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BSN HESI 266 MED SURG EXAM WITH VERIFIED
ANSWERS DETAILED RATIONALES GRADED A+
BSN HESI 266 Exam — Test Bank
SECTION 1: MANAGEMENT OF CARE & SAFETY (Questions 1–25)
1. The nurse receives report on four patients. Which patient should the nurse assess FIRST?
A. Heart-failure patient with 2+ pitting edema in lower extremities
B. Post-op hip-replacement patient reporting pain 6/10
C. COPD patient on 2 L NC with SpO₂ 92%
D. Diabetic patient with new red, warm area on plantar surface of foot
Rationale: Potential diabetic foot ulcer/infection is a medical emergency (risk for
sepsis/amputation); requires immediate inspection, off-loading, and provider notification.
Edema is chronic; pain is expected; SpO₂ 92% may be baseline. Source: BSN 266 HESI Medical-
Surgical Exam (Stuvia)
2. The nurse is delegating tasks to an experienced UAP for a stable heart-failure patient.
Which tasks are appropriate to delegate? (Select all that apply.)
A. Assist patient with ambulation to bathroom
B. Measure and record daily weight
C. Auscultate lung sounds after incentive spirometer
D. Reinforce teaching about 2-gram sodium diet
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E. Take vital signs and report abnormal findings
F. Assess for peripheral edema
Rationale: UAP may perform non-invasive, routine tasks (A, B, E). Auscultation (C) and
assessment (F) require nursing judgment; reinforcement of teaching (D) requires evaluation of
understanding—RN responsibility. Source: BSN 266 HESI Medical-Surgical Exam (Stuvia)
3. A post-op cholecystectomy patient's PCA pump is locked out after delivering 4 doses in 1
hour. The patient reports pain 8/10. FIRST action?
A. Call the provider for a higher basal rate
B. Administer the PRN morphine 4 mg IV from the narcotic drawer
C. Assess pain location, quality, and non-pharmacologic interventions
D. Discontinue PCA and switch to oral analgesics
Rationale: Assessment is always the first step before intervention. The nurse must assess the
pain characteristics, consider non-pharmacologic measures, and then determine the
appropriate pharmacologic intervention. Source: BSN 266 HESI Medical-Surgical Exam (Stuvia)
4. The charge nurse is making client assignments for the night shift. Which assignment is most
appropriate for the RN?
A. Assigning the most complex patient to the most experienced nurse
B. Assigning the most stable patient to the least experienced nurse
C. Assigning the most unstable patient to the float nurse
D. Assigning all patients equally regardless of acuity
Rationale: Patient assignments should match patient acuity with nurse competency. The most
complex patient should be assigned to the most experienced nurse. Source: BSN 266 HESI
Medical-Surgical Comprehensive Examination (Stuvia)
5. What is the primary purpose of the time-out procedure before surgery?
A. To take a break during a long procedure
B. To verify patient identity, procedure, and site before starting
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C. To document the procedure after completion
D. To discuss the patient's financial status
Rationale: The time-out is a safety procedure that verifies patient identity, the correct
procedure, and the correct site before initiating a procedure.
6. A nurse is caring for a patient who refuses a prescribed treatment. What is the nurse's most
appropriate action?
A. Administer the treatment against the patient's will
B. Respect the patient's right to refuse and document the refusal
C. Discharge the patient immediately
D. Ignore the refusal and continue with the treatment plan
Rationale: Patients have the right to refuse treatment. The nurse should respect the patient's
decision, document the refusal, and notify the provider.
7. Which of the following best describes the nurse's role as a patient advocate?
A. Making decisions for the patient
B. Protecting the patient's rights and ensuring informed consent
C. Avoiding communication with the patient's family
D. Following physician orders without question
Rationale: Patient advocacy involves protecting the patient's rights, ensuring informed consent,
and speaking up for the patient's needs and preferences.
8. A nurse is teaching a patient about a new medication. Which action best ensures patient
understanding?
A. Providing a printed handout and asking if the patient has questions
B. Using medical terminology to ensure accuracy
C. Asking the patient to repeat back the instructions in their own words
D. Teaching the patient at discharge when they are ready to leave
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Rationale: Asking the patient to repeat back instructions (teach-back method) confirms
understanding and identifies any gaps in knowledge.
9. Which of the following is an example of a nurse-sensitive outcome?
A. Hospital mortality rate
B. Patient satisfaction with physician care
C. Hospital-acquired pressure ulcer rate
D. Length of stay for pneumonia
Rationale: Nursing-sensitive outcomes are directly affected by nursing care, such as hospital-
acquired pressure ulcer rates, falls, and catheter-associated infections.
10. What is the purpose of the nursing process?
A. To provide a framework for delivering patient-centered care
B. To document nursing interventions for legal purposes
C. To standardize care across all patient populations
D. To replace the medical model of care
Rationale: The nursing process provides a systematic framework for delivering patient-centered
care through assessment, diagnosis, planning, implementation, and evaluation.
11. A nurse is caring for a patient who speaks limited English. Which action is most
appropriate?
A. Speaking loudly and slowly in English
B. Using a professional medical interpreter
C. Asking a family member to translate
D. Providing written materials in English only
Rationale: Using a professional medical interpreter ensures accurate communication and is
required by law. Family members should not be used as interpreters for medical information.
12. What is the primary purpose of a root cause analysis (RCA) after a patient safety event?
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BSN HESI 266 MED SURG EXAM WITH VERIFIED
ANSWERS DETAILED RATIONALES GRADED A+
BSN HESI 266 Exam — Test Bank
SECTION 1: MANAGEMENT OF CARE & SAFETY (Questions 1–25)
1. The nurse receives report on four patients. Which patient should the nurse assess FIRST?
A. Heart-failure patient with 2+ pitting edema in lower extremities
B. Post-op hip-replacement patient reporting pain 6/10
C. COPD patient on 2 L NC with SpO₂ 92%
D. Diabetic patient with new red, warm area on plantar surface of foot
Rationale: Potential diabetic foot ulcer/infection is a medical emergency (risk for
sepsis/amputation); requires immediate inspection, off-loading, and provider notification.
Edema is chronic; pain is expected; SpO₂ 92% may be baseline. Source: BSN 266 HESI Medical-
Surgical Exam (Stuvia)
2. The nurse is delegating tasks to an experienced UAP for a stable heart-failure patient.
Which tasks are appropriate to delegate? (Select all that apply.)
A. Assist patient with ambulation to bathroom
B. Measure and record daily weight
C. Auscultate lung sounds after incentive spirometer
D. Reinforce teaching about 2-gram sodium diet
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,Page 2 of 73
E. Take vital signs and report abnormal findings
F. Assess for peripheral edema
Rationale: UAP may perform non-invasive, routine tasks (A, B, E). Auscultation (C) and
assessment (F) require nursing judgment; reinforcement of teaching (D) requires evaluation of
understanding—RN responsibility. Source: BSN 266 HESI Medical-Surgical Exam (Stuvia)
3. A post-op cholecystectomy patient's PCA pump is locked out after delivering 4 doses in 1
hour. The patient reports pain 8/10. FIRST action?
A. Call the provider for a higher basal rate
B. Administer the PRN morphine 4 mg IV from the narcotic drawer
C. Assess pain location, quality, and non-pharmacologic interventions
D. Discontinue PCA and switch to oral analgesics
Rationale: Assessment is always the first step before intervention. The nurse must assess the
pain characteristics, consider non-pharmacologic measures, and then determine the
appropriate pharmacologic intervention. Source: BSN 266 HESI Medical-Surgical Exam (Stuvia)
4. The charge nurse is making client assignments for the night shift. Which assignment is most
appropriate for the RN?
A. Assigning the most complex patient to the most experienced nurse
B. Assigning the most stable patient to the least experienced nurse
C. Assigning the most unstable patient to the float nurse
D. Assigning all patients equally regardless of acuity
Rationale: Patient assignments should match patient acuity with nurse competency. The most
complex patient should be assigned to the most experienced nurse. Source: BSN 266 HESI
Medical-Surgical Comprehensive Examination (Stuvia)
5. What is the primary purpose of the time-out procedure before surgery?
A. To take a break during a long procedure
B. To verify patient identity, procedure, and site before starting
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,Page 3 of 73
C. To document the procedure after completion
D. To discuss the patient's financial status
Rationale: The time-out is a safety procedure that verifies patient identity, the correct
procedure, and the correct site before initiating a procedure.
6. A nurse is caring for a patient who refuses a prescribed treatment. What is the nurse's most
appropriate action?
A. Administer the treatment against the patient's will
B. Respect the patient's right to refuse and document the refusal
C. Discharge the patient immediately
D. Ignore the refusal and continue with the treatment plan
Rationale: Patients have the right to refuse treatment. The nurse should respect the patient's
decision, document the refusal, and notify the provider.
7. Which of the following best describes the nurse's role as a patient advocate?
A. Making decisions for the patient
B. Protecting the patient's rights and ensuring informed consent
C. Avoiding communication with the patient's family
D. Following physician orders without question
Rationale: Patient advocacy involves protecting the patient's rights, ensuring informed consent,
and speaking up for the patient's needs and preferences.
8. A nurse is teaching a patient about a new medication. Which action best ensures patient
understanding?
A. Providing a printed handout and asking if the patient has questions
B. Using medical terminology to ensure accuracy
C. Asking the patient to repeat back the instructions in their own words
D. Teaching the patient at discharge when they are ready to leave
3|Page
, Page 4 of 73
Rationale: Asking the patient to repeat back instructions (teach-back method) confirms
understanding and identifies any gaps in knowledge.
9. Which of the following is an example of a nurse-sensitive outcome?
A. Hospital mortality rate
B. Patient satisfaction with physician care
C. Hospital-acquired pressure ulcer rate
D. Length of stay for pneumonia
Rationale: Nursing-sensitive outcomes are directly affected by nursing care, such as hospital-
acquired pressure ulcer rates, falls, and catheter-associated infections.
10. What is the purpose of the nursing process?
A. To provide a framework for delivering patient-centered care
B. To document nursing interventions for legal purposes
C. To standardize care across all patient populations
D. To replace the medical model of care
Rationale: The nursing process provides a systematic framework for delivering patient-centered
care through assessment, diagnosis, planning, implementation, and evaluation.
11. A nurse is caring for a patient who speaks limited English. Which action is most
appropriate?
A. Speaking loudly and slowly in English
B. Using a professional medical interpreter
C. Asking a family member to translate
D. Providing written materials in English only
Rationale: Using a professional medical interpreter ensures accurate communication and is
required by law. Family members should not be used as interpreters for medical information.
12. What is the primary purpose of a root cause analysis (RCA) after a patient safety event?
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