BSN 266 – HESI Medical-Surgical Exam (Nightingale
College, 2026/2027) – Verified Questions & Answers
(Grade A, 100% Correct)
Q1
A 72-year-old male with heart failure is being discharged home. The nurse teaches him
to weigh himself each morning. Which instruction about daily weights is most important
for detecting fluid retention?
A. Call the provider if weight increases by 3 pounds in a day or 5 pounds in a week
B. Weigh weekly and record only if there is a change
C. Weigh after breakfast while wearing shoes for consistency
D. Skip weighing on days when feeling well
Correct Answer: A
Rationale: A weight gain of 3 pounds in a day or 5 pounds in a week indicates
significant fluid retention requiring provider notification and possible diuretic
adjustment. Weekly weighing would delay detection of worsening heart failure, so the
alternative misstates the appropriate frequency.
Q2
A 68-year-old male with COPD is receiving oxygen at 2 L/min via nasal cannula. The
nurse understands that low-flow oxygen is used in COPD because of which physiologic
concern?
A. COPD patients require less oxygen due to increased lung compliance
B. High-flow oxygen may suppress the hypoxic respiratory drive in COPD patients
C. High-flow oxygen causes bronchospasm in COPD patients
D. Low-flow oxygen prevents mucous plugging in COPD patients
Correct Answer: B
,Rationale: Many COPD patients rely on a hypoxic drive to breathe, so high-flow oxygen
can suppress respiratory effort and cause CO2 retention. The concern is not
bronchospasm or mucous plugging but the risk of hypoventilation, so the alternative
misstates the rationale.
Q3
The nurse is preparing to administer digoxin to a client with heart failure. Which
assessment finding should prompt the nurse to hold the dose and notify the healthcare
provider?
A. Apical pulse of 58 beats per minute
B. Blood pressure of 130/80 mmHg
C. Potassium level of 4.2 mEq/L
D. Respiratory rate of 18 breaths per minute
Correct Answer: A
Rationale: Digoxin should be held if the apical pulse is below 60 beats per minute in
adults, as bradycardia indicates potential digoxin toxicity. Potassium level of 4.2 is within
normal limits (3.5-5.0), and the blood pressure is acceptable.
Q4
A client with heart failure is prescribed furosemide (Lasix). Which electrolyte imbalance
should the nurse monitor most closely?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypermagnesemia
Correct Answer: B
,Rationale: Furosemide is a loop diuretic that causes potassium wasting, leading to
hypokalemia, which increases the risk of digoxin toxicity and cardiac arrhythmias.
Potassium levels should be monitored closely, and supplements may be prescribed.
Q5
A client with atrial fibrillation is prescribed warfarin. The nurse should monitor which
laboratory value to evaluate the effectiveness of this medication?
A. Serum potassium
B. International normalized ratio (INR)
C. Platelet count
D. Partial thromboplastin time (PTT)
Correct Answer: B
Rationale: The INR is the standardized test used to monitor the therapeutic efficacy of
warfarin therapy. The target INR for non-valvular atrial fibrillation is 2.0-3.0.
Q6
The nurse is caring for a client with a pulmonary embolism. Which finding indicates that
treatment with heparin is effective?
A. Decreased heart rate
B. Increased oxygen saturation
C. aPTT within therapeutic range
D. Decreased chest pain
Correct Answer: C
Rationale: Heparin therapy is monitored using the activated partial thromboplastin time
(aPTT). The goal is typically 1.5-2.5 times the control value. An aPTT within the
therapeutic range indicates that heparin is at an effective dose.
, Q7
A client on warfarin has an INR of 5.5 with no bleeding. The appropriate action is:
A. Administer vitamin K 10 mg IV
B. Hold warfarin and monitor INR
C. Administer protamine sulfate
D. Increase warfarin dose
Correct Answer: B
Rationale: For an INR of 5.5 without bleeding, the recommended action is to hold
warfarin and monitor the INR. Vitamin K may be considered if bleeding risk is high or
the INR is significantly elevated.
Q8
The antidote for heparin is:
A. Vitamin K
B. Protamine sulfate
C. Idarucizumab
D. Andexanet alfa
Correct Answer: B
Rationale: Protamine sulfate is the specific antidote for heparin. It is a positively
charged protein that binds to negatively charged heparin, neutralizing its anticoagulant
effect.
Q9
A client with hypertension is prescribed lisinopril. The nurse understands that the
mechanism of action of ACE inhibitors in hypertension is to:
A. Increase heart rate
B. Decrease preload and afterload
College, 2026/2027) – Verified Questions & Answers
(Grade A, 100% Correct)
Q1
A 72-year-old male with heart failure is being discharged home. The nurse teaches him
to weigh himself each morning. Which instruction about daily weights is most important
for detecting fluid retention?
A. Call the provider if weight increases by 3 pounds in a day or 5 pounds in a week
B. Weigh weekly and record only if there is a change
C. Weigh after breakfast while wearing shoes for consistency
D. Skip weighing on days when feeling well
Correct Answer: A
Rationale: A weight gain of 3 pounds in a day or 5 pounds in a week indicates
significant fluid retention requiring provider notification and possible diuretic
adjustment. Weekly weighing would delay detection of worsening heart failure, so the
alternative misstates the appropriate frequency.
Q2
A 68-year-old male with COPD is receiving oxygen at 2 L/min via nasal cannula. The
nurse understands that low-flow oxygen is used in COPD because of which physiologic
concern?
A. COPD patients require less oxygen due to increased lung compliance
B. High-flow oxygen may suppress the hypoxic respiratory drive in COPD patients
C. High-flow oxygen causes bronchospasm in COPD patients
D. Low-flow oxygen prevents mucous plugging in COPD patients
Correct Answer: B
,Rationale: Many COPD patients rely on a hypoxic drive to breathe, so high-flow oxygen
can suppress respiratory effort and cause CO2 retention. The concern is not
bronchospasm or mucous plugging but the risk of hypoventilation, so the alternative
misstates the rationale.
Q3
The nurse is preparing to administer digoxin to a client with heart failure. Which
assessment finding should prompt the nurse to hold the dose and notify the healthcare
provider?
A. Apical pulse of 58 beats per minute
B. Blood pressure of 130/80 mmHg
C. Potassium level of 4.2 mEq/L
D. Respiratory rate of 18 breaths per minute
Correct Answer: A
Rationale: Digoxin should be held if the apical pulse is below 60 beats per minute in
adults, as bradycardia indicates potential digoxin toxicity. Potassium level of 4.2 is within
normal limits (3.5-5.0), and the blood pressure is acceptable.
Q4
A client with heart failure is prescribed furosemide (Lasix). Which electrolyte imbalance
should the nurse monitor most closely?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypermagnesemia
Correct Answer: B
,Rationale: Furosemide is a loop diuretic that causes potassium wasting, leading to
hypokalemia, which increases the risk of digoxin toxicity and cardiac arrhythmias.
Potassium levels should be monitored closely, and supplements may be prescribed.
Q5
A client with atrial fibrillation is prescribed warfarin. The nurse should monitor which
laboratory value to evaluate the effectiveness of this medication?
A. Serum potassium
B. International normalized ratio (INR)
C. Platelet count
D. Partial thromboplastin time (PTT)
Correct Answer: B
Rationale: The INR is the standardized test used to monitor the therapeutic efficacy of
warfarin therapy. The target INR for non-valvular atrial fibrillation is 2.0-3.0.
Q6
The nurse is caring for a client with a pulmonary embolism. Which finding indicates that
treatment with heparin is effective?
A. Decreased heart rate
B. Increased oxygen saturation
C. aPTT within therapeutic range
D. Decreased chest pain
Correct Answer: C
Rationale: Heparin therapy is monitored using the activated partial thromboplastin time
(aPTT). The goal is typically 1.5-2.5 times the control value. An aPTT within the
therapeutic range indicates that heparin is at an effective dose.
, Q7
A client on warfarin has an INR of 5.5 with no bleeding. The appropriate action is:
A. Administer vitamin K 10 mg IV
B. Hold warfarin and monitor INR
C. Administer protamine sulfate
D. Increase warfarin dose
Correct Answer: B
Rationale: For an INR of 5.5 without bleeding, the recommended action is to hold
warfarin and monitor the INR. Vitamin K may be considered if bleeding risk is high or
the INR is significantly elevated.
Q8
The antidote for heparin is:
A. Vitamin K
B. Protamine sulfate
C. Idarucizumab
D. Andexanet alfa
Correct Answer: B
Rationale: Protamine sulfate is the specific antidote for heparin. It is a positively
charged protein that binds to negatively charged heparin, neutralizing its anticoagulant
effect.
Q9
A client with hypertension is prescribed lisinopril. The nurse understands that the
mechanism of action of ACE inhibitors in hypertension is to:
A. Increase heart rate
B. Decrease preload and afterload
