BSN HESI 266 MEDICAL-SURGICAL NURSING EXAM 2025 –100
QUESTION ACTUAL EXAM WITH VERIFIED ANSWERS AND
RATIONALES | COMPLETE STUDY & PREP GUIDE| DIGITAL PDF
INSTANT ACCESS
Q1: A patient with chronic heart failure is experiencing dyspnea and edema.
Which intervention is the highest priority?
A. Encourage low-sodium diet
B. Administer prescribed diuretic
C. Teach energy conservation techniques
D. Schedule daily weights
Rationale: Administering the prescribed diuretic addresses fluid overload and
relieves symptoms immediately.
Q2: A patient with pneumonia is receiving oxygen at 2 L/min via nasal cannula.
The nurse notes the patient’s SpO₂ is 85%. What is the best initial action?
A. Increase oxygen to 4 L/min
B. Assess the patient’s respiratory status and lung sounds
C. Notify the physician immediately
D. Encourage the patient to cough
Rationale: Assessment is the first priority to identify cause of hypoxemia before
adjusting oxygen.
Q3: A client with type 2 diabetes reports polyuria, polydipsia, and fatigue. The
nurse suspects:
A. Hypoglycemia
B. Hyperglycemia
C. Hypothyroidism
D. Addison’s disease
Rationale: Polyuria, polydipsia, and fatigue are classic signs of hyperglycemia.
,Q4: Which lab value is most important for a patient receiving heparin therapy?
A. INR
B. aPTT
C. PT
D. Platelet count
Rationale: Heparin therapy is monitored with aPTT to prevent bleeding
complications.
Q5: A postoperative patient develops sudden shortness of breath and pleuritic
chest pain. The nurse should first:
A. Administer pain medication
B. Elevate the head of the bed
C. Assess vital signs and oxygen saturation
D. Encourage coughing and deep breathing
Rationale: Rapid assessment is crucial to identify potential pulmonary embolism.
Q6: A patient with cirrhosis develops ascites. Which intervention is most
appropriate?
A. Administer high-protein diet
B. Restrict sodium intake and administer diuretics
C. Encourage fluid intake
D. Prepare for paracentesis immediately
Rationale: Sodium restriction and diuretics reduce fluid accumulation.
Paracentesis may be necessary if severe.
Q7: A patient with chronic kidney disease has a potassium level of 6.2 mEq/L.
Which action is priority?
A. Administer insulin and glucose as prescribed
B. Encourage high-potassium foods
, C. Check BUN and creatinine
D. Place patient on cardiac monitor
Rationale: Hyperkalemia can cause life-threatening arrhythmias, so monitoring
cardiac status is urgent.
Q8: Which nursing action is most appropriate for a patient with neutropenia?
A. Encourage visitors
B. Implement strict infection control precautions
C. Administer live vaccines
D. Provide a high-fiber diet
Rationale: Neutropenic patients are at high risk for infection; infection prevention
is priority.
Q9: A patient with COPD has a respiratory rate of 32/min and uses accessory
muscles. What should the nurse do first?
A. Administer bronchodilator
B. Encourage pursed-lip breathing
C. Assess oxygen saturation and lung sounds
D. Notify the physician immediately
Rationale: Assessment is the first step to determine the severity of respiratory
distress.
Q10: A patient with MI is prescribed nitroglycerin sublingually for chest pain. The
nurse should:
A. Administer while patient lying flat
B. Check blood pressure before administration
C. Give only after pain persists 30 minutes
D. Avoid monitoring vitals
Rationale: Nitroglycerin can cause hypotension; checking BP first is essential.
QUESTION ACTUAL EXAM WITH VERIFIED ANSWERS AND
RATIONALES | COMPLETE STUDY & PREP GUIDE| DIGITAL PDF
INSTANT ACCESS
Q1: A patient with chronic heart failure is experiencing dyspnea and edema.
Which intervention is the highest priority?
A. Encourage low-sodium diet
B. Administer prescribed diuretic
C. Teach energy conservation techniques
D. Schedule daily weights
Rationale: Administering the prescribed diuretic addresses fluid overload and
relieves symptoms immediately.
Q2: A patient with pneumonia is receiving oxygen at 2 L/min via nasal cannula.
The nurse notes the patient’s SpO₂ is 85%. What is the best initial action?
A. Increase oxygen to 4 L/min
B. Assess the patient’s respiratory status and lung sounds
C. Notify the physician immediately
D. Encourage the patient to cough
Rationale: Assessment is the first priority to identify cause of hypoxemia before
adjusting oxygen.
Q3: A client with type 2 diabetes reports polyuria, polydipsia, and fatigue. The
nurse suspects:
A. Hypoglycemia
B. Hyperglycemia
C. Hypothyroidism
D. Addison’s disease
Rationale: Polyuria, polydipsia, and fatigue are classic signs of hyperglycemia.
,Q4: Which lab value is most important for a patient receiving heparin therapy?
A. INR
B. aPTT
C. PT
D. Platelet count
Rationale: Heparin therapy is monitored with aPTT to prevent bleeding
complications.
Q5: A postoperative patient develops sudden shortness of breath and pleuritic
chest pain. The nurse should first:
A. Administer pain medication
B. Elevate the head of the bed
C. Assess vital signs and oxygen saturation
D. Encourage coughing and deep breathing
Rationale: Rapid assessment is crucial to identify potential pulmonary embolism.
Q6: A patient with cirrhosis develops ascites. Which intervention is most
appropriate?
A. Administer high-protein diet
B. Restrict sodium intake and administer diuretics
C. Encourage fluid intake
D. Prepare for paracentesis immediately
Rationale: Sodium restriction and diuretics reduce fluid accumulation.
Paracentesis may be necessary if severe.
Q7: A patient with chronic kidney disease has a potassium level of 6.2 mEq/L.
Which action is priority?
A. Administer insulin and glucose as prescribed
B. Encourage high-potassium foods
, C. Check BUN and creatinine
D. Place patient on cardiac monitor
Rationale: Hyperkalemia can cause life-threatening arrhythmias, so monitoring
cardiac status is urgent.
Q8: Which nursing action is most appropriate for a patient with neutropenia?
A. Encourage visitors
B. Implement strict infection control precautions
C. Administer live vaccines
D. Provide a high-fiber diet
Rationale: Neutropenic patients are at high risk for infection; infection prevention
is priority.
Q9: A patient with COPD has a respiratory rate of 32/min and uses accessory
muscles. What should the nurse do first?
A. Administer bronchodilator
B. Encourage pursed-lip breathing
C. Assess oxygen saturation and lung sounds
D. Notify the physician immediately
Rationale: Assessment is the first step to determine the severity of respiratory
distress.
Q10: A patient with MI is prescribed nitroglycerin sublingually for chest pain. The
nurse should:
A. Administer while patient lying flat
B. Check blood pressure before administration
C. Give only after pain persists 30 minutes
D. Avoid monitoring vitals
Rationale: Nitroglycerin can cause hypotension; checking BP first is essential.
