BSN HESI 266 Exam 2025
1) A client is recovering from a transurethral prostatectomy (TURP). Which activity should be limited
until after the first postoperative visit with the healthcare provider?
A) Drinking 3 liters of fluid daily
B) Engaging in light walking exercises
C) Lifting heavy objects or strenuous exercise
D) Resuming sexual activity
Answer: C) Lifting heavy objects or strenuous exercise
EXPLANATION: After TURP, avoid heavy lifting or strenuous activity to prevent bleeding and promote
healing.
2) A client with stage IV bone cancer rates pain 8/10. Which intervention should the nurse
implement?
A) Administer only non-opioid medications
B) Use relaxation techniques only
C) Administer opioid and non-opioid medications simultaneously
D) Delay medication until pain worsens
Answer: C) Administer opioid and non-opioid medications simultaneously
EXPLANATION: Combining opioids and non-opioids improves pain control by targeting multiple
pathways.
3) A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which
finding requires immediate reporting?
A) Rhinitis and nasal stuffiness
B) Low back pain and hypotension
C) Delayed painful rash with urticaria
D) Arthritic joint changes and chronic pain
Answer: B) Low back pain and hypotension
EXPLANATION: These symptoms indicate acute hemolytic transfusion reaction — a medical emergency.
4) Discharge teaching for diverticulosis includes which diet instruction?
A) Eat a bland diet, avoid spicy foods
B) Eat a high-fiber diet and increase fluids
C) Have small frequent meals, sit up 2 hours post-meal
D) Eat a soft diet with increased dairy
,Answer: B) Eat a high-fiber diet and increase fluids
EXPLANATION: High fiber prevents constipation and reduces colon pressure, preventing diverticulitis.
5) Increased blood clots in continuous bladder irrigation tubing post-TURP requires what initial
action?
A) Provide additional oral fluids
B) Measure intake and output
C) Increase bladder irrigation flow
D) Administer antispasmodic PRN
Answer: C) Increase bladder irrigation flow
EXPLANATION: Increasing irrigation flushes clots, preventing catheter blockage.
6) A lung cancer client using a morphine patch is short of breath and difficult to arouse with four
patches in place. Nurse action?
A) Leave all patches
B) Remove all morphine patches
C) Add another patch
D) Encourage rest
Answer: B) Remove all morphine patches
EXPLANATION: Multiple patches risk overdose causing respiratory depression; remove immediately.
7) Client brought to ER after falling down stairs with cast. Which finding needs immediate
intervention?
A) Mild discomfort
B) Right foot pale with sluggish capillary refill
C) Slight swelling around cast
D) Ability to wiggle toes
Answer: B) Right foot pale with sluggish capillary refill
EXPLANATION: Indicates compromised circulation, possibly compartment syndrome — urgent care
needed.
8) A young adult with type 2 diabetes admitted for hernia repair feels weak and jittery. What should
nurse do? (Select all that apply)
A) Check finger stick glucose
B) Assess skin temperature and moisture
C) Measure pulse and blood pressure
D) Encourage physical activity
E) Delay meal until after surgery
,Answer: A), B), C)
EXPLANATION: Assess for hypoglycemia which causes weakness and sweating; monitor vital signs
closely.
9) Which symptom is most concerning in a client with newly diagnosed type 1 diabetes?
A) Excessive thirst and frequent urination
B) Weight gain
C) Constipation
D) Hypertension
Answer: A) Excessive thirst and frequent urination
EXPLANATION: Classic signs of hyperglycemia and possible diabetic ketoacidosis risk.
10) The nurse is caring for a client with chronic kidney disease. Which lab value requires immediate
attention?
A) Serum potassium 6.2 mEq/L
B) Hemoglobin 12 g/dL
C) Sodium 138 mEq/L
D) Calcium 9 mg/dL
Answer: A) Serum potassium 6.2 mEq/L
EXPLANATION: Hyperkalemia (>5.0) can cause life-threatening arrhythmias.
11) What is the best way to prevent pressure ulcers in a bedridden client?
A) Apply lotion twice daily
B) Change position every 2 hours
C) Keep client on one side continuously
D) Use powder on skin
Answer: B) Change position every 2 hours
EXPLANATION: Frequent repositioning relieves pressure and improves circulation.
12) A client with chronic obstructive pulmonary disease (COPD) has a pulse oximetry reading of 85%.
What is the nurse’s first action?
A) Increase oxygen flow rate
B) Call respiratory therapy
C) Assess respiratory effort
D) Document the finding
Answer: C) Assess respiratory effort
EXPLANATION: Confirm oxygenation status and respiratory distress before interventions.
, 13) A client receiving IV antibiotics develops a red streak and swelling along the vein site. What is the
nurse’s priority action?
A) Apply warm compress
B) Stop IV and notify provider
C) Slow infusion rate
D) Document the findings
Answer: B) Stop IV and notify provider
EXPLANATION: Signs of phlebitis require stopping IV to prevent further tissue damage.
14) When teaching a client how to use an incentive spirometer, the nurse should instruct to:
A) Exhale forcefully into the device
B) Inhale deeply and hold breath for 3 seconds
C) Use only once per day
D) Breathe normally during use
Answer: B) Inhale deeply and hold breath for 3 seconds
EXPLANATION: Promotes lung expansion and prevents atelectasis.
15) Which of the following is an appropriate nursing action when a client refuses medication?
A) Force the medication
B) Document the refusal and notify the provider
C) Ignore the refusal
D) Ask another nurse to give the medication
Answer: B) Document the refusal and notify the provider
EXPLANATION: Respect patient autonomy, inform healthcare provider for follow-up.
16) Which finding suggests hypoglycemia in a client with diabetes?
A) Hot, dry skin
B) Tremors and sweating
C) Fruity breath odor
D) Increased urination
Answer: B) Tremors and sweating
EXPLANATION: Classic signs of low blood sugar requiring immediate intervention.
17) What is the proper site for intramuscular injection in adults?
A) Deltoid
B) Vastus lateralis
1) A client is recovering from a transurethral prostatectomy (TURP). Which activity should be limited
until after the first postoperative visit with the healthcare provider?
A) Drinking 3 liters of fluid daily
B) Engaging in light walking exercises
C) Lifting heavy objects or strenuous exercise
D) Resuming sexual activity
Answer: C) Lifting heavy objects or strenuous exercise
EXPLANATION: After TURP, avoid heavy lifting or strenuous activity to prevent bleeding and promote
healing.
2) A client with stage IV bone cancer rates pain 8/10. Which intervention should the nurse
implement?
A) Administer only non-opioid medications
B) Use relaxation techniques only
C) Administer opioid and non-opioid medications simultaneously
D) Delay medication until pain worsens
Answer: C) Administer opioid and non-opioid medications simultaneously
EXPLANATION: Combining opioids and non-opioids improves pain control by targeting multiple
pathways.
3) A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which
finding requires immediate reporting?
A) Rhinitis and nasal stuffiness
B) Low back pain and hypotension
C) Delayed painful rash with urticaria
D) Arthritic joint changes and chronic pain
Answer: B) Low back pain and hypotension
EXPLANATION: These symptoms indicate acute hemolytic transfusion reaction — a medical emergency.
4) Discharge teaching for diverticulosis includes which diet instruction?
A) Eat a bland diet, avoid spicy foods
B) Eat a high-fiber diet and increase fluids
C) Have small frequent meals, sit up 2 hours post-meal
D) Eat a soft diet with increased dairy
,Answer: B) Eat a high-fiber diet and increase fluids
EXPLANATION: High fiber prevents constipation and reduces colon pressure, preventing diverticulitis.
5) Increased blood clots in continuous bladder irrigation tubing post-TURP requires what initial
action?
A) Provide additional oral fluids
B) Measure intake and output
C) Increase bladder irrigation flow
D) Administer antispasmodic PRN
Answer: C) Increase bladder irrigation flow
EXPLANATION: Increasing irrigation flushes clots, preventing catheter blockage.
6) A lung cancer client using a morphine patch is short of breath and difficult to arouse with four
patches in place. Nurse action?
A) Leave all patches
B) Remove all morphine patches
C) Add another patch
D) Encourage rest
Answer: B) Remove all morphine patches
EXPLANATION: Multiple patches risk overdose causing respiratory depression; remove immediately.
7) Client brought to ER after falling down stairs with cast. Which finding needs immediate
intervention?
A) Mild discomfort
B) Right foot pale with sluggish capillary refill
C) Slight swelling around cast
D) Ability to wiggle toes
Answer: B) Right foot pale with sluggish capillary refill
EXPLANATION: Indicates compromised circulation, possibly compartment syndrome — urgent care
needed.
8) A young adult with type 2 diabetes admitted for hernia repair feels weak and jittery. What should
nurse do? (Select all that apply)
A) Check finger stick glucose
B) Assess skin temperature and moisture
C) Measure pulse and blood pressure
D) Encourage physical activity
E) Delay meal until after surgery
,Answer: A), B), C)
EXPLANATION: Assess for hypoglycemia which causes weakness and sweating; monitor vital signs
closely.
9) Which symptom is most concerning in a client with newly diagnosed type 1 diabetes?
A) Excessive thirst and frequent urination
B) Weight gain
C) Constipation
D) Hypertension
Answer: A) Excessive thirst and frequent urination
EXPLANATION: Classic signs of hyperglycemia and possible diabetic ketoacidosis risk.
10) The nurse is caring for a client with chronic kidney disease. Which lab value requires immediate
attention?
A) Serum potassium 6.2 mEq/L
B) Hemoglobin 12 g/dL
C) Sodium 138 mEq/L
D) Calcium 9 mg/dL
Answer: A) Serum potassium 6.2 mEq/L
EXPLANATION: Hyperkalemia (>5.0) can cause life-threatening arrhythmias.
11) What is the best way to prevent pressure ulcers in a bedridden client?
A) Apply lotion twice daily
B) Change position every 2 hours
C) Keep client on one side continuously
D) Use powder on skin
Answer: B) Change position every 2 hours
EXPLANATION: Frequent repositioning relieves pressure and improves circulation.
12) A client with chronic obstructive pulmonary disease (COPD) has a pulse oximetry reading of 85%.
What is the nurse’s first action?
A) Increase oxygen flow rate
B) Call respiratory therapy
C) Assess respiratory effort
D) Document the finding
Answer: C) Assess respiratory effort
EXPLANATION: Confirm oxygenation status and respiratory distress before interventions.
, 13) A client receiving IV antibiotics develops a red streak and swelling along the vein site. What is the
nurse’s priority action?
A) Apply warm compress
B) Stop IV and notify provider
C) Slow infusion rate
D) Document the findings
Answer: B) Stop IV and notify provider
EXPLANATION: Signs of phlebitis require stopping IV to prevent further tissue damage.
14) When teaching a client how to use an incentive spirometer, the nurse should instruct to:
A) Exhale forcefully into the device
B) Inhale deeply and hold breath for 3 seconds
C) Use only once per day
D) Breathe normally during use
Answer: B) Inhale deeply and hold breath for 3 seconds
EXPLANATION: Promotes lung expansion and prevents atelectasis.
15) Which of the following is an appropriate nursing action when a client refuses medication?
A) Force the medication
B) Document the refusal and notify the provider
C) Ignore the refusal
D) Ask another nurse to give the medication
Answer: B) Document the refusal and notify the provider
EXPLANATION: Respect patient autonomy, inform healthcare provider for follow-up.
16) Which finding suggests hypoglycemia in a client with diabetes?
A) Hot, dry skin
B) Tremors and sweating
C) Fruity breath odor
D) Increased urination
Answer: B) Tremors and sweating
EXPLANATION: Classic signs of low blood sugar requiring immediate intervention.
17) What is the proper site for intramuscular injection in adults?
A) Deltoid
B) Vastus lateralis
