BSN 266 HESI Med Surg Practice Exam Version 2 (2023/ 2024 Update) Questions and Verified Answers with Rationales|100% Correct| Grade A- Nightingale

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.

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:

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.

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.