BSN 266 HESI V2 (NIGHTINGALE COLLEGE) EXAM|REAL PRACTICE
QUESTIONS AND ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) LATEST 2026 UPDATE
Question 1 of 55
The nurse is evaluating a client's understanding about the DASH (Dietary Approaches to Stop Hypertension) eating
plan. Which behavior indicates that the client is adhering to the eating plan?
• A Uses only lactose-free dairy products.
• B Carefully cleans and peels all fresh fruit and vegetables.
• C No longer incudes grains in daily diet.
• D Enjoys fat-free yogurt as an occasional snack food.
Question 2 of 55
A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional
finding warrants the most immediate action by the nurse? [Hematocrit (Reference Range: Male: 42% to 52% (0.42
to 0.52 volume fraction)]
• A Further decline in level of consciousness.
• B Hematocrit of 30% (0.30 volume fraction)
• C Cold and dry skin.
• D Facial puffiness and periorbital edema
Question 3 of 55
The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow
in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse
document?
1|Page
,- A Deep full-thickness.
• B Full thickness.
• C Deep partial-thickness.
• D Superficial partial-thickness.
• A Urinary output.
• B Oxygen saturation.
• D Lung sounds.
Orthopneic position, sometimes called tripod position, is a sitting position where an individual leans slightly
forward with their arms propped up on an overbed table or their knees.
Orthopnea is the sensation of breathlessness in the recumbent (lying down) position, relieved by sitting or
standing.
Question 4 of 55
An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for
further treatment. Initial assessment includes a heart rate 128 beats/minute and irregular, respirations 38
breaths/minute, blood pressure 168/100 mm Hg, wheezes and crackles in all lung fields. An hour after the
administration of furosemide 60 mg intravenous (IV), which assessment(s) should the nurse obtain to determine
the client's response to treatment? (Select all that apply.)
• A Urinary output.
• B Oxygen saturation.
• C Pain scale.
• D Lung sounds.
2|Page
, • E Skin elasticity.
• B Crohn's disease with colectomy.
Question # 5
Rationale - B Crohn's disease with colectomy.
The nurse should recognize that clients with extensive intra-abdominal surgical history are not candidates for
peritoneal dialysis, as these clients may have decreased peritoneal membrane surface areas and scar tissue
formation, which would make it insufficient for adequate dialysis exchange.
Question 5 of 55
A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the
client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?
• A Nephrotic syndrome history.
• B Crohn's disease with colectomy.
• C Type 2 diabetes mellitus.
• D Latent hepatitis C.
• D Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
The three main things that the liver produces are albumin, bile (digestive enzymes), and prothrombin (clotting
factors).
Albumin plays many important roles including maintenance of appropriate osmotic pressure, binding and
transport of various substances like hormones, drugs etc. in blood, and neutralisation of free radicals. It prevents
fluid from leaking out of blood vessels into your tissues. Albumin is also responsible for transporting vitamins,
enzymes and hormones throughout your body. Albumin makes up 50% of the proteins found in your plasma.
Question 6 of 55
3|Page
, 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 clients with cirrhosis?
• A Decreased portacaval pressure with greater collateral circulation.
• B Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
• C Decreased renin-angiotensin response related to an increase in renal blood flow.
• D Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
• B Discuss approaches to chronic pain control with the client.
Question 7 of 55
While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences
on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the
nurse take?
• A Review the client's dietary intake of high-protein foods.
• B Discuss approaches to chronic pain control with the client.
• C Notify the healthcare provider of the finding immediately.
• D Assess the client's radial pulses and capillary refill time.
• B Minimize symptoms by wearing loose, comfortable clothing.
Question 8 of 55
Which information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux
disease (GERD)?
• A Adjust food intake to three full meals per day and no snacks.
• B Minimize symptoms by wearing loose, comfortable clothing.
• C Avoid participation in any aerobic exercise programs.
• D Sleep without pillows at night to maintain neck alignment.
• D Platelet count.
4|Page
QUESTIONS AND ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) LATEST 2026 UPDATE
Question 1 of 55
The nurse is evaluating a client's understanding about the DASH (Dietary Approaches to Stop Hypertension) eating
plan. Which behavior indicates that the client is adhering to the eating plan?
• A Uses only lactose-free dairy products.
• B Carefully cleans and peels all fresh fruit and vegetables.
• C No longer incudes grains in daily diet.
• D Enjoys fat-free yogurt as an occasional snack food.
Question 2 of 55
A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional
finding warrants the most immediate action by the nurse? [Hematocrit (Reference Range: Male: 42% to 52% (0.42
to 0.52 volume fraction)]
• A Further decline in level of consciousness.
• B Hematocrit of 30% (0.30 volume fraction)
• C Cold and dry skin.
• D Facial puffiness and periorbital edema
Question 3 of 55
The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow
in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse
document?
1|Page
,- A Deep full-thickness.
• B Full thickness.
• C Deep partial-thickness.
• D Superficial partial-thickness.
• A Urinary output.
• B Oxygen saturation.
• D Lung sounds.
Orthopneic position, sometimes called tripod position, is a sitting position where an individual leans slightly
forward with their arms propped up on an overbed table or their knees.
Orthopnea is the sensation of breathlessness in the recumbent (lying down) position, relieved by sitting or
standing.
Question 4 of 55
An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for
further treatment. Initial assessment includes a heart rate 128 beats/minute and irregular, respirations 38
breaths/minute, blood pressure 168/100 mm Hg, wheezes and crackles in all lung fields. An hour after the
administration of furosemide 60 mg intravenous (IV), which assessment(s) should the nurse obtain to determine
the client's response to treatment? (Select all that apply.)
• A Urinary output.
• B Oxygen saturation.
• C Pain scale.
• D Lung sounds.
2|Page
, • E Skin elasticity.
• B Crohn's disease with colectomy.
Question # 5
Rationale - B Crohn's disease with colectomy.
The nurse should recognize that clients with extensive intra-abdominal surgical history are not candidates for
peritoneal dialysis, as these clients may have decreased peritoneal membrane surface areas and scar tissue
formation, which would make it insufficient for adequate dialysis exchange.
Question 5 of 55
A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the
client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?
• A Nephrotic syndrome history.
• B Crohn's disease with colectomy.
• C Type 2 diabetes mellitus.
• D Latent hepatitis C.
• D Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
The three main things that the liver produces are albumin, bile (digestive enzymes), and prothrombin (clotting
factors).
Albumin plays many important roles including maintenance of appropriate osmotic pressure, binding and
transport of various substances like hormones, drugs etc. in blood, and neutralisation of free radicals. It prevents
fluid from leaking out of blood vessels into your tissues. Albumin is also responsible for transporting vitamins,
enzymes and hormones throughout your body. Albumin makes up 50% of the proteins found in your plasma.
Question 6 of 55
3|Page
, 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 clients with cirrhosis?
• A Decreased portacaval pressure with greater collateral circulation.
• B Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
• C Decreased renin-angiotensin response related to an increase in renal blood flow.
• D Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
• B Discuss approaches to chronic pain control with the client.
Question 7 of 55
While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences
on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the
nurse take?
• A Review the client's dietary intake of high-protein foods.
• B Discuss approaches to chronic pain control with the client.
• C Notify the healthcare provider of the finding immediately.
• D Assess the client's radial pulses and capillary refill time.
• B Minimize symptoms by wearing loose, comfortable clothing.
Question 8 of 55
Which information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux
disease (GERD)?
• A Adjust food intake to three full meals per day and no snacks.
• B Minimize symptoms by wearing loose, comfortable clothing.
• C Avoid participation in any aerobic exercise programs.
• D Sleep without pillows at night to maintain neck alignment.
• D Platelet count.
4|Page
