BSN HESI 266 MED SURG EXAM | EDITION |
NIGHTINGALE COLLEGE | REAL EXAM QUESTIONS
& VERIFIED ANSWERS | 100% CORRECT | GRADED
A+
1. A client with heart failure is receiving furosemide. Which serum potassium
level should the nurse report to the healthcare provider immediately?
A) 4.0 mEq/L
B) 3.8 mEq/L
C) 3.1 mEq/L
D) 5.0 mEq/L
Correct Answer: C
Furosemide is a loop diuretic that promotes potassium excretion. A potassium of
3.1 mEq/L indicates hypokalemia, which increases the risk of life-threatening
arrhythmias. The provider should be notified. 4.0 and 3.8 are within normal range
(3.5–5.0 mEq/L); 5.0 is at the upper limit but not the priority.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen at 4 L/min via nasal cannula. The nurse notes the client has become
confused and the respiratory rate is 9 breaths/min. What is the priority
action?
A) Increase the oxygen flow to 5 L/min.
B) Check the client’s oxygen saturation.
C) Assess the client’s level of consciousness and airway, and notify the
provider.
D) Place the client in a supine position.
Correct Answer: C
Clients with COPD and chronic CO₂ retention may rely on hypoxic drive to breathe.
High-flow oxygen can suppress this drive, causing hypoventilation and CO₂
,narcosis. The priority is to assess the client and notify the provider; oxygen should
be reduced as prescribed. Increasing oxygen would worsen the condition.
3. A client with left-sided heart failure is admitted with worsening dyspnea
and crackles in the lung bases. Which action should the nurse take first?
A) Administer furosemide IV as prescribed.
B) Place the client in high Fowler’s position.
C) Obtain an arterial blood gas.
D) Apply a 100% non-rebreather mask.
Correct Answer: B
Positioning the client in high Fowler’s position reduces venous return and
pulmonary congestion, improving ventilation and oxygenation. This low-risk action
can be done immediately while preparing other interventions. Oxygen and
diuretics are important but positioning is first.
4. A client is receiving packed red blood cells. Fifteen minutes after the
transfusion starts, the client develops chills, fever, and flank pain. What
should the nurse do first?
A) Slow the transfusion and give an antipyretic.
B) Stop the transfusion and maintain the IV line with normal saline.
C) Notify the healthcare provider and blood bank.
D) Obtain a urine specimen to evaluate for hemolysis.
Correct Answer: B
Chills, fever, and flank pain suggest an acute hemolytic transfusion reaction. The
first action is to stop the transfusion and keep the vein open with normal saline.
Notification and specimen collection occur after stopping the infusion.
5. A client with an acute myocardial infarction develops ventricular fibrillation.
What is the immediate nursing action?
A) Administer amiodarone IV push.
B) Begin cardiopulmonary resuscitation (CPR) and defibrillate.
C) Perform synchronized cardioversion.
D) Administer epinephrine IV.
,Correct Answer: B
Ventricular fibrillation is a cardiac arrest rhythm requiring immediate CPR and
defibrillation. Amiodarone and epinephrine may be given during the resuscitation,
but defibrillation is the priority. Synchronized cardioversion is used for unstable
tachycardia with a pulse.
6. A client with a suspected pulmonary embolism suddenly develops severe
dyspnea and a loud systolic murmur at the left sternal border. The nurse
suspects:
A) Myocardial infarction
B) Cardiac tamponade
C) Acute right ventricular failure
D) Papillary muscle rupture
Correct Answer: C
A pulmonary embolism increases pulmonary vascular resistance, leading to right
ventricular strain and failure. A new murmur (tricuspid regurgitation) can be heard
due to right ventricular dilation. The other options are not directly caused by a PE.
7. The nurse is caring for a client with a chest tube connected to a water-seal
drainage system. Continuous bubbling is noted in the water-seal chamber.
This finding indicates:
A) The lung has fully re-expanded.
B) An air leak in the system.
C) Normal fluctuation of pleural pressure.
D) The suction is working properly.
Correct Answer: B
Continuous bubbling in the water-seal chamber indicates an air leak. Tidaling
(fluctuation with respiration) is normal. Bubbling in the suction control chamber
indicates suction is on. Absence of fluctuation may indicate lung re-expansion or
obstruction.
8. A client with diabetic ketoacidosis is receiving regular insulin IV and normal
saline. Which laboratory value should the nurse monitor most closely?
, A) Serum calcium
B) Serum potassium
C) Serum albumin
D) Serum bilirubin
Correct Answer: B
During DKA treatment, insulin and fluid administration shift potassium into cells,
causing serum potassium to drop rapidly. Hypokalemia can cause life-threatening
arrhythmias. Potassium levels must be monitored frequently and supplemented as
prescribed.
9. A client with type 2 diabetes is prescribed metformin. The nurse should
hold the medication and notify the provider before which procedure?
A) Abdominal ultrasound
B) CT scan with IV contrast dye
C) Colonoscopy with sedation
D) MRI without contrast
Correct Answer: B
Metformin should be temporarily discontinued before procedures involving
iodinated contrast due to the risk of lactic acidosis, especially if renal function is
impaired. The other procedures do not require withholding metformin.
10.A client with a fractured femur is in Buck’s traction. The nurse should:
A) Remove the traction weights when repositioning.
B) Ensure that the weights hang freely and do not touch the floor.
C) Place a pillow under the client’s knee.
D) Release the traction when the client is bathing.
Correct Answer: B
For traction to be effective, the weights must hang freely. Traction should be
continuous; removing or releasing it interrupts treatment. A pillow under the knee
can cause contractures and interfere with the line of pull.
11.A client is 24 hours post-operative after a total hip arthroplasty. The client
develops sudden onset of dyspnea and confusion. The nurse should:
NIGHTINGALE COLLEGE | REAL EXAM QUESTIONS
& VERIFIED ANSWERS | 100% CORRECT | GRADED
A+
1. A client with heart failure is receiving furosemide. Which serum potassium
level should the nurse report to the healthcare provider immediately?
A) 4.0 mEq/L
B) 3.8 mEq/L
C) 3.1 mEq/L
D) 5.0 mEq/L
Correct Answer: C
Furosemide is a loop diuretic that promotes potassium excretion. A potassium of
3.1 mEq/L indicates hypokalemia, which increases the risk of life-threatening
arrhythmias. The provider should be notified. 4.0 and 3.8 are within normal range
(3.5–5.0 mEq/L); 5.0 is at the upper limit but not the priority.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen at 4 L/min via nasal cannula. The nurse notes the client has become
confused and the respiratory rate is 9 breaths/min. What is the priority
action?
A) Increase the oxygen flow to 5 L/min.
B) Check the client’s oxygen saturation.
C) Assess the client’s level of consciousness and airway, and notify the
provider.
D) Place the client in a supine position.
Correct Answer: C
Clients with COPD and chronic CO₂ retention may rely on hypoxic drive to breathe.
High-flow oxygen can suppress this drive, causing hypoventilation and CO₂
,narcosis. The priority is to assess the client and notify the provider; oxygen should
be reduced as prescribed. Increasing oxygen would worsen the condition.
3. A client with left-sided heart failure is admitted with worsening dyspnea
and crackles in the lung bases. Which action should the nurse take first?
A) Administer furosemide IV as prescribed.
B) Place the client in high Fowler’s position.
C) Obtain an arterial blood gas.
D) Apply a 100% non-rebreather mask.
Correct Answer: B
Positioning the client in high Fowler’s position reduces venous return and
pulmonary congestion, improving ventilation and oxygenation. This low-risk action
can be done immediately while preparing other interventions. Oxygen and
diuretics are important but positioning is first.
4. A client is receiving packed red blood cells. Fifteen minutes after the
transfusion starts, the client develops chills, fever, and flank pain. What
should the nurse do first?
A) Slow the transfusion and give an antipyretic.
B) Stop the transfusion and maintain the IV line with normal saline.
C) Notify the healthcare provider and blood bank.
D) Obtain a urine specimen to evaluate for hemolysis.
Correct Answer: B
Chills, fever, and flank pain suggest an acute hemolytic transfusion reaction. The
first action is to stop the transfusion and keep the vein open with normal saline.
Notification and specimen collection occur after stopping the infusion.
5. A client with an acute myocardial infarction develops ventricular fibrillation.
What is the immediate nursing action?
A) Administer amiodarone IV push.
B) Begin cardiopulmonary resuscitation (CPR) and defibrillate.
C) Perform synchronized cardioversion.
D) Administer epinephrine IV.
,Correct Answer: B
Ventricular fibrillation is a cardiac arrest rhythm requiring immediate CPR and
defibrillation. Amiodarone and epinephrine may be given during the resuscitation,
but defibrillation is the priority. Synchronized cardioversion is used for unstable
tachycardia with a pulse.
6. A client with a suspected pulmonary embolism suddenly develops severe
dyspnea and a loud systolic murmur at the left sternal border. The nurse
suspects:
A) Myocardial infarction
B) Cardiac tamponade
C) Acute right ventricular failure
D) Papillary muscle rupture
Correct Answer: C
A pulmonary embolism increases pulmonary vascular resistance, leading to right
ventricular strain and failure. A new murmur (tricuspid regurgitation) can be heard
due to right ventricular dilation. The other options are not directly caused by a PE.
7. The nurse is caring for a client with a chest tube connected to a water-seal
drainage system. Continuous bubbling is noted in the water-seal chamber.
This finding indicates:
A) The lung has fully re-expanded.
B) An air leak in the system.
C) Normal fluctuation of pleural pressure.
D) The suction is working properly.
Correct Answer: B
Continuous bubbling in the water-seal chamber indicates an air leak. Tidaling
(fluctuation with respiration) is normal. Bubbling in the suction control chamber
indicates suction is on. Absence of fluctuation may indicate lung re-expansion or
obstruction.
8. A client with diabetic ketoacidosis is receiving regular insulin IV and normal
saline. Which laboratory value should the nurse monitor most closely?
, A) Serum calcium
B) Serum potassium
C) Serum albumin
D) Serum bilirubin
Correct Answer: B
During DKA treatment, insulin and fluid administration shift potassium into cells,
causing serum potassium to drop rapidly. Hypokalemia can cause life-threatening
arrhythmias. Potassium levels must be monitored frequently and supplemented as
prescribed.
9. A client with type 2 diabetes is prescribed metformin. The nurse should
hold the medication and notify the provider before which procedure?
A) Abdominal ultrasound
B) CT scan with IV contrast dye
C) Colonoscopy with sedation
D) MRI without contrast
Correct Answer: B
Metformin should be temporarily discontinued before procedures involving
iodinated contrast due to the risk of lactic acidosis, especially if renal function is
impaired. The other procedures do not require withholding metformin.
10.A client with a fractured femur is in Buck’s traction. The nurse should:
A) Remove the traction weights when repositioning.
B) Ensure that the weights hang freely and do not touch the floor.
C) Place a pillow under the client’s knee.
D) Release the traction when the client is bathing.
Correct Answer: B
For traction to be effective, the weights must hang freely. Traction should be
continuous; removing or releasing it interrupts treatment. A pillow under the knee
can cause contractures and interfere with the line of pull.
11.A client is 24 hours post-operative after a total hip arthroplasty. The client
develops sudden onset of dyspnea and confusion. The nurse should:
