BSN HESI 266 Consolidated BSN HESI 266
Med Surg BSN 266 HESI Med Surg 70
Practice Exam (2023 2024 Update) Questions
And Verified Answers
1. A client experiences an AOB incompatibility reaction after multiple blood
transfusions. Which finding should the nurse report immediately to the health
care provider?
a. low back pain and hypotension
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
d. arthritic joint changes and chronic pain: a. low back pain and hypotension
2. When conducting discharge teaching for a client diagnosed with
diverticulosis, which diet instruction should the nurse include?
a. Have small frequent meals and sit up for at least two hours after meals.
b. Eat a bland diet and avoid spicy foods.
c. Eat a high-fiber diet and increase fluid intake.
d. Eat a soft diet with increased intake of milk and milk products: c. Eat a high-
fiber diet and increase fluid intake.
3. The nurse observes an increased number of blood clots in the drainage
tubing of a client with continuous bladder irrigation following a transurethral
resection of the prostate (TURP). What is the best initial nursing action?
a. Provide additional oral fluid intake
b. Measure the client's intake and output.
,c. Increase the flow of the bladder irrigation
d. Administer a PRN dose of an antispasmodic agent: c. Increase the flow of the
bladder irrigation
4. A client with lung cancer who wears subcutaneous morphine sulfate patch for
pain is short of breath and is difficult to arouse. When performing a head to toe
assessment, the nurse discovers four analgesic patches on the client's body.
Which intervention should the nurse implement first?
A. Remove all of the morphine patches
B. Administer a narcotic antagonist
C. Apply oxygen per face mask
D. Measure the client's blood pressure: B. Administer a narcotic antagonist
5. After falling down the basement steps, a client is brought to the emergency
room. X-ray confirms that the client's right leg is fractured. Following application
of a leg cast, which assessment finding warrants immediate intervention by the
nurse?
a. Circumferential edema of right foot.
b. Complaint of throbbing right leg pain.
c. Right foot pale with sluggish capillary refill.
d. Increased temperature to lower extremity: c. Right foot pale with sluggish
capillary refill
The answer indicates a potential problem with the blood circulation in the client's
right foot. When a leg cast is applied, it should not interfere with the blood flow to
the foot. However, if the foot becomes pale and the capillary refill is sluggish, it
suggests that the blood flow might be compromised. Capillary refill is the time
taken for color to return to an external capillary bed after pressure is applied to
cause blanching. Normal capillary refill time is usually less than 2 seconds. Sluggish
or delayed capillary refill can be a sign of peripheral vascular disease, shock, or
hypothermia. In this case, it could be due to the cast being too tight, causing a
reduction in blood flow to the foot. This is a serious condition that requires
immediate intervention by the nurse to prevent further complications such as tissue
, necrosis due to lack of oxygen and nutrients. The nurse may need to adjust or
remove the cast to restore proper blood flow.
6. An overweight, young adult who was recently diagnosed with type 2 diabetes
mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very
weak and jittery. Which actions should the nurse implement?
(Select all that apply.)
A. Check his fingerstick glucose level
B. Assess his skin temperature and moisture
C. Measure his pulse and blood pressure
D. Document anxiety on the surgical checklist
E. Administer a PRN dose of regular insulin: A. Check finger stick glucose
B. Assess skin temperature and moisture
C. Measure pulse and blood pressure
ANSWER: (CAM)
7. A client who underwent cardiac stent placement four days ago arrives to the
emergency department reporting a sudden onset of chest pressure and shortness
of breath. Which action should the nurse take next?
a. Listen for extra heart sounds, murmurs, and rhythm with the bell ofthe
stethoscope.
b. Evaluate upper and lower extremities for perfusion, pulse volume,and
pitting edema.
c. Verify troponin level assessments are scheduled every 3-6 hours for a
series of three.
d. Obtain a 12-lead electrocardiogram and begin continuous cardiac
monitor-ing.: d. Obtain a 12-lead electrocardiogram and begin continuous
cardiac monitoring
8. While completing a health assessment for a client with migraine headaches,
the nurse assesses bilateral weakness in the clients hand grips. The client reports
joint pain and trouble twisting a door knob due to weaknesses. Which action
should the nurses take in response to these figures?
a. Implement fall precautions to reduce the clients risk of injury.
Med Surg BSN 266 HESI Med Surg 70
Practice Exam (2023 2024 Update) Questions
And Verified Answers
1. A client experiences an AOB incompatibility reaction after multiple blood
transfusions. Which finding should the nurse report immediately to the health
care provider?
a. low back pain and hypotension
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
d. arthritic joint changes and chronic pain: a. low back pain and hypotension
2. When conducting discharge teaching for a client diagnosed with
diverticulosis, which diet instruction should the nurse include?
a. Have small frequent meals and sit up for at least two hours after meals.
b. Eat a bland diet and avoid spicy foods.
c. Eat a high-fiber diet and increase fluid intake.
d. Eat a soft diet with increased intake of milk and milk products: c. Eat a high-
fiber diet and increase fluid intake.
3. The nurse observes an increased number of blood clots in the drainage
tubing of a client with continuous bladder irrigation following a transurethral
resection of the prostate (TURP). What is the best initial nursing action?
a. Provide additional oral fluid intake
b. Measure the client's intake and output.
,c. Increase the flow of the bladder irrigation
d. Administer a PRN dose of an antispasmodic agent: c. Increase the flow of the
bladder irrigation
4. A client with lung cancer who wears subcutaneous morphine sulfate patch for
pain is short of breath and is difficult to arouse. When performing a head to toe
assessment, the nurse discovers four analgesic patches on the client's body.
Which intervention should the nurse implement first?
A. Remove all of the morphine patches
B. Administer a narcotic antagonist
C. Apply oxygen per face mask
D. Measure the client's blood pressure: B. Administer a narcotic antagonist
5. After falling down the basement steps, a client is brought to the emergency
room. X-ray confirms that the client's right leg is fractured. Following application
of a leg cast, which assessment finding warrants immediate intervention by the
nurse?
a. Circumferential edema of right foot.
b. Complaint of throbbing right leg pain.
c. Right foot pale with sluggish capillary refill.
d. Increased temperature to lower extremity: c. Right foot pale with sluggish
capillary refill
The answer indicates a potential problem with the blood circulation in the client's
right foot. When a leg cast is applied, it should not interfere with the blood flow to
the foot. However, if the foot becomes pale and the capillary refill is sluggish, it
suggests that the blood flow might be compromised. Capillary refill is the time
taken for color to return to an external capillary bed after pressure is applied to
cause blanching. Normal capillary refill time is usually less than 2 seconds. Sluggish
or delayed capillary refill can be a sign of peripheral vascular disease, shock, or
hypothermia. In this case, it could be due to the cast being too tight, causing a
reduction in blood flow to the foot. This is a serious condition that requires
immediate intervention by the nurse to prevent further complications such as tissue
, necrosis due to lack of oxygen and nutrients. The nurse may need to adjust or
remove the cast to restore proper blood flow.
6. An overweight, young adult who was recently diagnosed with type 2 diabetes
mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very
weak and jittery. Which actions should the nurse implement?
(Select all that apply.)
A. Check his fingerstick glucose level
B. Assess his skin temperature and moisture
C. Measure his pulse and blood pressure
D. Document anxiety on the surgical checklist
E. Administer a PRN dose of regular insulin: A. Check finger stick glucose
B. Assess skin temperature and moisture
C. Measure pulse and blood pressure
ANSWER: (CAM)
7. A client who underwent cardiac stent placement four days ago arrives to the
emergency department reporting a sudden onset of chest pressure and shortness
of breath. Which action should the nurse take next?
a. Listen for extra heart sounds, murmurs, and rhythm with the bell ofthe
stethoscope.
b. Evaluate upper and lower extremities for perfusion, pulse volume,and
pitting edema.
c. Verify troponin level assessments are scheduled every 3-6 hours for a
series of three.
d. Obtain a 12-lead electrocardiogram and begin continuous cardiac
monitor-ing.: d. Obtain a 12-lead electrocardiogram and begin continuous
cardiac monitoring
8. While completing a health assessment for a client with migraine headaches,
the nurse assesses bilateral weakness in the clients hand grips. The client reports
joint pain and trouble twisting a door knob due to weaknesses. Which action
should the nurses take in response to these figures?
a. Implement fall precautions to reduce the clients risk of injury.
