BSN 266 HESI Med Surg Exam 2025/2026 - 100%
Correct Questions & Graded A Verified Answers for
Nightingale College
A 68-year-old client with chronic heart failure is prescribed furosemide 40 mg IV push
twice daily. Which assessment finding requires immediate nursing intervention?
A) Urine output 800 mL in 8 hours
B) Serum potassium 3.2 mEq/L
C) Blood pressure 110/70 mmHg
1. D) Weight gain of 1 pound since yesterday
Answer: B
Rationale: Hypokalemia (serum potassium <3.5 mEq/L) is a serious complication of
loop diuretics like furosemide and can lead to life-threatening cardiac dysrhythmias,
requiring immediate potassium replacement.
A client with acute myocardial infarction receives tissue plasminogen activator (tPA).
Which finding indicates the medication is effective?
A) Chest pain decreases from 10/10 to 2/10
B) Heart rate increases from 80 to 110 bpm
C) Blood pressure drops from 140/90 to 90/60
2. D) Respiratory rate increases from 18 to 24
Answer: A
Rationale: tPA dissolves coronary artery clots to restore blood flow. Decreased chest
pain indicates restored myocardial perfusion and successful reperfusion therapy.
A nurse cares for a client with COPD receiving oxygen at 2 L/min via nasal cannula. The
client appears restless and confused. Which action is most appropriate?
A) Increase oxygen to 4 L/min
B) Obtain arterial blood gases
C) Administer sedative medication
3. D) Check oxygen saturation with pulse oximetry
,Answer: B
Rationale: COPD clients depend on hypoxic drive for respiration. Restlessness and
confusion may indicate CO2 narcosis from oxygen-induced hypoventilation, requiring
ABG analysis to confirm respiratory acidosis.
A client with type 1 diabetes reports feeling shaky and sweaty 2 hours after breakfast.
Which action should the nurse take first?
A) Give 1 unit regular insulin
B) Check blood glucose level
C) Provide orange juice
4. D) Call the healthcare provider
Answer: B
Rationale: These are classic signs of hypoglycemia. The nurse must first confirm
hypoglycemia with glucose testing before treating with carbohydrates.
A client with acute kidney injury has urine output of 200 mL in 24 hours. Which dietary
modification is most important?
A) Restrict protein to 40 g/day
B) Limit sodium to 2 g/day
C) Increase carbohydrate intake
5. D) Provide high-phosphorus foods
Answer: A
Rationale: Oliguric AKI requires protein restriction to reduce nitrogen waste
accumulation and prevent azotemia, while maintaining adequate calories to prevent
catabolism.
A client post-thyroidectomy complains of tingling around the mouth. Which
complication should the nurse suspect?
A) Thyroid storm
B) Hypocalcemia
C) Hemorrhage
6. D) Laryngeal nerve damage
Answer: B
, Rationale: Parathyroid glands may be damaged during thyroidectomy, causing
hypocalcemia. Perioral tingling and paresthesias are early signs requiring calcium
replacement.
A client with cirrhosis develops increasing abdominal girth and shortness of breath.
Which intervention is priority?
A) Administer diuretics
B) Measure abdominal girth
C) Prepare for paracentesis
7. D) Restrict fluids to 1 L/day
Answer: C
Rationale: Tense ascites causing respiratory compromise requires therapeutic
paracentesis for immediate symptom relief and improved ventilation.
A client with Parkinson's disease experiences "on-off" phenomena. Which medication
adjustment helps?
A) Increase carbidopa-levodopa frequency
B) Add amantadine
C) Switch to dopamine agonist
8. D) Decrease protein intake
Answer: A
Rationale: "On-off" phenomena indicate end-of-dose deterioration. More frequent,
smaller doses of carbidopa-levodopa provide smoother symptom control.
A client with rheumatoid arthritis receives methotrexate. Which lab value requires
monitoring?
A) Hemoglobin
B) Liver enzymes
C) Creatinine
9. D) Glucose
Answer: B
Rationale: Methotrexate is hepatotoxic and requires regular liver function monitoring to
detect drug-induced hepatitis or cirrhosis.
Correct Questions & Graded A Verified Answers for
Nightingale College
A 68-year-old client with chronic heart failure is prescribed furosemide 40 mg IV push
twice daily. Which assessment finding requires immediate nursing intervention?
A) Urine output 800 mL in 8 hours
B) Serum potassium 3.2 mEq/L
C) Blood pressure 110/70 mmHg
1. D) Weight gain of 1 pound since yesterday
Answer: B
Rationale: Hypokalemia (serum potassium <3.5 mEq/L) is a serious complication of
loop diuretics like furosemide and can lead to life-threatening cardiac dysrhythmias,
requiring immediate potassium replacement.
A client with acute myocardial infarction receives tissue plasminogen activator (tPA).
Which finding indicates the medication is effective?
A) Chest pain decreases from 10/10 to 2/10
B) Heart rate increases from 80 to 110 bpm
C) Blood pressure drops from 140/90 to 90/60
2. D) Respiratory rate increases from 18 to 24
Answer: A
Rationale: tPA dissolves coronary artery clots to restore blood flow. Decreased chest
pain indicates restored myocardial perfusion and successful reperfusion therapy.
A nurse cares for a client with COPD receiving oxygen at 2 L/min via nasal cannula. The
client appears restless and confused. Which action is most appropriate?
A) Increase oxygen to 4 L/min
B) Obtain arterial blood gases
C) Administer sedative medication
3. D) Check oxygen saturation with pulse oximetry
,Answer: B
Rationale: COPD clients depend on hypoxic drive for respiration. Restlessness and
confusion may indicate CO2 narcosis from oxygen-induced hypoventilation, requiring
ABG analysis to confirm respiratory acidosis.
A client with type 1 diabetes reports feeling shaky and sweaty 2 hours after breakfast.
Which action should the nurse take first?
A) Give 1 unit regular insulin
B) Check blood glucose level
C) Provide orange juice
4. D) Call the healthcare provider
Answer: B
Rationale: These are classic signs of hypoglycemia. The nurse must first confirm
hypoglycemia with glucose testing before treating with carbohydrates.
A client with acute kidney injury has urine output of 200 mL in 24 hours. Which dietary
modification is most important?
A) Restrict protein to 40 g/day
B) Limit sodium to 2 g/day
C) Increase carbohydrate intake
5. D) Provide high-phosphorus foods
Answer: A
Rationale: Oliguric AKI requires protein restriction to reduce nitrogen waste
accumulation and prevent azotemia, while maintaining adequate calories to prevent
catabolism.
A client post-thyroidectomy complains of tingling around the mouth. Which
complication should the nurse suspect?
A) Thyroid storm
B) Hypocalcemia
C) Hemorrhage
6. D) Laryngeal nerve damage
Answer: B
, Rationale: Parathyroid glands may be damaged during thyroidectomy, causing
hypocalcemia. Perioral tingling and paresthesias are early signs requiring calcium
replacement.
A client with cirrhosis develops increasing abdominal girth and shortness of breath.
Which intervention is priority?
A) Administer diuretics
B) Measure abdominal girth
C) Prepare for paracentesis
7. D) Restrict fluids to 1 L/day
Answer: C
Rationale: Tense ascites causing respiratory compromise requires therapeutic
paracentesis for immediate symptom relief and improved ventilation.
A client with Parkinson's disease experiences "on-off" phenomena. Which medication
adjustment helps?
A) Increase carbidopa-levodopa frequency
B) Add amantadine
C) Switch to dopamine agonist
8. D) Decrease protein intake
Answer: A
Rationale: "On-off" phenomena indicate end-of-dose deterioration. More frequent,
smaller doses of carbidopa-levodopa provide smoother symptom control.
A client with rheumatoid arthritis receives methotrexate. Which lab value requires
monitoring?
A) Hemoglobin
B) Liver enzymes
C) Creatinine
9. D) Glucose
Answer: B
Rationale: Methotrexate is hepatotoxic and requires regular liver function monitoring to
detect drug-induced hepatitis or cirrhosis.
