BSN 266 – HESI MEDICAL-SURGICAL PRACTICE EXAM V2 (NIGHTINGALE COLLEGE, 2026/2027) –
VERIFIED QUESTIONS, ANSWERS, AND RATIONALES (GRADE A, 100% CORRECT)
Questions 1–100
1. A client with heart failure has an order for furosemide (Lasix) 40 mg IV push. Which assessment
finding indicates the medication is having the desired effect?
A) Blood pressure 100/60 mm Hg
B) Weight decrease of 2 kg in 24 hours
C) Urine output of 50 mL/hour
D) Clear breath sounds
Answer D: Clear breath sounds
Rationale: Furosemide reduces preload by promoting diuresis. The desired effect in heart failure is relief of
pulmonary congestion, evidenced by clear breath sounds.
2. A client with chest pain receives sublingual nitroglycerin. Which side effect should the nurse
anticipate?
A) Headache
B) Bradycardia
C) Hypertension
D) Dizziness
Answer A: Headache
Rationale: Nitroglycerin causes vasodilation, which can lead to headache due to cerebral vessel dilation.
3. A client with atrial fibrillation is prescribed warfarin (Coumadin). Which lab value indicates
therapeutic anticoagulation?
A) aPTT 1.5–2.5 times control
B) INR 2.0–3.0
C) Platelets 150,000/mm³
D) PT 1.5–2.5 times control
Answer B: INR 2.0–3.0
Rationale: Warfarin therapy is monitored by INR; for atrial fibrillation, the target INR is 2.0–3.0.
,4. A client is 2 hours post-cardiac catheterization via the femoral artery. The nurse notes the groin
site is swollen and the pedal pulse is weak. What should the nurse do first?
A) Apply firm pressure 1 inch above the insertion site
B) Elevate the leg
C) Remove the pressure dressing
D) Notify the healthcare provider
Answer A: Apply firm pressure 1 inch above the insertion site
Rationale: This indicates possible bleeding/hematoma at the site. Firm pressure above the site can help
occlude the artery and control bleeding.
5. A client with heart failure calls the clinic and reports that he cannot put his shoes on because they
are too tight. Which additional information should the nurse obtain?
A) What time did he take his medication?
B) Has his weight changed in the last several days?
C) Is he still able to tighten his belt buckle?
D) How many hours did he sleep last night?
Answer B: Has his weight changed in the last several days?
Rationale: Weight gain of 2–3 pounds in 24 hours or 5 pounds in a week indicates fluid retention, a key sign
of worsening heart failure.
6. A client with COPD has an oxygen saturation of 88%. Which action should the nurse take first?
A) Administer oxygen at 2 L/min via nasal cannula
B) Assess the client's respiratory rate and lung sounds
C) Notify the healthcare provider
D) Position the client in high Fowler's position
Answer B: Assess the client's respiratory rate and lung sounds
Rationale: Before initiating any intervention, the nurse should assess the client's respiratory status to
determine the cause of desaturation.
7. A client with diabetes mellitus who has gangrene of the toes to the midfoot is being planned for
care. Which goal should be included in this client's plan of care?
A) Promote wound healing
, B) Prevent infection
C) Increase mobility
D) Manage pain
Answer B: Prevent infection
Rationale: For a client with gangrene, preventing infection is the priority to avoid further tissue damage and
potential sepsis.
8. A female client who received a nephrotoxic drug is admitted with acute renal failure and asks the
nurse if she will need dialysis for the rest of her life. Which pathophysiologic consequence should the
nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides?
A) Nephron obstruction
B) Glomerular filtration rate increase
C) Renal artery stenosis
D) Urinary obstruction
Answer A: Nephron obstruction
Rationale: Acute tubular necrosis causes obstruction of nephrons from cellular debris, which is often
reversible with supportive care including temporary dialysis.
9. An emaciated homeless client presents to the emergency department complaining of a productive
cough, with blood-tinged sputum and night sweats. Which action is most important for the
emergency department triage nurse to implement?
A) Administer antibiotics immediately
B) Obtain a chest X-ray
C) Initiate airborne infection precautions
D) Collect a sputum culture
Answer C: Initiate airborne infection precautions
Rationale: The client's symptoms suggest tuberculosis, which requires airborne precautions (N95 mask,
negative pressure room) to prevent transmission.
10. A client is being discharged following radioactive seed implantation for prostate cancer. What is
the most important information that the nurse should provide to this client's family?
A) Follow exposure precautions
B) Encourage the client to rest
VERIFIED QUESTIONS, ANSWERS, AND RATIONALES (GRADE A, 100% CORRECT)
Questions 1–100
1. A client with heart failure has an order for furosemide (Lasix) 40 mg IV push. Which assessment
finding indicates the medication is having the desired effect?
A) Blood pressure 100/60 mm Hg
B) Weight decrease of 2 kg in 24 hours
C) Urine output of 50 mL/hour
D) Clear breath sounds
Answer D: Clear breath sounds
Rationale: Furosemide reduces preload by promoting diuresis. The desired effect in heart failure is relief of
pulmonary congestion, evidenced by clear breath sounds.
2. A client with chest pain receives sublingual nitroglycerin. Which side effect should the nurse
anticipate?
A) Headache
B) Bradycardia
C) Hypertension
D) Dizziness
Answer A: Headache
Rationale: Nitroglycerin causes vasodilation, which can lead to headache due to cerebral vessel dilation.
3. A client with atrial fibrillation is prescribed warfarin (Coumadin). Which lab value indicates
therapeutic anticoagulation?
A) aPTT 1.5–2.5 times control
B) INR 2.0–3.0
C) Platelets 150,000/mm³
D) PT 1.5–2.5 times control
Answer B: INR 2.0–3.0
Rationale: Warfarin therapy is monitored by INR; for atrial fibrillation, the target INR is 2.0–3.0.
,4. A client is 2 hours post-cardiac catheterization via the femoral artery. The nurse notes the groin
site is swollen and the pedal pulse is weak. What should the nurse do first?
A) Apply firm pressure 1 inch above the insertion site
B) Elevate the leg
C) Remove the pressure dressing
D) Notify the healthcare provider
Answer A: Apply firm pressure 1 inch above the insertion site
Rationale: This indicates possible bleeding/hematoma at the site. Firm pressure above the site can help
occlude the artery and control bleeding.
5. A client with heart failure calls the clinic and reports that he cannot put his shoes on because they
are too tight. Which additional information should the nurse obtain?
A) What time did he take his medication?
B) Has his weight changed in the last several days?
C) Is he still able to tighten his belt buckle?
D) How many hours did he sleep last night?
Answer B: Has his weight changed in the last several days?
Rationale: Weight gain of 2–3 pounds in 24 hours or 5 pounds in a week indicates fluid retention, a key sign
of worsening heart failure.
6. A client with COPD has an oxygen saturation of 88%. Which action should the nurse take first?
A) Administer oxygen at 2 L/min via nasal cannula
B) Assess the client's respiratory rate and lung sounds
C) Notify the healthcare provider
D) Position the client in high Fowler's position
Answer B: Assess the client's respiratory rate and lung sounds
Rationale: Before initiating any intervention, the nurse should assess the client's respiratory status to
determine the cause of desaturation.
7. A client with diabetes mellitus who has gangrene of the toes to the midfoot is being planned for
care. Which goal should be included in this client's plan of care?
A) Promote wound healing
, B) Prevent infection
C) Increase mobility
D) Manage pain
Answer B: Prevent infection
Rationale: For a client with gangrene, preventing infection is the priority to avoid further tissue damage and
potential sepsis.
8. A female client who received a nephrotoxic drug is admitted with acute renal failure and asks the
nurse if she will need dialysis for the rest of her life. Which pathophysiologic consequence should the
nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides?
A) Nephron obstruction
B) Glomerular filtration rate increase
C) Renal artery stenosis
D) Urinary obstruction
Answer A: Nephron obstruction
Rationale: Acute tubular necrosis causes obstruction of nephrons from cellular debris, which is often
reversible with supportive care including temporary dialysis.
9. An emaciated homeless client presents to the emergency department complaining of a productive
cough, with blood-tinged sputum and night sweats. Which action is most important for the
emergency department triage nurse to implement?
A) Administer antibiotics immediately
B) Obtain a chest X-ray
C) Initiate airborne infection precautions
D) Collect a sputum culture
Answer C: Initiate airborne infection precautions
Rationale: The client's symptoms suggest tuberculosis, which requires airborne precautions (N95 mask,
negative pressure room) to prevent transmission.
10. A client is being discharged following radioactive seed implantation for prostate cancer. What is
the most important information that the nurse should provide to this client's family?
A) Follow exposure precautions
B) Encourage the client to rest
