BSN 246 HESI-RN Med-Surg Nightingale NEWEST
EXAM 2026 LATEST VERSION WITH REAL COMPLETE
QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES|| VERIFIED 100% ACTUAL
FINAL EXAM WITH VERIFIED ANSWERS &
QUESTIONS || LATEST UPDATE 2026-2027
A client in the emergency department is bleeding profusely from a
gunshot wound to the abdomen. What action should the nurse
immediately?
A.
Place the client in a 45-degree Trendelenburg position to promote
cerebral blood flow.
B.
Turn the client prone to place pressure on the abdominal wound to
help staunch the bleeding.
C.
Maintain the client in a supine position to reduce diaphragmatic
pressure and visualize the wound.
D.
Put the client on the right side to apply pressure to the liver and spleen
to stop hemorrhaging.
C
Rationale: Placing the client in a supine position reduces diaphragmatic
pressure, thereby enhancing oxygenation, and allows for visualization
of the abdominal wound. Option A compromises diaphragmatic
expansion and inhibits pressoreceptor activity. Option B places the
client at risk of evisceration of the abdominal wound and increased
bleeding. Option D will not stop internal bleeding in the liver and
spleen caused by the gunshot wound.
,The client is return demonstrating wrapping of the left limb amputated
above the knee. The nurse evaluates the client is starting the wrapping
method correctly when the client places the end of the bandage at
which point?
A.
Around the waist
B.
At the inner aspect of the left stump
C.
At the outer aspect of the left stump
D.
At the left groin area
A
Rationale: The waist is the anchor point for the bandage for an above
the knee amputation.
A postoperative client receives a Schedule II opioid analgesic for pain.
Which assessment finding requires the most immediate intervention by
the nurse?
A.
Hypoactive bowel sounds with abdominal distention
B.
Client reports continued pain of 8 on a 10-point scale
C.
Respiratory rate of 12 breaths/min, with O2 saturation of 85%
D.
Client reports nausea after receiving the medication
C
Rationale:Administration of a Schedule II opioid analgesic can result in
respiratory depression, which requires immediate intervention by the
nurse to prevent respiratory arrest. Options A, B, and D require action
by the nurse but are of less priority than option C.
,When developing a discharge teaching plan for a client after the
insertion of a permanent pacemaker, the nurse writes a goal of "The
client will verbalize symptoms of pacemaker failure." Which behavior
indicates that the goal has been met?
A.
The client demonstrates the procedures to change the rate of the
pacemaker using a magnet.
B.
The client carries a card in his wallet stating the type and serial number
of the pacemaker.
C.
The client tells the nurse that it is important to report redness and
tenderness at the insertion site.
D.
The client states that changes in the pulse and feelings of dizziness are
significant changes.
D
Rationale:Changes in pulse rate and/or rhythm may indicate pacer
failure. Feelings of dizziness may be caused by a decreased heart rate,
leading to decreased cardiac output. The rate of a pacemaker is not
changed by a client, although the client may be familiar with this
procedure as explained by his health care provider. Option B is an
important step in preparing the client for discharge but does not
demonstrate knowledge of the symptoms of pacer failure. Option C
indicates symptoms of possible incisional infection or irritation but does
not indicate pacer failure.
, Which consideration is most important when the nurse is assigning a
room for a client being admitted with progressive systemic sclerosis
(scleroderma)?
A.
Provide a room that can be kept warm.
B.
Make sure that the room can be kept dark.
C.
Keep the client close to the nursing unit.
D.
Select a room that is visible from the nurses' desk.
A
Rationale:Abnormal blood flow in response to cold (Raynaud
phenomenon) is precipitated in clients with scleroderma. Option B is
not a significant factor. Stress can also precipitate the severe pain of
Raynaud phenomenon, so a quiet environment is preferred to option C,
which is often very noisy. Option D is not necessary.
EXAM 2026 LATEST VERSION WITH REAL COMPLETE
QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES|| VERIFIED 100% ACTUAL
FINAL EXAM WITH VERIFIED ANSWERS &
QUESTIONS || LATEST UPDATE 2026-2027
A client in the emergency department is bleeding profusely from a
gunshot wound to the abdomen. What action should the nurse
immediately?
A.
Place the client in a 45-degree Trendelenburg position to promote
cerebral blood flow.
B.
Turn the client prone to place pressure on the abdominal wound to
help staunch the bleeding.
C.
Maintain the client in a supine position to reduce diaphragmatic
pressure and visualize the wound.
D.
Put the client on the right side to apply pressure to the liver and spleen
to stop hemorrhaging.
C
Rationale: Placing the client in a supine position reduces diaphragmatic
pressure, thereby enhancing oxygenation, and allows for visualization
of the abdominal wound. Option A compromises diaphragmatic
expansion and inhibits pressoreceptor activity. Option B places the
client at risk of evisceration of the abdominal wound and increased
bleeding. Option D will not stop internal bleeding in the liver and
spleen caused by the gunshot wound.
,The client is return demonstrating wrapping of the left limb amputated
above the knee. The nurse evaluates the client is starting the wrapping
method correctly when the client places the end of the bandage at
which point?
A.
Around the waist
B.
At the inner aspect of the left stump
C.
At the outer aspect of the left stump
D.
At the left groin area
A
Rationale: The waist is the anchor point for the bandage for an above
the knee amputation.
A postoperative client receives a Schedule II opioid analgesic for pain.
Which assessment finding requires the most immediate intervention by
the nurse?
A.
Hypoactive bowel sounds with abdominal distention
B.
Client reports continued pain of 8 on a 10-point scale
C.
Respiratory rate of 12 breaths/min, with O2 saturation of 85%
D.
Client reports nausea after receiving the medication
C
Rationale:Administration of a Schedule II opioid analgesic can result in
respiratory depression, which requires immediate intervention by the
nurse to prevent respiratory arrest. Options A, B, and D require action
by the nurse but are of less priority than option C.
,When developing a discharge teaching plan for a client after the
insertion of a permanent pacemaker, the nurse writes a goal of "The
client will verbalize symptoms of pacemaker failure." Which behavior
indicates that the goal has been met?
A.
The client demonstrates the procedures to change the rate of the
pacemaker using a magnet.
B.
The client carries a card in his wallet stating the type and serial number
of the pacemaker.
C.
The client tells the nurse that it is important to report redness and
tenderness at the insertion site.
D.
The client states that changes in the pulse and feelings of dizziness are
significant changes.
D
Rationale:Changes in pulse rate and/or rhythm may indicate pacer
failure. Feelings of dizziness may be caused by a decreased heart rate,
leading to decreased cardiac output. The rate of a pacemaker is not
changed by a client, although the client may be familiar with this
procedure as explained by his health care provider. Option B is an
important step in preparing the client for discharge but does not
demonstrate knowledge of the symptoms of pacer failure. Option C
indicates symptoms of possible incisional infection or irritation but does
not indicate pacer failure.
, Which consideration is most important when the nurse is assigning a
room for a client being admitted with progressive systemic sclerosis
(scleroderma)?
A.
Provide a room that can be kept warm.
B.
Make sure that the room can be kept dark.
C.
Keep the client close to the nursing unit.
D.
Select a room that is visible from the nurses' desk.
A
Rationale:Abnormal blood flow in response to cold (Raynaud
phenomenon) is precipitated in clients with scleroderma. Option B is
not a significant factor. Stress can also precipitate the severe pain of
Raynaud phenomenon, so a quiet environment is preferred to option C,
which is often very noisy. Option D is not necessary.
