ESTUDYR
BSN HESI 266 MOST TESTED QUESTIONS AND
ANSWERS GRADED A+ WITH RATIONALES
A client is recovering from a transurethral prostatectomy (TURP). Which activity should be
limited until after the first postoperative visit with the healthcare provider?
A. Driving a car
B. Lifting >10 lb
C. Drinking 3 L of fluid daily
D. Walking up stairs
Rationale: After TURP, fluid intake is often regulated to avoid overdistention and help manage
bladder irrigation; follow HCP guidance at first postop visit.
A client with stage IV bone cancer rates pain high on a 1–10 scale. Which intervention should
the nurse implement?
A. Give only non-opioid analgesics first
B. Offer distraction techniques only
C. Administer opioid and non-opioid medications simultaneously
D. Wait to see if pain decreases spontaneously
Rationale: Severe cancer pain often requires multimodal analgesia (opioid +
adjuvant/nonopioid) for effective control.
After multiple transfusions a patient develops an ABO incompatibility. Which finding should
be reported immediately?
A. Low back pain and hypotension
B. Rhinitis and nasal stuffiness
C. Delayed urticarial rash
D. Chronic arthritic changes
Rationale: Low back pain and hypotension suggest acute hemolytic transfusion reaction — life-
threatening and urgent.
Discharge teaching for diverticulosis should include:
A. Small frequent meals and sitting up 2 hours postprandial
B. Bland diet—avoid spicy foods
C. Eat a high-fiber diet and increase fluid intake
D. Soft diet with increased milk products
Rationale: High fiber and fluids help prevent constipation and diverticular complications.
,ESTUDYR
For a client with continuous bladder irrigation after TURP and increased blood clots in tubing,
the best initial action is:
A. Give additional oral fluids
B. Measure intake and output
C. Increase the flow of bladder irrigation
D. Administer PRN antispasmodic
Rationale: Increasing irrigation flushes clots to maintain patency; monitor output and notify
HCP if bleeding persists.
A lung cancer patient wearing a morphine patch is difficult to arouse and you find four
patches adhered. The immediate action is:
A. Apply oxygen only
B. Call rapid response and leave patches intact
C. Remove all morphine patches
D. Administer naloxone IM immediately
Rationale: Multiple patches increase opioid dose → remove patches to stop absorption; then
assess airway/breathing and give naloxone if needed.
After a fall and leg fracture with cast, which finding warrants immediate intervention?
A. Circumferential edema of right foot
B. Throbbing leg pain complaint
C. Right foot pale with sluggish capillary refill
D. Increased leg temperature
Rationale: Pallor and delayed cap refill suggest compromised perfusion (possible compartment
syndrome or arterial compromise).
Young adult diabetic preop for hernia repair Feeling weak/jittery — first actions (select all
that apply):
A. Check fingerstick glucose
B. Assess skin temperature/moisture
C. Measure pulse and blood pressure
D. Hold surgery and reschedule
Answers: A, B, C
Rationale: Hypoglycemia assessment and vital sign/skin checks are immediate; then treat per
protocol.
Four days after stent placement a patient has sudden chest pressure & SOB. The nurse
should next:
A. Listen for extra heart sounds
B. Evaluate extremity perfusion
, ESTUDYR
C. Verify scheduled troponins
D. Obtain 12-lead ECG and begin continuous cardiac monitoring
Rationale: New chest symptoms after PCI require immediate ECG and monitoring for
myocardial ischemia/arrhythmia.
Client with migraine and bilateral hand weakness: nurse should:
A. Implement fall precautions
B. Tell client migraine relief will fix weakness
C. Gather additional assessment data about pain and weakness
D. Refer to occupational therapy immediately
Rationale: Neurologic weakness requires further assessment to rule out stroke/neuropathy
before intervention.
During PUVA therapy, overexposure is indicated by:
A. Thick plaques with silvery scales
B. Tenderness on palpation and generalized erythema
C. Brown greasy papules on face
D. Photophobia only
Rationale: Erythema and tenderness indicate sunburn/overexposure from PUVA.
Post-gastric bypass with suspected anastomotic leak (fever, tachy, hypotension trend):
priority intervention:
A. Encourage turning
B. Monitor skin breakdown
C. Strict IV fluid replacement
D. Assess wound drainage daily
Rationale: Leak can cause sepsis/hypovolemia — aggressive IV fluid resuscitation is key.
Raynaud’s disease pain management advice:
A. Rub painful areas vigorously
B. Expect IV pain meds frequently
C. Enroll in pain clinic only
D. Wear gloves when handling cold items
Rationale: Cold protection (gloves) prevents vasospasm and painful episodes in Raynaud’s.
Newly diagnosed Crohn’s disease asks about diet restrictions. Nurse response:
A. Restrict fluids primarily
B. Limit calcium/iron foods
C. Avoid gluten always
BSN HESI 266 MOST TESTED QUESTIONS AND
ANSWERS GRADED A+ WITH RATIONALES
A client is recovering from a transurethral prostatectomy (TURP). Which activity should be
limited until after the first postoperative visit with the healthcare provider?
A. Driving a car
B. Lifting >10 lb
C. Drinking 3 L of fluid daily
D. Walking up stairs
Rationale: After TURP, fluid intake is often regulated to avoid overdistention and help manage
bladder irrigation; follow HCP guidance at first postop visit.
A client with stage IV bone cancer rates pain high on a 1–10 scale. Which intervention should
the nurse implement?
A. Give only non-opioid analgesics first
B. Offer distraction techniques only
C. Administer opioid and non-opioid medications simultaneously
D. Wait to see if pain decreases spontaneously
Rationale: Severe cancer pain often requires multimodal analgesia (opioid +
adjuvant/nonopioid) for effective control.
After multiple transfusions a patient develops an ABO incompatibility. Which finding should
be reported immediately?
A. Low back pain and hypotension
B. Rhinitis and nasal stuffiness
C. Delayed urticarial rash
D. Chronic arthritic changes
Rationale: Low back pain and hypotension suggest acute hemolytic transfusion reaction — life-
threatening and urgent.
Discharge teaching for diverticulosis should include:
A. Small frequent meals and sitting up 2 hours postprandial
B. Bland diet—avoid spicy foods
C. Eat a high-fiber diet and increase fluid intake
D. Soft diet with increased milk products
Rationale: High fiber and fluids help prevent constipation and diverticular complications.
,ESTUDYR
For a client with continuous bladder irrigation after TURP and increased blood clots in tubing,
the best initial action is:
A. Give additional oral fluids
B. Measure intake and output
C. Increase the flow of bladder irrigation
D. Administer PRN antispasmodic
Rationale: Increasing irrigation flushes clots to maintain patency; monitor output and notify
HCP if bleeding persists.
A lung cancer patient wearing a morphine patch is difficult to arouse and you find four
patches adhered. The immediate action is:
A. Apply oxygen only
B. Call rapid response and leave patches intact
C. Remove all morphine patches
D. Administer naloxone IM immediately
Rationale: Multiple patches increase opioid dose → remove patches to stop absorption; then
assess airway/breathing and give naloxone if needed.
After a fall and leg fracture with cast, which finding warrants immediate intervention?
A. Circumferential edema of right foot
B. Throbbing leg pain complaint
C. Right foot pale with sluggish capillary refill
D. Increased leg temperature
Rationale: Pallor and delayed cap refill suggest compromised perfusion (possible compartment
syndrome or arterial compromise).
Young adult diabetic preop for hernia repair Feeling weak/jittery — first actions (select all
that apply):
A. Check fingerstick glucose
B. Assess skin temperature/moisture
C. Measure pulse and blood pressure
D. Hold surgery and reschedule
Answers: A, B, C
Rationale: Hypoglycemia assessment and vital sign/skin checks are immediate; then treat per
protocol.
Four days after stent placement a patient has sudden chest pressure & SOB. The nurse
should next:
A. Listen for extra heart sounds
B. Evaluate extremity perfusion
, ESTUDYR
C. Verify scheduled troponins
D. Obtain 12-lead ECG and begin continuous cardiac monitoring
Rationale: New chest symptoms after PCI require immediate ECG and monitoring for
myocardial ischemia/arrhythmia.
Client with migraine and bilateral hand weakness: nurse should:
A. Implement fall precautions
B. Tell client migraine relief will fix weakness
C. Gather additional assessment data about pain and weakness
D. Refer to occupational therapy immediately
Rationale: Neurologic weakness requires further assessment to rule out stroke/neuropathy
before intervention.
During PUVA therapy, overexposure is indicated by:
A. Thick plaques with silvery scales
B. Tenderness on palpation and generalized erythema
C. Brown greasy papules on face
D. Photophobia only
Rationale: Erythema and tenderness indicate sunburn/overexposure from PUVA.
Post-gastric bypass with suspected anastomotic leak (fever, tachy, hypotension trend):
priority intervention:
A. Encourage turning
B. Monitor skin breakdown
C. Strict IV fluid replacement
D. Assess wound drainage daily
Rationale: Leak can cause sepsis/hypovolemia — aggressive IV fluid resuscitation is key.
Raynaud’s disease pain management advice:
A. Rub painful areas vigorously
B. Expect IV pain meds frequently
C. Enroll in pain clinic only
D. Wear gloves when handling cold items
Rationale: Cold protection (gloves) prevents vasospasm and painful episodes in Raynaud’s.
Newly diagnosed Crohn’s disease asks about diet restrictions. Nurse response:
A. Restrict fluids primarily
B. Limit calcium/iron foods
C. Avoid gluten always
