BSN HESI 266 Med Surg Exam (Latest 2023\/ 2024 Update) Questions and Verified Answers|100% Correct| Already Graded A- Nightingale<\/p>\n\n\n\n
BSN HESI 266 Med Surg Exam (Latest 2023\/
2024 Update) Questions and Verified
Answers|100% Correct| Already Graded ANightingale
Q: The nurse should explain to a client with lung cancer that pleurodesis is performed to
achieve which expected outcome?
A. Prevent the formation of effusion fluid.
B. Remove fluid from the intrapleural space.
C. Debulk tumor to maintain patency of air passages. Relieve empyema after pneumonectomy
Answer:
A
Rationale
Instillation of a sclerosing agent to create pleurodesis is aimed at preventing the formation of a
pleural effusion by causing the pleural spaces sealed together, thereby preventing the
accumulation of pleural fluid.
Q: The nurse obtains a client’s history that includes right mastectomy and radiation therapy for
cancer of the breast 10 years ago. Which current health problem should the nurse consider is a
consequence of the radiation therapy?
A. Asthma.
B. Myocardial infarction.
C. Chronic esophagitis with gastroesophageal reflux. Pathologic fracture of two ribs on the right
chest
Answer:
D Rationale
The ribs lie in the radiation pathway and lose density over time, becoming thin and brittle, so the
occurence of two right-sided ribs with pathological fractures resulting without evidence of
trauma is related to radiation damage
Q: Three weeks after discharge for an acute myocardial infarction (MI), a client returns to the
cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells the nurse
that he sleeps fine but that his wife moved into the spare bedroom to sleep when he returned<\/p>\n\n\n\n
home. He states, “I guess we will never have sex again after this.” Which response is best for the
nurse to provide?
A. Sexual intercourse can be strenuous on your heart, but closeness and intimacy, such as
holding and cuddling, can be maintained with your wife. B. Sexual activity can be resumed
whenever you and your wife feel like it because the sexual response is more emotional rather
than physical.
C. You should discuss your questions about your sexual activity with your healthcare provider
because sexual activity may be limited by your heart damage.
D. Sexual activity is similar in cardiac workload and energy expenditure as climbing two flights
of stairs and may be resumed like other activities
Answer:
D Rationale
Sexual intercourse after an MI, or acute coronary syndrome, has been found to require no more
energy expenditure or cardiac stress than walking briskly up two flights of stairs, so if you do not
experience shortness of breath or chest discomfort doing the stairs then you should be okay to
resume sexual activity
Q: The nurse is caring for a client scheduled to undergo insertion of a percu- taneous
endoscopic gastrostomy (PEG) tube. The client asks the nurse to ex- plain how a PEG tube
differs from a gastrostomy tube (GT). Which explanation best describes how they are different?
A. Method of insertion. B. Location of the tubes. C. Diameter of the tubes.
D. Procedure for feedings.
Answer:
A Rationale
The best explanation of how a PEG tube differs from a GT is by the method of insertion. GT
insertion involves making an incision in the wall of the abdomen and
suturing the tube to the gastric wall. A PEG tube is more commonly used due to the fact it does
not require general anesthesia and less invasive due to being inserted with endoscopic
visualization through the esophagus into the stomach and then pulled through a small incision in
the abdominal wall and held in place by a tiny plastic device called a “bumper” that holds the gtube in place inside the stomach and a small water-filled balloon which keeps the stomach in
place against the abdominal wall
Q: A client with a recent history of blood in his stools is scheduled for a proc- tosigmoidoscopy.
The nurse should implement which protocols to prepare the client for this procedure? (Select all
that apply.)
Select all that apply
A. Obtain consent for the procedure. B. Initiate preoperative sedation.
C. Begin fast the morning of the procedure.<\/p>\n\n\n\n
D. Administer an enema before the procedure.
E. Provide a clear-liquid diet 48 hours before the procedure
Answer:
D,E Rationale
The usual preoperative preparation for proctosigmoidoscopy entails obtaining the client’s consent
to the procedure, a clear-liquid diet for 24 to 48 hours prior to the procedure, administration of an
enema, and fasting on the morning of the procedure.
Q: A female client with type 2 diabetes mellitus reports dysuria. Which as- sessment finding is
most important for the nurse to report to the healthcare provider?
A. Suprapublic pain and distention.
B. Bounding pulse at 100 beats\/minute. C. Fingerstick glucose of 300 mg\/dl.
D. Small vesicular perineal lesions.
Answer:
C Rationale
Elevated fingerstick glucose levels need to be reported to the healthcare provider, so a plan of
care can be adjusted to treat the elevated glucose level. Also, elevated glucose levels spill into the
urine and provide a medium for bacterial growth
Q: When planning care for a client with right renal calculi, which nursing diagnosis has the
highest priority?
A. Acute pain related to movement of the stone.
B. Impaired urinary elimination related to obstructed flow of urine. C. Risk for infection related
to urinary stasis.
D. Deficient knowledge related to need for prevention of recurrence of calculi.-
Answer:
A Rationale
The nursing diagnosis of the highest priority is “Acute pain related the the renal calculi’s
movement”.
Q: A client asks the nurse about the purpose of beginning chemotherapy (CT) because the
tumor is still very small. Which information supports the explanation that the nurse should
provide?
A. Side effects are less likely if therapy is started early. B. Collateral circulation increases as the
tumor grows.<\/p>\n\n\n\n
C. The sensitivity of cancer cells to CT is based on cell cycle rate. D. The cell count of the tumor
reduces by half with each dose
Answer:
D Rationale
Initiating chemotherapy while the tumor is small provides a better chance of erad- icating all
cancer cells because 50% of cancer cells or tumor cells are killed with each dose.
Q: The nurse is caring for a client with end stage liver disease who is being assessed for the
presence of asterixis. To assess the client for asterixis, what position should the nurse ask the
client to demonstrate?
A. Extend the left arm laterally with the left palm upward.
B. Extend the arm, dorsiflex the wrist, and extend the fingers. C. Extend the arms and hold this
position for 30 seconds.
D. Extend arms with both legs adducted to shoulder width.
Answer:
B Rationale
Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in
hepatic encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist
causing rapid, non-rhythmic extension and flexion of the wrist while attempting to hold position.
Q: The nurse is caring for a client who is two days postoperative. Which observation should
alert the nurse to call the Rapid Response Team (RRT)? A. Fresh bleeding noted on abdominal
surgical wound dressing.
B. Pulse change from 85 to160 beats\/minute lasting more than 10 minutes. C. Temperature of
103.1 F and white blood cell (WBC) count of 16,000 mm3. D. Weakness, diaphoresis,
complaints of feeling faint. BP 100\/56 mm Hg.
Answer:
B Rationale
The RRT should be called to intervene for a client with an acute life-threatening change, such as
a pulse change resulting in tachycardia for a prolonged time in a post-operative client.
Q: The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing
action should be included in the plan of care?
A. Perform active range of motion three times daily. B. Monitor for Battle’s sign every four
hours.
C. Teach measures to avoid the Valsalva maneuver. Maintain the head of bed in a flat position
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