A blood glucose level of 350 mg/dL indicates hyperglycemia, requiring
insulin to lower glucose levels. Oral glucose is for hypoglycemia, and restricting
carbohydrates is not immediate. Lewis, Medical-Surgical Nursing, Ch. 49.
4. A client with chronic obstructive pulmonary disease (COPD) is experiencing
dyspnea. Which position should the nurse place the client in?
A. Supine
, 2
B. Prone
C. High Fowler’s
D. Trendelenburg
Correct Answer: C (High Fowler’s)
Rationale: High Fowler’s position promotes lung expansion and eases breathing in
COPD clients. Supine and prone positions may worsen dyspnea, and Trendelenburg is
not indicated. Lewis, Medical-Surgical Nursing, Ch. 28.
5. A client with suspected appendicitis reports right lower quadrant pain. Which
assessment should the nurse perform first?
A. Palpate for rebound tenderness
B. Auscultate bowel sounds
C. Check for fever
D. Assess for psoas sign
Correct Answer: C (Check for fever)
Rationale: Fever is a key indicator of appendicitis and should be assessed first to guide
further evaluation. Palpation may cause pain, and auscultation is less urgent. Lewis,
Medical-Surgical Nursing, Ch. 43.
6. A client with a new colostomy is concerned about odor. What should the nurse
recommend?
A. Avoid all vegetables
B. Use a deodorizing pouch
C. Irrigate the colostomy twice daily
D. Apply petroleum jelly around the stoma
Correct Answer: B (Use a deodorizing pouch)
Rationale: Deodorizing pouches control odor effectively. Avoiding vegetables is
unnecessary, irrigation is not always required, and petroleum jelly may interfere with
appliance adhesion. Lewis, Medical-Surgical Nursing, Ch. 43.
7. A client with pneumonia has a temperature of 101.8°F. Which intervention is most
appropriate?
A. Administer antipyretics as prescribed
B. Apply a heating pad
C. Restrict fluid intake
D. Encourage bed rest without intervention
Correct Answer: A (Administer antipyretics as prescribed)
Rationale: Antipyretics reduce fever and improve comfort in pneumonia. Heating pads
may worsen fever, and fluids should be encouraged. Lewis, Medical-Surgical Nursing,
Ch. 27.
8. A client with a history of atrial fibrillation is prescribed warfarin. Which laboratory
value should the nurse monitor?
A. Platelet count
B. International Normalized Ratio (INR)
C. Hemoglobin A1c
D. Serum creatinine
Correct Answer: B (International Normalized Ratio (INR))
Rationale: INR monitors anticoagulation therapy effectiveness with warfarin, ensuring
therapeutic levels. Lewis, Medical-Surgical Nursing, Ch. 34.
, 3
9. A client with peptic ulcer disease reports epigastric pain. Which dietary
recommendation should the nurse provide?
A. Avoid spicy foods
B. Increase caffeine intake
C. Consume large meals
D. Eat immediately before bed
Correct Answer: A (Avoid spicy foods)
Rationale: Spicy foods can exacerbate ulcer pain. Small, frequent meals and avoiding
caffeine are recommended. Lewis, Medical-Surgical Nursing, Ch. 42.
10. A client with a fractured femur is in traction. Which nursing action is priority?
A. Check skin integrity under traction
B. Encourage active range of motion
C. Remove traction weights daily
D. Apply lotion to the affected leg
Correct Answer: A (Check skin integrity under traction)
Rationale: Traction can cause skin breakdown, making skin integrity checks critical to
prevent complications. Lewis, Medical-Surgical Nursing, Ch. 63.
11. A client with cirrhosis reports abdominal distension. Which assessment should the
nurse prioritize?
A. Measure abdominal girth
B. Palpate for rebound tenderness
C. Auscultate for bruits
D. Check for jaundice
Correct Answer: A (Measure abdominal girth)
Rationale: Abdominal distension in cirrhosis may indicate ascites, and measuring girth
monitors fluid accumulation. Lewis, Medical-Surgical Nursing, Ch. 44.
12. A client with acute pancreatitis has severe abdominal pain. Which position should
the nurse encourage?
A. Supine with legs elevated
B. Side-lying with knees flexed
C. Prone with head turned
D. Sitting upright
Correct Answer: B (Side-lying with knees flexed)
Rationale: Side-lying with knees flexed reduces pressure on the pancreas, alleviating
pain. Lewis, Medical-Surgical Nursing, Ch. 44.
13. A client with a history of stroke has dysphagia. Which nursing intervention is most
appropriate?
A. Offer thin liquids
B. Thicken liquids as prescribed
C. Encourage rapid eating
D. Provide a straw for all fluids
Correct Answer: B (Thicken liquids as prescribed)
Rationale: Thickened liquids reduce aspiration risk in clients with dysphagia. Lewis,
Medical-Surgical Nursing, Ch. 59.
14. A client with a new tracheostomy requires suctioning. Which action ensures safety?
A. Suction for 20 seconds continuously
, 4
B. Use a clean catheter for each pass
C. Apply suction while inserting the catheter
D. Suction for no more than 10 seconds per pass
Correct Answer: D (Suction for no more than 10 seconds per pass)
Rationale: Limiting suctioning to 10 seconds prevents hypoxia and mucosal damage.
Lewis, Medical-Surgical Nursing, Ch. 28.
15. A client with chronic kidney disease reports nausea. Which dietary restriction
should the nurse reinforce?
A. Low-sodium diet
B. High-protein diet
C. Low-potassium diet
D. High-carbohydrate diet
Correct Answer: C (Low-potassium diet)
Rationale: CKD causes potassium retention, and a low-potassium diet reduces
complications like hyperkalemia. Lewis, Medical-Surgical Nursing, Ch. 46.
16. A client with a history of hypertension is admitted with chest pain. Which diagnostic
test should the nurse expect?
A. Electrocardiogram (ECG)
B. Complete blood count (CBC)
C. Thyroid function tests
D. Blood glucose level
Correct Answer: A (Electrocardiogram (ECG))
Rationale: An ECG assesses for cardiac ischemia, a common cause of chest pain in
hypertensive clients. Lewis, Medical-Surgical Nursing, Ch. 34.
17. A client with a burn injury is at risk for infection. Which intervention is most
effective?
A. Apply lotion to intact skin
B. Use sterile technique for wound care
C. Encourage high-calorie snacks
D. Limit visitors to one per day
Correct Answer: B (Use sterile technique for wound care)
Rationale: Sterile technique prevents infection in burn wounds, which lack a protective
skin barrier. Lewis, Medical-Surgical Nursing, Ch. 25.
18. A client with a history of asthma reports wheezing. Which medication should the
nurse administer first?
A. Albuterol inhaler
B. Prednisone orally
C. Montelukast daily
D. Fluticasone inhaler
Correct Answer: A (Albuterol inhaler)
Rationale: Albuterol, a short-acting bronchodilator, provides rapid relief for acute
wheezing in asthma. Lewis, Medical-Surgical Nursing, Ch. 28.
19. A client with a spinal cord injury at T6 reports a severe headache. Which action
should the nurse take first?
A. Administer acetaminophen
B. Check blood pressure
