1
BSN 266 HESI Med Surg
Proctored Exam 2025 – 100%
Verified Full Exam with A+
Answers | Actual Test Bank |
Nightingale College
1. A client with heart failure reports a 4-pound weight gain in 2 days. What is the
nurse’s priority action?
a) Encourage increased physical activity.
b) Notify the healthcare provider.
c) Administer a diuretic as prescribed.
d) Restrict dietary sodium intake.
Correct Answer: b) Notify the healthcare provider.
Rationale: A 4-pound weight gain in 2 days indicates fluid retention, a critical finding in
heart failure that may signal worsening condition or decompensation, requiring
immediate provider notification for evaluation and possible medication adjustment.
2. A client is prescribed furosemide 40 mg IV. The available concentration is 10
mg/mL. How many mL should the nurse administer?
a) 2 mL
b) 4 mL
c) 6 mL
d) 8 mL
Correct Answer: b) 4 mL
Rationale: To calculate: 40 mg ÷ 10 mg/mL = 4 mL. This ensures the correct dose is
administered safely.
3. A client with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 88%. What is the nurse’s priority action?
a) Increase oxygen flow to 6 L/min.
b) Administer a bronchodilator as prescribed.
c) Encourage pursed-lip breathing.
d) Notify the healthcare provider immediately.
Correct Answer: c) Encourage pursed-lip breathing.
Rationale: An oxygen saturation of 88% is expected in COPD due to chronic hypoxemia.
, 2
Pursed-lip breathing helps improve oxygenation by prolonging exhalation and reducing
air trapping.
4. A client with type 1 diabetes reports nausea and a blood glucose of 350 mg/dL.
What should the nurse suspect?
a) Hypoglycemia
b) Diabetic ketoacidosis
c) Hyperosmolar hyperglycemic state
d) Insulin resistance
Correct Answer: b) Diabetic ketoacidosis
Rationale: Nausea and elevated blood glucose in type 1 diabetes suggest diabetic
ketoacidosis, a life-threatening condition due to insulin deficiency and ketone production,
requiring urgent intervention.
5. A client is receiving heparin 5,000 units subcutaneously. The available
concentration is 10,000 units/mL. How many mL should the nurse administer?
a) 0.5 mL
b) 1 mL
c) 1.5 mL
d) 2 mL
Correct Answer: a) 0.5 mL
Rationale: To calculate: 5,000 units ÷ 10,000 units/mL = 0.5 mL. This ensures accurate
dosing to prevent bleeding or clotting complications.
6. A client with a new colostomy reports leakage around the stoma. What should the
nurse do first?
a) Change the pouch immediately.
b) Assess the stoma and surrounding skin.
c) Apply a barrier cream to the stoma.
d) Notify the healthcare provider.
Correct Answer: b) Assess the stoma and surrounding skin.
Rationale: Leakage may indicate improper pouch fit or skin breakdown, so assessing the
stoma and surrounding skin is the first step to determine the cause and guide intervention.
7. A client with pneumonia has a temperature of 102.2°F. What is the nurse’s priority
intervention?
a) Administer an antipyretic as prescribed.
b) Apply a cooling blanket.
c) Increase fluid intake.
d) Notify the healthcare provider.
Correct Answer: a) Administer an antipyretic as prescribed.
Rationale: A fever of 102.2°F requires prompt administration of an antipyretic to reduce
temperature and improve client comfort, as per standard pneumonia management.
8. A client is prescribed warfarin and has an INR of 4.0. What should the nurse expect
the provider to order?
a) Increase the warfarin dose.
b) Hold the warfarin dose.
c) Administer heparin.
d) Continue the current dose.
Correct Answer: b) Hold the warfarin dose.
, 3
Rationale: An INR of 4.0 is above the therapeutic range (2.0–3.0), indicating an
increased bleeding risk, so the provider is likely to hold the dose and monitor the client.
9. A client with a history of myocardial infarction reports chest pain. What is the
nurse’s priority action?
a) Administer nitroglycerin as prescribed.
b) Obtain an electrocardiogram (ECG).
c) Notify the healthcare provider immediately.
d) Administer oxygen at 2 L/min via nasal cannula.
Correct Answer: d) Administer oxygen at 2 L/min via nasal cannula.
Rationale: Oxygen administration is the priority to ensure adequate myocardial
oxygenation in a client with chest pain and a history of myocardial infarction.
10. A client with acute pancreatitis reports severe abdominal pain. Which position
should the nurse encourage?
a) Supine with legs elevated
b) Side-lying with knees bent
c) Prone with head turned
d) Sitting upright
Correct Answer: b) Side-lying with knees bent
Rationale: The side-lying position with knees bent reduces abdominal tension and
pressure on the pancreas, alleviating pain in acute pancreatitis.
11. A client is prescribed albuterol for asthma. Which adverse effect should the nurse
monitor?
a) Bradycardia
b) Tremors
c) Hypotension
d) Hyperglycemia
Correct Answer: b) Tremors
Rationale: Albuterol, a beta-2 agonist, commonly causes tremors due to stimulation of
beta-adrenergic receptors in skeletal muscle.
12. A client with a urinary catheter develops fever and cloudy urine. What should the
nurse do first?
a) Change the catheter immediately.
b) Obtain a urine culture.
c) Increase fluid intake.
d) Notify the healthcare provider.
Correct Answer: b) Obtain a urine culture.
Rationale: Fever and cloudy urine suggest a urinary tract infection, so obtaining a urine
culture is the first step to identify the causative organism and guide treatment.
13. A client is receiving vancomycin IV and reports itching. What should the nurse do?
a) Continue the infusion and monitor.
b) Slow the infusion rate.
c) Stop the infusion and notify the provider.
d) Administer an antihistamine.
Correct Answer: c) Stop the infusion and notify the provider.
Rationale: Itching may indicate an allergic reaction or red man syndrome with
vancomycin, requiring immediate cessation of the infusion and provider notification.
, 4
14. A client with diabetes reports a blood glucose level of 50 mg/dL and shakiness. What
is the nurse’s priority action?
a) Administer 15 grams of a fast-acting carbohydrate.
b) Notify the healthcare provider.
c) Administer insulin as prescribed.
d) Encourage the client to rest.
Correct Answer: a) Administer 15 grams of a fast-acting carbohydrate.
Rationale: A blood glucose level of 50 mg/dL with symptoms indicates hypoglycemia,
requiring immediate administration of 15 grams of a fast-acting carbohydrate to restore
glucose levels.
15. A client with a new tracheostomy has difficulty breathing. What is the nurse’s
priority action?
a) Change the tracheostomy tube.
b) Suction the tracheostomy as needed.
c) Administer oxygen at 6 L/min.
d) Notify the healthcare provider.
Correct Answer: b) Suction the tracheostomy as needed.
Rationale: Difficulty breathing may indicate mucus obstruction in the tracheostomy, so
suctioning is the priority to maintain airway patency.
16. A client is prescribed digoxin and reports nausea and visual disturbances. What
should the nurse do?
a) Administer an antiemetic.
b) Notify the healthcare provider.
c) Encourage the client to rest.
d) Continue the medication and monitor.
Correct Answer: b) Notify the healthcare provider.
Rationale: Nausea and visual disturbances are signs of digoxin toxicity, requiring
immediate provider notification for evaluation and possible dose adjustment.
17. A client with a pressure ulcer is prescribed a high-protein diet. What is the rationale
for this intervention?
a) Reduce infection risk
b) Promote wound healing
c) Decrease edema
d) Improve circulation
Correct Answer: b) Promote wound healing
Rationale: A high-protein diet provides essential amino acids for tissue repair and
collagen synthesis, promoting healing of pressure ulcers.
18. A client is receiving ceftriaxone 1 g IV in 100 mL of 0.9% sodium chloride over 30
minutes. What rate should the nurse set the IV pump to in mL/hr?
a) 100 mL/hr
b) 150 mL/hr
c) 200 mL/hr
d) 300 mL/hr
Correct Answer: c) 200 mL/hr
Rationale: To calculate: (100 mL / 30 min) × 60 min/hr = 200 mL/hr. This ensures the
correct infusion rate for safe administration.
BSN 266 HESI Med Surg
Proctored Exam 2025 – 100%
Verified Full Exam with A+
Answers | Actual Test Bank |
Nightingale College
1. A client with heart failure reports a 4-pound weight gain in 2 days. What is the
nurse’s priority action?
a) Encourage increased physical activity.
b) Notify the healthcare provider.
c) Administer a diuretic as prescribed.
d) Restrict dietary sodium intake.
Correct Answer: b) Notify the healthcare provider.
Rationale: A 4-pound weight gain in 2 days indicates fluid retention, a critical finding in
heart failure that may signal worsening condition or decompensation, requiring
immediate provider notification for evaluation and possible medication adjustment.
2. A client is prescribed furosemide 40 mg IV. The available concentration is 10
mg/mL. How many mL should the nurse administer?
a) 2 mL
b) 4 mL
c) 6 mL
d) 8 mL
Correct Answer: b) 4 mL
Rationale: To calculate: 40 mg ÷ 10 mg/mL = 4 mL. This ensures the correct dose is
administered safely.
3. A client with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 88%. What is the nurse’s priority action?
a) Increase oxygen flow to 6 L/min.
b) Administer a bronchodilator as prescribed.
c) Encourage pursed-lip breathing.
d) Notify the healthcare provider immediately.
Correct Answer: c) Encourage pursed-lip breathing.
Rationale: An oxygen saturation of 88% is expected in COPD due to chronic hypoxemia.
, 2
Pursed-lip breathing helps improve oxygenation by prolonging exhalation and reducing
air trapping.
4. A client with type 1 diabetes reports nausea and a blood glucose of 350 mg/dL.
What should the nurse suspect?
a) Hypoglycemia
b) Diabetic ketoacidosis
c) Hyperosmolar hyperglycemic state
d) Insulin resistance
Correct Answer: b) Diabetic ketoacidosis
Rationale: Nausea and elevated blood glucose in type 1 diabetes suggest diabetic
ketoacidosis, a life-threatening condition due to insulin deficiency and ketone production,
requiring urgent intervention.
5. A client is receiving heparin 5,000 units subcutaneously. The available
concentration is 10,000 units/mL. How many mL should the nurse administer?
a) 0.5 mL
b) 1 mL
c) 1.5 mL
d) 2 mL
Correct Answer: a) 0.5 mL
Rationale: To calculate: 5,000 units ÷ 10,000 units/mL = 0.5 mL. This ensures accurate
dosing to prevent bleeding or clotting complications.
6. A client with a new colostomy reports leakage around the stoma. What should the
nurse do first?
a) Change the pouch immediately.
b) Assess the stoma and surrounding skin.
c) Apply a barrier cream to the stoma.
d) Notify the healthcare provider.
Correct Answer: b) Assess the stoma and surrounding skin.
Rationale: Leakage may indicate improper pouch fit or skin breakdown, so assessing the
stoma and surrounding skin is the first step to determine the cause and guide intervention.
7. A client with pneumonia has a temperature of 102.2°F. What is the nurse’s priority
intervention?
a) Administer an antipyretic as prescribed.
b) Apply a cooling blanket.
c) Increase fluid intake.
d) Notify the healthcare provider.
Correct Answer: a) Administer an antipyretic as prescribed.
Rationale: A fever of 102.2°F requires prompt administration of an antipyretic to reduce
temperature and improve client comfort, as per standard pneumonia management.
8. A client is prescribed warfarin and has an INR of 4.0. What should the nurse expect
the provider to order?
a) Increase the warfarin dose.
b) Hold the warfarin dose.
c) Administer heparin.
d) Continue the current dose.
Correct Answer: b) Hold the warfarin dose.
, 3
Rationale: An INR of 4.0 is above the therapeutic range (2.0–3.0), indicating an
increased bleeding risk, so the provider is likely to hold the dose and monitor the client.
9. A client with a history of myocardial infarction reports chest pain. What is the
nurse’s priority action?
a) Administer nitroglycerin as prescribed.
b) Obtain an electrocardiogram (ECG).
c) Notify the healthcare provider immediately.
d) Administer oxygen at 2 L/min via nasal cannula.
Correct Answer: d) Administer oxygen at 2 L/min via nasal cannula.
Rationale: Oxygen administration is the priority to ensure adequate myocardial
oxygenation in a client with chest pain and a history of myocardial infarction.
10. A client with acute pancreatitis reports severe abdominal pain. Which position
should the nurse encourage?
a) Supine with legs elevated
b) Side-lying with knees bent
c) Prone with head turned
d) Sitting upright
Correct Answer: b) Side-lying with knees bent
Rationale: The side-lying position with knees bent reduces abdominal tension and
pressure on the pancreas, alleviating pain in acute pancreatitis.
11. A client is prescribed albuterol for asthma. Which adverse effect should the nurse
monitor?
a) Bradycardia
b) Tremors
c) Hypotension
d) Hyperglycemia
Correct Answer: b) Tremors
Rationale: Albuterol, a beta-2 agonist, commonly causes tremors due to stimulation of
beta-adrenergic receptors in skeletal muscle.
12. A client with a urinary catheter develops fever and cloudy urine. What should the
nurse do first?
a) Change the catheter immediately.
b) Obtain a urine culture.
c) Increase fluid intake.
d) Notify the healthcare provider.
Correct Answer: b) Obtain a urine culture.
Rationale: Fever and cloudy urine suggest a urinary tract infection, so obtaining a urine
culture is the first step to identify the causative organism and guide treatment.
13. A client is receiving vancomycin IV and reports itching. What should the nurse do?
a) Continue the infusion and monitor.
b) Slow the infusion rate.
c) Stop the infusion and notify the provider.
d) Administer an antihistamine.
Correct Answer: c) Stop the infusion and notify the provider.
Rationale: Itching may indicate an allergic reaction or red man syndrome with
vancomycin, requiring immediate cessation of the infusion and provider notification.
, 4
14. A client with diabetes reports a blood glucose level of 50 mg/dL and shakiness. What
is the nurse’s priority action?
a) Administer 15 grams of a fast-acting carbohydrate.
b) Notify the healthcare provider.
c) Administer insulin as prescribed.
d) Encourage the client to rest.
Correct Answer: a) Administer 15 grams of a fast-acting carbohydrate.
Rationale: A blood glucose level of 50 mg/dL with symptoms indicates hypoglycemia,
requiring immediate administration of 15 grams of a fast-acting carbohydrate to restore
glucose levels.
15. A client with a new tracheostomy has difficulty breathing. What is the nurse’s
priority action?
a) Change the tracheostomy tube.
b) Suction the tracheostomy as needed.
c) Administer oxygen at 6 L/min.
d) Notify the healthcare provider.
Correct Answer: b) Suction the tracheostomy as needed.
Rationale: Difficulty breathing may indicate mucus obstruction in the tracheostomy, so
suctioning is the priority to maintain airway patency.
16. A client is prescribed digoxin and reports nausea and visual disturbances. What
should the nurse do?
a) Administer an antiemetic.
b) Notify the healthcare provider.
c) Encourage the client to rest.
d) Continue the medication and monitor.
Correct Answer: b) Notify the healthcare provider.
Rationale: Nausea and visual disturbances are signs of digoxin toxicity, requiring
immediate provider notification for evaluation and possible dose adjustment.
17. A client with a pressure ulcer is prescribed a high-protein diet. What is the rationale
for this intervention?
a) Reduce infection risk
b) Promote wound healing
c) Decrease edema
d) Improve circulation
Correct Answer: b) Promote wound healing
Rationale: A high-protein diet provides essential amino acids for tissue repair and
collagen synthesis, promoting healing of pressure ulcers.
18. A client is receiving ceftriaxone 1 g IV in 100 mL of 0.9% sodium chloride over 30
minutes. What rate should the nurse set the IV pump to in mL/hr?
a) 100 mL/hr
b) 150 mL/hr
c) 200 mL/hr
d) 300 mL/hr
Correct Answer: c) 200 mL/hr
Rationale: To calculate: (100 mL / 30 min) × 60 min/hr = 200 mL/hr. This ensures the
correct infusion rate for safe administration.
