BSN 266 — HESI Medical-Surgical Exam | Complete Questions
with Verified Correct Answers & Detailed Explanations –
2026/2027 Update | Graded A+
Question 1
A client with chronic heart failure suddenly develops severe dyspnea, bilateral
crackles, pink frothy sputum, and an oxygen saturation of 82%. Which
intervention should the nurse perform first?
A. Administer prescribed IV furosemide
B. Place the client in high-Fowler's position
C. Obtain a 12-lead ECG
D. Restrict the client's oral fluid intake
Correct Answer: B. Place the client in high-Fowler's position
Explanation:
The findings indicate acute pulmonary edema, a life-threatening
complication of heart failure. The immediate priority is to improve ventilation
and oxygenation by positioning the client upright, preferably in high-Fowler's
position. Furosemide and other therapies are important, but positioning and
airway/oxygenation take priority under the ABC framework.
Question 2
A client with COPD is receiving oxygen at 2 L/min through a nasal cannula.
The client becomes increasingly drowsy, and the respiratory rate decreases
from 20/min to 10/min. Which action should the nurse take?
A. Increase oxygen to 6 L/min
B. Continue the current oxygen and reassess in 1 hour
C. Assess the client's respiratory status and notify the healthcare provider
D. Encourage the client to ambulate
Correct Answer: C. Assess the client's respiratory status and notify the
healthcare provider
1
,Explanation:
Increasing somnolence and decreasing respiratory rate may indicate
hypoventilation and worsening respiratory failure. The nurse should
immediately assess airway, breathing, oxygen saturation, and mental status
and notify the provider. Oxygen should be titrated according to the prescribed
target rather than automatically increased to a high flow rate.
Question 3
A client with diabetic ketoacidosis has a serum potassium level of 3.0 mEq/L.
An IV insulin infusion is prescribed. Which action is most appropriate?
A. Begin the insulin infusion immediately
B. Hold insulin and notify the healthcare provider
C. Administer sodium bicarbonate first
D. Restrict IV fluids
Correct Answer: B. Hold insulin and notify the healthcare provider
Explanation:
Insulin drives potassium from the bloodstream into cells, which can make
hypokalemia significantly worse. A potassium level of 3.0 mEq/L places the
client at risk for dangerous dysrhythmias. Potassium replacement is generally
required before insulin is initiated when potassium is significantly low.
Question 4
A client with a small-bowel obstruction has persistent vomiting, abdominal
distention, and absent bowel sounds. Which finding requires the nurse's
immediate intervention?
A. Abdominal pain rated 6/10
B. Heart rate of 118/min
C. Urine output of 20 mL/hr
D. Mild abdominal distention
Correct Answer: C. Urine output of 20 mL/hr
2
,Explanation:
Urine output below approximately 30 mL/hr in an adult may indicate
inadequate renal perfusion and significant fluid-volume deficit. With bowel
obstruction and vomiting, the client is at high risk for dehydration and
electrolyte abnormalities. The finding requires prompt assessment and
intervention.
Question 5
A client with a history of atrial fibrillation is receiving warfarin. Which
laboratory value is most important for evaluating therapeutic effectiveness?
A. aPTT
B. INR
C. Platelet count
D. Serum sodium
Correct Answer: B. INR
Explanation:
Warfarin therapy is monitored primarily using the international normalized
ratio (INR). The therapeutic range depends on the indication, but many
clients with atrial fibrillation have a target INR around 2.0–3.0. Excessively
elevated INR increases bleeding risk.
Question 6
A client receiving IV heparin develops bleeding from the gums and has an
unexpectedly elevated aPTT. Which medication should the nurse anticipate
administering if severe anticoagulant-related bleeding occurs?
A. Vitamin K
B. Protamine sulfate
C. Naloxone
D. Acetylcysteine
Correct Answer: B. Protamine sulfate
3
, Explanation:
Protamine sulfate is the reversal agent for unfractionated heparin. Vitamin K
reverses warfarin, naloxone reverses opioid effects, and acetylcysteine is used
for acetaminophen toxicity.
Question 7
A client with acute kidney injury has a potassium level of 6.8 mEq/L. Which
finding requires the nurse's greatest concern?
A. Muscle weakness
B. Nausea
C. Peaked T waves on ECG
D. Mild peripheral edema
Correct Answer: C. Peaked T waves on ECG
Explanation:
Severe hyperkalemia can cause life-threatening cardiac dysrhythmias.
Peaked T waves are a classic early ECG manifestation. Severe hyperkalemia
requires rapid intervention to stabilize the myocardium and lower serum
potassium.
Question 8
A client with chronic kidney disease is prescribed epoetin alfa. Which
laboratory value should the nurse monitor most closely?
A. Hemoglobin
B. Sodium
C. Amylase
D. Bilirubin
Correct Answer: A. Hemoglobin
Explanation:
Epoetin alfa stimulates red blood cell production and is used to treat anemia
4
with Verified Correct Answers & Detailed Explanations –
2026/2027 Update | Graded A+
Question 1
A client with chronic heart failure suddenly develops severe dyspnea, bilateral
crackles, pink frothy sputum, and an oxygen saturation of 82%. Which
intervention should the nurse perform first?
A. Administer prescribed IV furosemide
B. Place the client in high-Fowler's position
C. Obtain a 12-lead ECG
D. Restrict the client's oral fluid intake
Correct Answer: B. Place the client in high-Fowler's position
Explanation:
The findings indicate acute pulmonary edema, a life-threatening
complication of heart failure. The immediate priority is to improve ventilation
and oxygenation by positioning the client upright, preferably in high-Fowler's
position. Furosemide and other therapies are important, but positioning and
airway/oxygenation take priority under the ABC framework.
Question 2
A client with COPD is receiving oxygen at 2 L/min through a nasal cannula.
The client becomes increasingly drowsy, and the respiratory rate decreases
from 20/min to 10/min. Which action should the nurse take?
A. Increase oxygen to 6 L/min
B. Continue the current oxygen and reassess in 1 hour
C. Assess the client's respiratory status and notify the healthcare provider
D. Encourage the client to ambulate
Correct Answer: C. Assess the client's respiratory status and notify the
healthcare provider
1
,Explanation:
Increasing somnolence and decreasing respiratory rate may indicate
hypoventilation and worsening respiratory failure. The nurse should
immediately assess airway, breathing, oxygen saturation, and mental status
and notify the provider. Oxygen should be titrated according to the prescribed
target rather than automatically increased to a high flow rate.
Question 3
A client with diabetic ketoacidosis has a serum potassium level of 3.0 mEq/L.
An IV insulin infusion is prescribed. Which action is most appropriate?
A. Begin the insulin infusion immediately
B. Hold insulin and notify the healthcare provider
C. Administer sodium bicarbonate first
D. Restrict IV fluids
Correct Answer: B. Hold insulin and notify the healthcare provider
Explanation:
Insulin drives potassium from the bloodstream into cells, which can make
hypokalemia significantly worse. A potassium level of 3.0 mEq/L places the
client at risk for dangerous dysrhythmias. Potassium replacement is generally
required before insulin is initiated when potassium is significantly low.
Question 4
A client with a small-bowel obstruction has persistent vomiting, abdominal
distention, and absent bowel sounds. Which finding requires the nurse's
immediate intervention?
A. Abdominal pain rated 6/10
B. Heart rate of 118/min
C. Urine output of 20 mL/hr
D. Mild abdominal distention
Correct Answer: C. Urine output of 20 mL/hr
2
,Explanation:
Urine output below approximately 30 mL/hr in an adult may indicate
inadequate renal perfusion and significant fluid-volume deficit. With bowel
obstruction and vomiting, the client is at high risk for dehydration and
electrolyte abnormalities. The finding requires prompt assessment and
intervention.
Question 5
A client with a history of atrial fibrillation is receiving warfarin. Which
laboratory value is most important for evaluating therapeutic effectiveness?
A. aPTT
B. INR
C. Platelet count
D. Serum sodium
Correct Answer: B. INR
Explanation:
Warfarin therapy is monitored primarily using the international normalized
ratio (INR). The therapeutic range depends on the indication, but many
clients with atrial fibrillation have a target INR around 2.0–3.0. Excessively
elevated INR increases bleeding risk.
Question 6
A client receiving IV heparin develops bleeding from the gums and has an
unexpectedly elevated aPTT. Which medication should the nurse anticipate
administering if severe anticoagulant-related bleeding occurs?
A. Vitamin K
B. Protamine sulfate
C. Naloxone
D. Acetylcysteine
Correct Answer: B. Protamine sulfate
3
, Explanation:
Protamine sulfate is the reversal agent for unfractionated heparin. Vitamin K
reverses warfarin, naloxone reverses opioid effects, and acetylcysteine is used
for acetaminophen toxicity.
Question 7
A client with acute kidney injury has a potassium level of 6.8 mEq/L. Which
finding requires the nurse's greatest concern?
A. Muscle weakness
B. Nausea
C. Peaked T waves on ECG
D. Mild peripheral edema
Correct Answer: C. Peaked T waves on ECG
Explanation:
Severe hyperkalemia can cause life-threatening cardiac dysrhythmias.
Peaked T waves are a classic early ECG manifestation. Severe hyperkalemia
requires rapid intervention to stabilize the myocardium and lower serum
potassium.
Question 8
A client with chronic kidney disease is prescribed epoetin alfa. Which
laboratory value should the nurse monitor most closely?
A. Hemoglobin
B. Sodium
C. Amylase
D. Bilirubin
Correct Answer: A. Hemoglobin
Explanation:
Epoetin alfa stimulates red blood cell production and is used to treat anemia
4
