BSN 266 HESI MED SURG EXAM Practice Questions
with Verified Answers & Detailed Rationales
QUESTION 1
An adult who was recently diagnosed with glaucoma tells the nurse, "It
feels like I am driving through a tunnel." The client expresses great concern
about going blind. Which nursing instruction is most important for the
nurse to provide?
A) Eat a diet high in carotene
B) Wear prescription glasses
C) Maintain prescribed eye drop regimen
D) Avoid frequent eye pressure measurements
CORRECT ANSWER: C) Maintain prescribed eye drop regimen
Rationale: Adherence to the prescribed eye drop regimen is critical to control
intraocular pressure and prevent further vision loss in glaucoma. Tunnel
vision indicates advanced glaucoma with peripheral field loss. Dietary
changes and glasses do not treat the underlying pressure problem.
QUESTION 2
Which information should the nurse include in the teaching plan for a client
diagnosed with gastroesophageal reflux disease (GERD)?
A) Adjust food intake to three full meals per day and no snacks
B) Sleep without pillows at night to maintain neck alignment
,C) Minimize symptoms by wearing loose, comfortable clothing
D) Avoid participation in any aerobic exercise programs
CORRECT ANSWER: C) Minimize symptoms by wearing loose,
comfortable clothing
Rationale: Tight clothing around the abdomen increases intra-abdominal
pressure, which can worsen GERD symptoms by promoting reflux. Smaller,
more frequent meals are recommended rather than three large meals.
Elevating the head of the bed is advised.
QUESTION 3
A client arrives to the emergency department reporting an intermittent
fever and night sweats for the past 3 weeks and has developed a
productive cough containing small amounts of blood. Which intervention
should the nurse prioritize?
A) Move into airborne isolation
B) Collect specimens for blood cultures
C) Arrange transport for radiographic imaging
D) Obtain a sputum sample
CORRECT ANSWER: A) Move into airborne isolation
Rationale: The client's symptoms (fever, night sweats, productive cough with
hemoptysis) are classic for tuberculosis, which requires airborne precautions.
The priority is to prevent transmission by placing the client in airborne
isolation before further diagnostic testing.
,QUESTION 4
A nurse is caring for a client with chronic pancreatitis who reports persistent
gnawing abdominal pain. To help the client manage the pain, which
assessment data is most important for the nurse to obtain?
A) Activity level of bowel sounds
B) Eating patterns of dietary intake
C) Level and amount of physical activity
D) Color and consistency of feces
CORRECT ANSWER: B) Eating patterns of dietary intake
Rationale: In chronic pancreatitis, pain is often triggered or worsened by food
intake due to pancreatic enzyme stimulation. Understanding the client's
eating patterns helps identify pain triggers and guide dietary modifications
for pain management.
QUESTION 5
An older adult client with a long history of COPD is admitted with
progressive shortness of breath and a persistent cough. The client is
anxious and is complaining of a dry mouth. Which intervention should the
nurse implement?
A) Apply a tight-flow Venturi mask
B) Encourage client to drink water
C) Assist client to an upright position
D) Administer a prescribed sedative
, CORRECT ANSWER: C) Assist client to an upright position
Rationale: The priority intervention for a client with COPD exacerbation and
shortness of breath is to position the client upright (high-Fowler's) to
maximize lung expansion and ease breathing. Sedatives should be avoided as
they can depress respiratory drive.
QUESTION 6
Which action should the nurse implement to reduce the risk of vesicant
extravasation in a client who is receiving intravenous chemotherapy?
A) Monitor the client's intravenous site hourly during the treatment
B) Keep the head of the bed elevated until the treatment is completed
C) Instruct the client to drink plenty of fluids during the treatment
D) Administer an antiemetic before starting the chemotherapy
CORRECT ANSWER: A) Monitor the client's intravenous site hourly
during the treatment
Rationale: Vesicant chemotherapy agents can cause severe tissue damage if
extravasation occurs. Hourly monitoring of the IV site during infusion allows
early detection of infiltration or extravasation, minimizing tissue injury.
QUESTION 7
The nurse is evaluating a client's understanding about the DASH (Dietary
with Verified Answers & Detailed Rationales
QUESTION 1
An adult who was recently diagnosed with glaucoma tells the nurse, "It
feels like I am driving through a tunnel." The client expresses great concern
about going blind. Which nursing instruction is most important for the
nurse to provide?
A) Eat a diet high in carotene
B) Wear prescription glasses
C) Maintain prescribed eye drop regimen
D) Avoid frequent eye pressure measurements
CORRECT ANSWER: C) Maintain prescribed eye drop regimen
Rationale: Adherence to the prescribed eye drop regimen is critical to control
intraocular pressure and prevent further vision loss in glaucoma. Tunnel
vision indicates advanced glaucoma with peripheral field loss. Dietary
changes and glasses do not treat the underlying pressure problem.
QUESTION 2
Which information should the nurse include in the teaching plan for a client
diagnosed with gastroesophageal reflux disease (GERD)?
A) Adjust food intake to three full meals per day and no snacks
B) Sleep without pillows at night to maintain neck alignment
,C) Minimize symptoms by wearing loose, comfortable clothing
D) Avoid participation in any aerobic exercise programs
CORRECT ANSWER: C) Minimize symptoms by wearing loose,
comfortable clothing
Rationale: Tight clothing around the abdomen increases intra-abdominal
pressure, which can worsen GERD symptoms by promoting reflux. Smaller,
more frequent meals are recommended rather than three large meals.
Elevating the head of the bed is advised.
QUESTION 3
A client arrives to the emergency department reporting an intermittent
fever and night sweats for the past 3 weeks and has developed a
productive cough containing small amounts of blood. Which intervention
should the nurse prioritize?
A) Move into airborne isolation
B) Collect specimens for blood cultures
C) Arrange transport for radiographic imaging
D) Obtain a sputum sample
CORRECT ANSWER: A) Move into airborne isolation
Rationale: The client's symptoms (fever, night sweats, productive cough with
hemoptysis) are classic for tuberculosis, which requires airborne precautions.
The priority is to prevent transmission by placing the client in airborne
isolation before further diagnostic testing.
,QUESTION 4
A nurse is caring for a client with chronic pancreatitis who reports persistent
gnawing abdominal pain. To help the client manage the pain, which
assessment data is most important for the nurse to obtain?
A) Activity level of bowel sounds
B) Eating patterns of dietary intake
C) Level and amount of physical activity
D) Color and consistency of feces
CORRECT ANSWER: B) Eating patterns of dietary intake
Rationale: In chronic pancreatitis, pain is often triggered or worsened by food
intake due to pancreatic enzyme stimulation. Understanding the client's
eating patterns helps identify pain triggers and guide dietary modifications
for pain management.
QUESTION 5
An older adult client with a long history of COPD is admitted with
progressive shortness of breath and a persistent cough. The client is
anxious and is complaining of a dry mouth. Which intervention should the
nurse implement?
A) Apply a tight-flow Venturi mask
B) Encourage client to drink water
C) Assist client to an upright position
D) Administer a prescribed sedative
, CORRECT ANSWER: C) Assist client to an upright position
Rationale: The priority intervention for a client with COPD exacerbation and
shortness of breath is to position the client upright (high-Fowler's) to
maximize lung expansion and ease breathing. Sedatives should be avoided as
they can depress respiratory drive.
QUESTION 6
Which action should the nurse implement to reduce the risk of vesicant
extravasation in a client who is receiving intravenous chemotherapy?
A) Monitor the client's intravenous site hourly during the treatment
B) Keep the head of the bed elevated until the treatment is completed
C) Instruct the client to drink plenty of fluids during the treatment
D) Administer an antiemetic before starting the chemotherapy
CORRECT ANSWER: A) Monitor the client's intravenous site hourly
during the treatment
Rationale: Vesicant chemotherapy agents can cause severe tissue damage if
extravasation occurs. Hourly monitoring of the IV site during infusion allows
early detection of infiltration or extravasation, minimizing tissue injury.
QUESTION 7
The nurse is evaluating a client's understanding about the DASH (Dietary
