BSN 266 HESI V2 UPDATED MED SURG EXAM (NEW
2025/ 2026 UPDATE) | QUESTIONS AND ANSWERS |
GRADE A | 100% CORRECT (COMPLETE ANSWERS) –
NIGHTINGALE
Neutrophil count- The patient is experiencing infection, so a nurse should review the neutrophil count
before contacting the HCP.
While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent
drainage from the wounds. Before reporting the finding, what is the best lab value to evaluate?
Demonstrate the use of visual scanning during meals to the client and family.
An older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual perception
and she only eats half of the food on her meal tray. Her family expresses concern about her nutritional
status. How should the nurse respond to the family's concern?
High Fowler's Position- High fowlers helps to decrease venous return, which decreases fluid volume in
the heart that results in decreased cardiac workload.
Best position for respiratory distress?
High risk for injury
A patient with peripheral artery disease has marked peripheral neuropath. An appropriate nursing
diagnosis for the patient is
Check feet every day for cuts or injuries.
,Type 2 diabetes patient discharge teaching patient and family
Institute Contact precautions for staff and visitors
Send wound drainage for culture and sensitivity
Monitor the clients WBC count
Plan of care for patient with skin lesions of lower extremities with possible MRSA. SATA
Hematemesis- - Contact HCP if blood is visible in body fluids such as hematemesis.
A patient with acute anterior wall MI 1 week ago is given low-dose aspirin. The medication is related to
which problem and HCP should be notified?
Elevated blood urea nitrogen (BUN)
For a patient with SLE exacerbation what is the most important to report which assessment finding?
Rate of pain on a scale from 0-10.
Before selecting a medication to administer, which action should the nurse implement in the post-op
patient who reports incisional pain and has 2 PRN analgesia available in MAR?
Keep patient NPO- Patient should be kept NPO until procedure is successfully completed. The patient
should not take anything by mouth.
Patient had bariatric surgery 2 months ago who developed post-op strictures who is experiencing
nausea and vomiting and anorexia who is admitted for fluid resuscitation. Which intervention should the
nurse implement?
,Vital sign changes and ECGs- Priority parameters are vital sign changes related to hypovolemia and ECG
changes due to serum electrolyte loss, which can be life threatening.
Acute Kidney Injury due to aminoglycoside antibiotic moved from oliguric phase to the diuretic phase.
Which parameters are most important to monitor?
Nuts, chocolate, dark greens, and spinach.
Patient has a calcium oxalate renal stone. Which food are you going to teach the patient to avoid?
Pancreatitis- complications include pancreatitis that may manifest with upper left quadrant or mid-
epigastric pain which radiates to the back and accompanied by nausea, vomiting, and fever.
A patient had a cholecystectomy 2 days ago, the patient is febrile, abdominal pain radiating to the back
and has had 3 episodes of vomiting in the last 8 hours. The patient is exhibiting symptoms for which
condition?
Uncompensated Metabolic Alkalosis
Patient has a bowel obstruction and ABGs read ph- 7.50 PaCO2-42 and HCO3-33. How would you define
this acid base balance?
Prescription strength Corticosteroids- decrease inflammation and help manage psoriasis plaques.
Psoriasis is a skin cell proliferation of the surface of the skin causing thick silvery scales or itchy red
patches.
Psoriasis with silvery, scaly areas on elbows and palms that burn and bleed. Which prescription should
the nurse teach the client to use for skin condition?
Provide a soft bristled toothbrush- allows for gentle cleaning with less risk of trauma than a hard bristled
brush. Candidiasis often called oral thrush which is a fungal infection of the mouth, it is common in
babies, people with immune deficiency, and those who use steroid sprays for asthma.
, Patient with AIDs and oral candidiasis has several painful mouth ulcers. The nurse delegates oral care to
the UAP and discusses how to assist client. What instructions do you give to the UAP?
Continue maintenance regimen and walks
A young adult with osteoarthritis of both knee's desires to continue daily walks at the park with friends.
how should the nurse respond?
Increase insulin dose.
Patient with diabetes mellitus with upper respiratory infection. Which changes in blood glucose
management should the nurse tell the client to expect?
**
What discharge instructions does the nurse provide for a patient with BPH following transurethral
needle ablation (TUNA)?
**
Patient with ileal conduit urinary diversion. Which finding indicates to the nurse that the client is
experiencing complications?
Signs of FVE- sx/sy of right sided heart failure include jugular venous distension, liver engorgement
(hepatomegaly) with ascites, and peripheral edema, loss of appetite, and nausea and vomiting.
Which cue would lead the nurse to further assess the client for other symptoms of right sided heart
failure in a patient with sinus tachycardia?
**
2025/ 2026 UPDATE) | QUESTIONS AND ANSWERS |
GRADE A | 100% CORRECT (COMPLETE ANSWERS) –
NIGHTINGALE
Neutrophil count- The patient is experiencing infection, so a nurse should review the neutrophil count
before contacting the HCP.
While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent
drainage from the wounds. Before reporting the finding, what is the best lab value to evaluate?
Demonstrate the use of visual scanning during meals to the client and family.
An older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual perception
and she only eats half of the food on her meal tray. Her family expresses concern about her nutritional
status. How should the nurse respond to the family's concern?
High Fowler's Position- High fowlers helps to decrease venous return, which decreases fluid volume in
the heart that results in decreased cardiac workload.
Best position for respiratory distress?
High risk for injury
A patient with peripheral artery disease has marked peripheral neuropath. An appropriate nursing
diagnosis for the patient is
Check feet every day for cuts or injuries.
,Type 2 diabetes patient discharge teaching patient and family
Institute Contact precautions for staff and visitors
Send wound drainage for culture and sensitivity
Monitor the clients WBC count
Plan of care for patient with skin lesions of lower extremities with possible MRSA. SATA
Hematemesis- - Contact HCP if blood is visible in body fluids such as hematemesis.
A patient with acute anterior wall MI 1 week ago is given low-dose aspirin. The medication is related to
which problem and HCP should be notified?
Elevated blood urea nitrogen (BUN)
For a patient with SLE exacerbation what is the most important to report which assessment finding?
Rate of pain on a scale from 0-10.
Before selecting a medication to administer, which action should the nurse implement in the post-op
patient who reports incisional pain and has 2 PRN analgesia available in MAR?
Keep patient NPO- Patient should be kept NPO until procedure is successfully completed. The patient
should not take anything by mouth.
Patient had bariatric surgery 2 months ago who developed post-op strictures who is experiencing
nausea and vomiting and anorexia who is admitted for fluid resuscitation. Which intervention should the
nurse implement?
,Vital sign changes and ECGs- Priority parameters are vital sign changes related to hypovolemia and ECG
changes due to serum electrolyte loss, which can be life threatening.
Acute Kidney Injury due to aminoglycoside antibiotic moved from oliguric phase to the diuretic phase.
Which parameters are most important to monitor?
Nuts, chocolate, dark greens, and spinach.
Patient has a calcium oxalate renal stone. Which food are you going to teach the patient to avoid?
Pancreatitis- complications include pancreatitis that may manifest with upper left quadrant or mid-
epigastric pain which radiates to the back and accompanied by nausea, vomiting, and fever.
A patient had a cholecystectomy 2 days ago, the patient is febrile, abdominal pain radiating to the back
and has had 3 episodes of vomiting in the last 8 hours. The patient is exhibiting symptoms for which
condition?
Uncompensated Metabolic Alkalosis
Patient has a bowel obstruction and ABGs read ph- 7.50 PaCO2-42 and HCO3-33. How would you define
this acid base balance?
Prescription strength Corticosteroids- decrease inflammation and help manage psoriasis plaques.
Psoriasis is a skin cell proliferation of the surface of the skin causing thick silvery scales or itchy red
patches.
Psoriasis with silvery, scaly areas on elbows and palms that burn and bleed. Which prescription should
the nurse teach the client to use for skin condition?
Provide a soft bristled toothbrush- allows for gentle cleaning with less risk of trauma than a hard bristled
brush. Candidiasis often called oral thrush which is a fungal infection of the mouth, it is common in
babies, people with immune deficiency, and those who use steroid sprays for asthma.
, Patient with AIDs and oral candidiasis has several painful mouth ulcers. The nurse delegates oral care to
the UAP and discusses how to assist client. What instructions do you give to the UAP?
Continue maintenance regimen and walks
A young adult with osteoarthritis of both knee's desires to continue daily walks at the park with friends.
how should the nurse respond?
Increase insulin dose.
Patient with diabetes mellitus with upper respiratory infection. Which changes in blood glucose
management should the nurse tell the client to expect?
**
What discharge instructions does the nurse provide for a patient with BPH following transurethral
needle ablation (TUNA)?
**
Patient with ileal conduit urinary diversion. Which finding indicates to the nurse that the client is
experiencing complications?
Signs of FVE- sx/sy of right sided heart failure include jugular venous distension, liver engorgement
(hepatomegaly) with ascites, and peripheral edema, loss of appetite, and nausea and vomiting.
Which cue would lead the nurse to further assess the client for other symptoms of right sided heart
failure in a patient with sinus tachycardia?
**
