BSN HESI 266 Med Surg Exam (
Update) Questions & Verified Answers, 100%
Guaranteed Pass || Complete A+ Guide -
Nightingale
1. A client with heart failure is prescribed furosemide
(Lasix) and digoxin (Lanoxin). Which assessment finding is
most concerning?
A. Weight loss of 1 kg in 24 hours
B. Serum potassium level of 3.2 mEq/L
C. Blood pressure of 110/70 mm Hg
D. Urine output of 40 mL/hr
Answer: B
Rationale: Hypokalemia (potassium <3.5 mEq/L)
increases the risk of digoxin toxicity, leading to fatal
dysrhythmias. Weight loss of 1 kg/day is expected with
diuresis. BP 110/70 is acceptable. Urine output >30
mL/hr is normal.
1
,2. A client post-cardiac catheterization reports severe
back pain. The puncture site is stable, but vital signs are
BP 100/60, HR 110. What is the priority action?
A. Administer morphine for pain
B. Reposition the client
C. Assess for retroperitoneal bleeding
D. Apply ice to the puncture site
Answer: C
Rationale: Severe back pain with tachycardia and
hypotension after cardiac catheterization suggests
retroperitoneal bleeding, a life-threatening complication.
The nurse should immediately notify the provider and
assess for hemoglobin drop.
3. A client with angina is prescribed nitroglycerin
sublingual. Which instruction is correct?
2
,A. Swallow the tablet with water
B. Take one tablet every 5 minutes up to three doses
C. Store the bottle in a warm, humid place
D. Expect immediate relief within 30 seconds
Answer: B
Rationale: Nitroglycerin sublingual is taken one tablet
every 5 minutes for up to three doses if pain persists. It
should be stored in a dark, cool, dry place. Relief
typically occurs in 1–3 minutes.
4. A client with atrial fibrillation is on warfarin
(Coumadin). Which laboratory value indicates therapeutic
effect?
A. INR 1.0
B. INR 2.5
C. aPTT 60 seconds
D. Platelets 150,000
3
, Answer: B
Rationale: Therapeutic INR for atrial fibrillation on
warfarin is 2.0–3.0. INR 1.0 is subtherapeutic. aPTT
monitors heparin, not warfarin.
5. A client with hypertension is started on lisinopril
(Prinivil). Which adverse effect requires immediate action?
A. Dry cough
B. Angioedema (swelling of lips/tongue)
C. Dizziness
D. Fatigue
Answer: B
Rationale: Angioedema is a life-threatening allergic
reaction to ACE inhibitors requiring immediate
discontinuation and emergency treatment. Dry cough is
common but not immediately dangerous.
4
Update) Questions & Verified Answers, 100%
Guaranteed Pass || Complete A+ Guide -
Nightingale
1. A client with heart failure is prescribed furosemide
(Lasix) and digoxin (Lanoxin). Which assessment finding is
most concerning?
A. Weight loss of 1 kg in 24 hours
B. Serum potassium level of 3.2 mEq/L
C. Blood pressure of 110/70 mm Hg
D. Urine output of 40 mL/hr
Answer: B
Rationale: Hypokalemia (potassium <3.5 mEq/L)
increases the risk of digoxin toxicity, leading to fatal
dysrhythmias. Weight loss of 1 kg/day is expected with
diuresis. BP 110/70 is acceptable. Urine output >30
mL/hr is normal.
1
,2. A client post-cardiac catheterization reports severe
back pain. The puncture site is stable, but vital signs are
BP 100/60, HR 110. What is the priority action?
A. Administer morphine for pain
B. Reposition the client
C. Assess for retroperitoneal bleeding
D. Apply ice to the puncture site
Answer: C
Rationale: Severe back pain with tachycardia and
hypotension after cardiac catheterization suggests
retroperitoneal bleeding, a life-threatening complication.
The nurse should immediately notify the provider and
assess for hemoglobin drop.
3. A client with angina is prescribed nitroglycerin
sublingual. Which instruction is correct?
2
,A. Swallow the tablet with water
B. Take one tablet every 5 minutes up to three doses
C. Store the bottle in a warm, humid place
D. Expect immediate relief within 30 seconds
Answer: B
Rationale: Nitroglycerin sublingual is taken one tablet
every 5 minutes for up to three doses if pain persists. It
should be stored in a dark, cool, dry place. Relief
typically occurs in 1–3 minutes.
4. A client with atrial fibrillation is on warfarin
(Coumadin). Which laboratory value indicates therapeutic
effect?
A. INR 1.0
B. INR 2.5
C. aPTT 60 seconds
D. Platelets 150,000
3
, Answer: B
Rationale: Therapeutic INR for atrial fibrillation on
warfarin is 2.0–3.0. INR 1.0 is subtherapeutic. aPTT
monitors heparin, not warfarin.
5. A client with hypertension is started on lisinopril
(Prinivil). Which adverse effect requires immediate action?
A. Dry cough
B. Angioedema (swelling of lips/tongue)
C. Dizziness
D. Fatigue
Answer: B
Rationale: Angioedema is a life-threatening allergic
reaction to ACE inhibitors requiring immediate
discontinuation and emergency treatment. Dry cough is
common but not immediately dangerous.
4
