BSN HESI MED-SURG 266 EXAM
NIGHTINGALE COLLEGE QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
100% GUARANTEED PASS!!
<LATEST VERSION>
1. A patient with chronic obstructive pulmonary disease (COPD) presents
with increasing shortness of breath and a respiratory rate of 28 breaths/min.
Which intervention should the nurse implement first?
A. Administer a high-flow oxygen mask at 10 L/min
B. Encourage pursed-lip breathing
C. Obtain an arterial blood gas (ABG)
D. Place the patient in Trendelenburg position
Answer: B. Encourage pursed-lip breathing
Rationale: Pursed-lip breathing helps slow exhalation and reduces air trapping in
COPD patients, improving gas exchange. High-flow oxygen can suppress hypoxic
drive in COPD, and Trendelenburg is not indicated. ABGs are important but are
not the immediate intervention.
,2. A patient is scheduled for a cholecystectomy. The nurse reviews
preoperative labs and notes an INR of 2.5. Which action should the nurse
take?
A. Proceed with surgery as planned
B. Notify the surgeon
C. Administer vitamin K immediately
D. Place the patient on NPO status
Answer: B. Notify the surgeon
Rationale: An INR of 2.5 indicates an increased risk of bleeding. The surgeon
must be informed before proceeding with surgery. Vitamin K may be indicated but
is not administered without physician orders.
3. A patient receiving IV furosemide 40 mg daily reports muscle cramps and
weakness. Lab results: K⁺ 2.8 mEq/L. What is the priority nursing action?
A. Administer potassium supplement as ordered
B. Hold furosemide and notify the provider
C. Encourage high-potassium foods
D. Increase IV fluids
Answer: B. Hold furosemide and notify the provider
Rationale: Severe hypokalemia increases the risk for arrhythmias. The provider
should be notified to adjust medications and order potassium replacement safely.
4. Which electrolyte imbalance is most likely in a patient with prolonged
vomiting?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypocalcemia
,Answer: B. Hypokalemia
Rationale: Vomiting causes loss of gastric fluids rich in potassium and hydrogen
ions, leading to hypokalemia and metabolic alkalosis.
5. A patient is receiving morphine sulfate via PCA for post-op pain. The nurse
should monitor for which adverse effect as the highest priority?
A. Sedation
B. Constipation
C. Hypotension
D. Respiratory depression
Answer: D. Respiratory depression
Rationale: Opioids can depress the respiratory center in the brain, which can be
life-threatening. Sedation and constipation are also concerns but less immediately
dangerous.
6. A patient with left-sided heart failure reports dyspnea and orthopnea.
Which assessment finding supports pulmonary congestion?
A. Jugular vein distention
B. Bilateral lower extremity edema
C. Crackles in the lungs
D. Hepatomegaly
Answer: C. Crackles in the lungs
Rationale: Left-sided heart failure causes pulmonary venous congestion, leading
to fluid accumulation in the alveoli, heard as crackles.
7. A patient with hypertension is prescribed lisinopril. Which instruction
should the nurse provide?
A. Avoid foods high in potassium
B. Change positions slowly to prevent dizziness
, C. Take the medication only when blood pressure is high
D. Monitor for signs of hypoglycemia
Answer: B. Change positions slowly to prevent dizziness
Rationale: ACE inhibitors can cause hypotension, especially after the first dose.
Patients should rise slowly to prevent falls.
8. A patient is scheduled for abdominal surgery and asks why the nurse is
teaching coughing and deep breathing exercises. Which response is most
accurate?
A. “It helps prevent lung infections after surgery.”
B. “It decreases your pain after surgery.”
C. “It helps reduce nausea from anesthesia.”
D. “It improves your circulation.”
Answer: A. “It helps prevent lung infections after surgery.”
Rationale: Coughing and deep breathing prevent postoperative atelectasis and
pneumonia.
9. A patient with hyponatremia (Na⁺ 124 mEq/L) is lethargic and confused.
Which action should the nurse prioritize?
A. Administer IV 0.9% NaCl slowly
B. Encourage oral water intake
C. Restrict sodium intake
D. Monitor for bradycardia
Answer: A. Administer IV 0.9% NaCl slowly
Rationale: Symptomatic hyponatremia can cause cerebral edema. Carefully
administered isotonic saline restores sodium safely.
NIGHTINGALE COLLEGE QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
100% GUARANTEED PASS!!
<LATEST VERSION>
1. A patient with chronic obstructive pulmonary disease (COPD) presents
with increasing shortness of breath and a respiratory rate of 28 breaths/min.
Which intervention should the nurse implement first?
A. Administer a high-flow oxygen mask at 10 L/min
B. Encourage pursed-lip breathing
C. Obtain an arterial blood gas (ABG)
D. Place the patient in Trendelenburg position
Answer: B. Encourage pursed-lip breathing
Rationale: Pursed-lip breathing helps slow exhalation and reduces air trapping in
COPD patients, improving gas exchange. High-flow oxygen can suppress hypoxic
drive in COPD, and Trendelenburg is not indicated. ABGs are important but are
not the immediate intervention.
,2. A patient is scheduled for a cholecystectomy. The nurse reviews
preoperative labs and notes an INR of 2.5. Which action should the nurse
take?
A. Proceed with surgery as planned
B. Notify the surgeon
C. Administer vitamin K immediately
D. Place the patient on NPO status
Answer: B. Notify the surgeon
Rationale: An INR of 2.5 indicates an increased risk of bleeding. The surgeon
must be informed before proceeding with surgery. Vitamin K may be indicated but
is not administered without physician orders.
3. A patient receiving IV furosemide 40 mg daily reports muscle cramps and
weakness. Lab results: K⁺ 2.8 mEq/L. What is the priority nursing action?
A. Administer potassium supplement as ordered
B. Hold furosemide and notify the provider
C. Encourage high-potassium foods
D. Increase IV fluids
Answer: B. Hold furosemide and notify the provider
Rationale: Severe hypokalemia increases the risk for arrhythmias. The provider
should be notified to adjust medications and order potassium replacement safely.
4. Which electrolyte imbalance is most likely in a patient with prolonged
vomiting?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypocalcemia
,Answer: B. Hypokalemia
Rationale: Vomiting causes loss of gastric fluids rich in potassium and hydrogen
ions, leading to hypokalemia and metabolic alkalosis.
5. A patient is receiving morphine sulfate via PCA for post-op pain. The nurse
should monitor for which adverse effect as the highest priority?
A. Sedation
B. Constipation
C. Hypotension
D. Respiratory depression
Answer: D. Respiratory depression
Rationale: Opioids can depress the respiratory center in the brain, which can be
life-threatening. Sedation and constipation are also concerns but less immediately
dangerous.
6. A patient with left-sided heart failure reports dyspnea and orthopnea.
Which assessment finding supports pulmonary congestion?
A. Jugular vein distention
B. Bilateral lower extremity edema
C. Crackles in the lungs
D. Hepatomegaly
Answer: C. Crackles in the lungs
Rationale: Left-sided heart failure causes pulmonary venous congestion, leading
to fluid accumulation in the alveoli, heard as crackles.
7. A patient with hypertension is prescribed lisinopril. Which instruction
should the nurse provide?
A. Avoid foods high in potassium
B. Change positions slowly to prevent dizziness
, C. Take the medication only when blood pressure is high
D. Monitor for signs of hypoglycemia
Answer: B. Change positions slowly to prevent dizziness
Rationale: ACE inhibitors can cause hypotension, especially after the first dose.
Patients should rise slowly to prevent falls.
8. A patient is scheduled for abdominal surgery and asks why the nurse is
teaching coughing and deep breathing exercises. Which response is most
accurate?
A. “It helps prevent lung infections after surgery.”
B. “It decreases your pain after surgery.”
C. “It helps reduce nausea from anesthesia.”
D. “It improves your circulation.”
Answer: A. “It helps prevent lung infections after surgery.”
Rationale: Coughing and deep breathing prevent postoperative atelectasis and
pneumonia.
9. A patient with hyponatremia (Na⁺ 124 mEq/L) is lethargic and confused.
Which action should the nurse prioritize?
A. Administer IV 0.9% NaCl slowly
B. Encourage oral water intake
C. Restrict sodium intake
D. Monitor for bradycardia
Answer: A. Administer IV 0.9% NaCl slowly
Rationale: Symptomatic hyponatremia can cause cerebral edema. Carefully
administered isotonic saline restores sodium safely.
