BSN 266 HESI Med Surg Practice Exam
Version 2 (2023\/ 2024 Update) Questions and
Verified Answers with Rationales|100%
Correct| Grade A- Nightingale
Q: What types of medications should the nurse expect to administer to a client during an acute
respiratory distress episode?
A. Vasodilators and hormones.
B. Analgesics and sedatives.
C. Anticoagulants and expectorants.
D. Bronchodilators and steroids.
Answer:
D. Bronchodilators and steroids.
Rationale
Besides supplemental oxygen, this client with ARDS needs medications to widen air passages,
increase air space, and reduce alveolar membrane inflammation, such as bronchodilators and
steroids.
Q: A female client is brought to the clinic by her daughter for a flu shot. She has lost significant
weight since the last visit. She has poor personal hygiene and inadequate clothing for the
weather. The client states that she lives alone and denies problems or concerns. What action
should the nurse implement?
A. Notify social services immediately of suspected elderly abuse.
B. Discuss the need for mental health counseling with the daughter.
C. Explain to the client that she needs to take better care of herself.
D. Collect further data to determine whether self-neglect is occurring.
Answer:
D. Collect further data to determine whether self-neglect is occurring.
Rationale
Changes in weight and hygiene may be indicators of self-neglect or neglect by family members.
Further assessment is needed before notifying social services or discussing a need for counseling.<\/p>\n\n\n\n
Q: The nurse is assisting a client out of bed for the first time after surgery. What action should
the nurse do first?
A. Place a chair at a right angle to the bedside.
B. Encourage deep breathing prior to standing.
C. Help the client to sit and dangle legs on the side of the bed.
D. Allow the client to sit with the bed in a high Fowler’s position.
Answer:
D. Allow the client to sit with the bed in a high Fowler’s position.
Rationale
The first step is to raise the head of the bed to a high Fowler’s position, which allow venous
return to compensate from lying flat and the vasodilation effects of perioperative drugs. This
helps prevent the client from becoming light-headed and decreases the chance of a client fall.
Q: A 32-year-old female client complains of severe abdominal pain each month before her
menstrual period, painful intercourse, and painful defecation. Which additional history should
the nurse obtain that is consistent with the client’s complaints?
A. Frequent urinary tract infections.
B. Inability to get pregnant.
C. Premenstrual syndrome.
D. Chronic use of laxatives.
Answer:
B. Inability to get pregnant.
Rationale
Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common symptoms of
endometriosis, which is the abnormal displacement of endometrial tissue in the dependent areas
of the pelvic peritoneum. A history of infertility is another common finding associated with
endometriosis.
Q: The nurse would be correct in withholding a dose of digoxin in a client with congestive
heart failure without specific instruction from the healthcare provider if the client’s
A. serum digoxin level is 1.5.
B. blood pressure is 104\/68.
C. serum potassium level is 3.
D. apical pulse is 68\/min.
Answer:<\/p>\n\n\n\n
C. serum potassium level is 3.
Rationale
Hypokalemia can precipitate digitalis toxicity in persons receiving digoxin which will increase
the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq\/L).
Q: In assessing cancer risk, the nurse identifies which woman as being at greatest risk of
developing breast cancer?
A. A 35-year-old multipara who never breastfed.
B. A 50-year-old whose mother had unilateral breast cancer.
C. A 55-year-old whose mother-in-law had bilateral breast cancer.
D. A 20-year-old whose menarche occurred at age 9.
Answer:
B. A 50-year-old whose mother had unilateral breast cancer.
Rationale
The most predictive risk factors for development of breast cancer are over 40 years of age and a
positive family history (occurrence in the immediate family, i.e., mother or sister). Other risk
factors include nulliparity, no history of breastfeeding, early menarche and late menopause, but
are not considered as predictive as a positive history of an immediate family member and over 40
years old.
Q: A client taking a thiazide diuretic for the past six months has a serum potassium level of 3.
The nurse anticipates which change in prescription for the client?
A. The dosage of the diuretic will be decreased.
B. The diuretic will be discontinued.
C. A potassium supplement will be prescribed.
D. The dosage of the diuretic will be increased.
Answer:
C. A potassium supplement will be prescribed.
Rationale
This client’s potassium level is too low (normal is 3.5 to 5). Taking a thiazide diuretic often
results in a loss of potassium, so a potassium supplement needs to be prescribed to restore a
normal serum potassium level.
Q: Which milestone indicates to the nurse successful achievement of young adulthood?
A. Demonstrates a conceptualization of death and dying.<\/p>\n\n\n\n
B. Completes education and becomes self-supporting.
C. Creates a new definition of self and roles with others.
D. Develops a strong need for parental support and approval.
Answer:
B. Completes education and becomes self-supporting.
Rationale
Transitioning through young adulthood is characterized by establishing independence as an
adult, and includes developmental tasks such as completing education, beginning a career, and
becoming self-supporting (B). (A and C) are characteristic of adolescence. Although strong
bonds with parents are an expected finding for this age group, the need for support and approval
(D) indicates dependency, which is a developmental delay.
Q: A client is admitted to the medical intensive care unit with a diagnosis of myocardial
infarction. The client’s history indicates the infarction occurred ten hours ago. Which laboratory
test result would the nurse expect this client to exhibit?
A. Elevated LDH.
B. Elevated serum amylase.
C. Elevated CK-MB.
D. Elevated hematocrit.
Answer:
C. Elevated CK-MB.
Rationale
The cardiac isoenzyme CK-MB (C) is the one of the cardiac markers to indicate myocardial
damage in the presence of MI symptoms and after a positive troponin. The troponin levels will
elevate within 2-3 hours indicating myocardial ischemia, followed by the CK-MB cardiac
markers within 6-9 hours, peaking within 12 to 20 hours after myocardial infarction (MI).
Q: A client who is fully awake after a gastroscopy asks the nurse for something to drink. After
confirming that liquids are allowed, which assessment action should the nurse consider a
priority?
A. Listen to bilateral lung and bowel sounds.
B. Obtain the client’s pulse and blood pressure.
C. Assist the client to the bathroom to void.
D. Check the client’s gag and swallow reflexes.
Answer:
D. Check the client’s gag and swallow reflexes.
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