BSN HESI 266 Med Surg Updated Exam Review |
Complete Questions with Answers and Rationales
| Latest Update 2026/2027- Graded A+
Nightingale College
Question 1
An older adult client with a long history of chronic obstructive pulmonary disease
(COPD) is admitted with progressive shortness of breath and a persistent cough. She is
anxious and is complaining of a dry mouth. Which intervention should the nurse
implement?
A. Administer a prescribed sedative
B. Assist client to an upright position
C. Encourage client to drink water
D. Apply a high flow venturi mask
Answer: B
Rationale: Upright positioning maximizes lung expansion and reduces work of
breathing. Sedatives are contraindicated in COPD as they can suppress respiratory
drive.
Question 2
A client with multiple sclerosis (MS) is admitted to the medical unit. The client reports
fatigue, muscle weakness, and diplopia. Which action should the nurse implement to
reduce the client's risk for falls? (Select all that apply.)
A. Provide assistance to bedside commode
B. Provide frequent rest periods
C. Offer to assist with warm baths in the morning
D. Monitor pulse ox during activities
E. Teach to patch one eye while walking
Answer: A, B, E
Rationale: Assistance with ambulation reduces fall risk. Frequent rest periods combat
MS-related fatigue. Patching one eye eliminates diplopia (double vision) during
ambulation. Warm baths can exacerbate MS symptoms. Pulse ox monitoring does not
directly reduce fall risk.
pg. 1
,Question 3
A client arrives to the ED following a motor vehicle collision. The nurse observes the
client experiencing increasing dyspnea and notes absent breath sounds on the left side.
Which procedure should the nurse prepare for the client?
A. Bronchoscopy
B. Chest tube insertion
C. Endotracheal intubation
D. Pulmonary function test
Answer: B
Rationale: Absent breath sounds with dyspnea after trauma suggests pneumothorax or
hemothorax, requiring chest tube insertion to re-expand the lung.
Question 4
Following a transurethral resection of the prostate (TURP), a client is discharged from
the hospital with an indwelling urinary catheter. Which instruction is most important
for the nurse to include in the discharge teaching plan?
A. Eliminate all spicy foods from your diet
B. Drink 3 liters of water each day
C. Clamp the catheter when taking a shower
D. Avoid driving a car for 2 weeks
Answer: B
Rationale: Increased fluid intake (3L/day) maintains urine flow, prevents clot
formation, and reduces risk of catheter obstruction.
Question 5
An adult woman with Graves disease is admitted with severe dehydration and
malnutrition. She is currently restless and refusing to eat. Which action is most
important for the nurse to implement?
A. Teach client relaxation techniques
B. Determine the client's food preferences
C. Maintain a patent intravenous site
D. Keep room temperature cool
Answer: C
pg. 2
,Rationale: Maintaining a patent IV site is priority for fluid resuscitation and
medication administration in severe dehydration.
Question 6
A client tells the clinic nurse about experiencing burning on urination, and assessment
reveals that the client had sexual intercourse four days ago with a person who was a
casual acquaintance. Which action should the nurse implement?
A. Obtain a specimen of urethral drainage for culture
B. Observe the perineal area for a chancre-like lesion
C. Identify all sexual partners in the last four days
D. Assess for perineal itching erythema and excoriation
Answer: A
Rationale: Urethral discharge with burning suggests urethritis; obtaining a culture
specimen identifies the causative organism for targeted treatment.
Question 7
The nurse is caring for a client admitted to the hospital with a tentative diagnosis of
bacterial meningitis. Which diagnostic procedure should the nurse prepare the client
for?
A. Lumbar puncture
B. Skull radiography
C. MRI
D. CT
Answer: A
Rationale: Lumbar puncture is the definitive diagnostic test for bacterial meningitis to
obtain cerebrospinal fluid for culture and analysis.
Question 8
An older adult client with long term type 2 DM is seen in the clinic for a routine health
assessment. Which assessment would the nurse complete to determine if a patient with
type 2 DM is experiencing long term complications? (Select all that apply.)
A. Sensation in feet and legs
B. Skin condition of lower extremities
C. Visual acuity
D. Serum creatinine and blood urea nitrogen (BUN)
E. Signs of respiratory tract infection
pg. 3
, Answer: A, B, C, D
Rationale: Long-term DM complications include neuropathy (foot sensation), skin
breakdown, retinopathy (visual acuity), and nephropathy (BUN/creatinine). Respiratory
infection is not a long-term complication.
Question 9
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs,
and massive ascites. Which mechanism contributes to edema and ascites in a client with
cirrhosis?
A. Decreased portacaval pressure with greater collateral circulation
B. Hypoalbuminemia that results in decreased colloidal oncotic pressure
C. Decreased renin angiotensin response related to an increase in renal blood flow
D. Hyperaldosteronism causing an increased sodium absorption in renal tubes
Answer: B
Rationale: Liver damage in cirrhosis decreases albumin synthesis, reducing colloidal
oncotic pressure and causing fluid to leak into tissues (edema) and abdomen (ascites).
Question 10
The nurse is planning care for an older adult client who experienced a cerebrovascular
accident several weeks ago. The client has expressive aphasia (Broca's aphasia) and
often becomes frustrated with the nursing staff. Which intervention should the nurse
implement?
A. Encourage client's use of picture charts
B. Speak slowly to the client
C. Ask the client simple questions
D. Teach the client use of basic sign language
Answer: A
Rationale: Picture charts provide an alternative communication method for clients
with expressive aphasia who understand language but cannot verbalize.
Question 11
Which client has the highest risk for developing skin cancer?
A. A 70 year old fair skinned client who works as a secretary
B. A 65 year old fair skinned client who works as a construction worker
pg. 4
Complete Questions with Answers and Rationales
| Latest Update 2026/2027- Graded A+
Nightingale College
Question 1
An older adult client with a long history of chronic obstructive pulmonary disease
(COPD) is admitted with progressive shortness of breath and a persistent cough. She is
anxious and is complaining of a dry mouth. Which intervention should the nurse
implement?
A. Administer a prescribed sedative
B. Assist client to an upright position
C. Encourage client to drink water
D. Apply a high flow venturi mask
Answer: B
Rationale: Upright positioning maximizes lung expansion and reduces work of
breathing. Sedatives are contraindicated in COPD as they can suppress respiratory
drive.
Question 2
A client with multiple sclerosis (MS) is admitted to the medical unit. The client reports
fatigue, muscle weakness, and diplopia. Which action should the nurse implement to
reduce the client's risk for falls? (Select all that apply.)
A. Provide assistance to bedside commode
B. Provide frequent rest periods
C. Offer to assist with warm baths in the morning
D. Monitor pulse ox during activities
E. Teach to patch one eye while walking
Answer: A, B, E
Rationale: Assistance with ambulation reduces fall risk. Frequent rest periods combat
MS-related fatigue. Patching one eye eliminates diplopia (double vision) during
ambulation. Warm baths can exacerbate MS symptoms. Pulse ox monitoring does not
directly reduce fall risk.
pg. 1
,Question 3
A client arrives to the ED following a motor vehicle collision. The nurse observes the
client experiencing increasing dyspnea and notes absent breath sounds on the left side.
Which procedure should the nurse prepare for the client?
A. Bronchoscopy
B. Chest tube insertion
C. Endotracheal intubation
D. Pulmonary function test
Answer: B
Rationale: Absent breath sounds with dyspnea after trauma suggests pneumothorax or
hemothorax, requiring chest tube insertion to re-expand the lung.
Question 4
Following a transurethral resection of the prostate (TURP), a client is discharged from
the hospital with an indwelling urinary catheter. Which instruction is most important
for the nurse to include in the discharge teaching plan?
A. Eliminate all spicy foods from your diet
B. Drink 3 liters of water each day
C. Clamp the catheter when taking a shower
D. Avoid driving a car for 2 weeks
Answer: B
Rationale: Increased fluid intake (3L/day) maintains urine flow, prevents clot
formation, and reduces risk of catheter obstruction.
Question 5
An adult woman with Graves disease is admitted with severe dehydration and
malnutrition. She is currently restless and refusing to eat. Which action is most
important for the nurse to implement?
A. Teach client relaxation techniques
B. Determine the client's food preferences
C. Maintain a patent intravenous site
D. Keep room temperature cool
Answer: C
pg. 2
,Rationale: Maintaining a patent IV site is priority for fluid resuscitation and
medication administration in severe dehydration.
Question 6
A client tells the clinic nurse about experiencing burning on urination, and assessment
reveals that the client had sexual intercourse four days ago with a person who was a
casual acquaintance. Which action should the nurse implement?
A. Obtain a specimen of urethral drainage for culture
B. Observe the perineal area for a chancre-like lesion
C. Identify all sexual partners in the last four days
D. Assess for perineal itching erythema and excoriation
Answer: A
Rationale: Urethral discharge with burning suggests urethritis; obtaining a culture
specimen identifies the causative organism for targeted treatment.
Question 7
The nurse is caring for a client admitted to the hospital with a tentative diagnosis of
bacterial meningitis. Which diagnostic procedure should the nurse prepare the client
for?
A. Lumbar puncture
B. Skull radiography
C. MRI
D. CT
Answer: A
Rationale: Lumbar puncture is the definitive diagnostic test for bacterial meningitis to
obtain cerebrospinal fluid for culture and analysis.
Question 8
An older adult client with long term type 2 DM is seen in the clinic for a routine health
assessment. Which assessment would the nurse complete to determine if a patient with
type 2 DM is experiencing long term complications? (Select all that apply.)
A. Sensation in feet and legs
B. Skin condition of lower extremities
C. Visual acuity
D. Serum creatinine and blood urea nitrogen (BUN)
E. Signs of respiratory tract infection
pg. 3
, Answer: A, B, C, D
Rationale: Long-term DM complications include neuropathy (foot sensation), skin
breakdown, retinopathy (visual acuity), and nephropathy (BUN/creatinine). Respiratory
infection is not a long-term complication.
Question 9
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs,
and massive ascites. Which mechanism contributes to edema and ascites in a client with
cirrhosis?
A. Decreased portacaval pressure with greater collateral circulation
B. Hypoalbuminemia that results in decreased colloidal oncotic pressure
C. Decreased renin angiotensin response related to an increase in renal blood flow
D. Hyperaldosteronism causing an increased sodium absorption in renal tubes
Answer: B
Rationale: Liver damage in cirrhosis decreases albumin synthesis, reducing colloidal
oncotic pressure and causing fluid to leak into tissues (edema) and abdomen (ascites).
Question 10
The nurse is planning care for an older adult client who experienced a cerebrovascular
accident several weeks ago. The client has expressive aphasia (Broca's aphasia) and
often becomes frustrated with the nursing staff. Which intervention should the nurse
implement?
A. Encourage client's use of picture charts
B. Speak slowly to the client
C. Ask the client simple questions
D. Teach the client use of basic sign language
Answer: A
Rationale: Picture charts provide an alternative communication method for clients
with expressive aphasia who understand language but cannot verbalize.
Question 11
Which client has the highest risk for developing skin cancer?
A. A 70 year old fair skinned client who works as a secretary
B. A 65 year old fair skinned client who works as a construction worker
pg. 4
