BSN 246 HESI - Medical Surgical Nursing Latest Update with
complete questions and correct detailed answers \verified 100%
\Actual Exam 2026-2027 \Graded A+ Nightingale College
The nurse is working at a first aid booth for a spring training game on a hot day. A
spectator comes in, reporting that he is not feeling well. Vital signs are temp 104.1
F, pulse 132 BPM, respirs 26 breaths/min, and blood pressure 106/66 mm Hg. He
trips over his feet as the nurse leads him to a cot. What is the priory action of the
nurse?
a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the victim with cool water and remove his shirt
d. encourage drinking of cool water or sports drink
C
The spectator shows signs of heat stroke, which is a medical emergency. The
spectator should be transported to the ED ASAP. The nurs should take actions to
lower his body temp in teh meantime by removing his shirt and sponging his
body with cool water. Lowering body temp by drinking cool fluids or taking
acetaminophen is not as effective in an emergency situation. The client needs to
be cooled quickly and is a priority for treatment
,The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL solution
of dextrose 5% in 0.45% saline. The client states that the area around the IV site
burns. What intervention does the nurse perform first?
a. assess for a blood return
b. notify the physician
c. document the finding
d. stop the IV infusion
D
Potassium is a severe tissue irritant. The safest action is to discontinue the solution
that contains the potassium and discontinue the IV altogether, in which case the
client would need another site started. Assessing for a blood return may or may
not be successful. The solution could be diluted (less potassium) and the rate
could be slowed once it is determined that the needle is in the vein.
A nurse is caring for an older adult client who lives alone. Which economic
situation presents the most serious problem for this client?
a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income
D
Older adults on fixed incomes are unable to adjust their income to meet rising
costs associated with meeting basic needs
,Controlling pain is important to promoting wellness. Unrelieved pain has been
associated with
a. prolonged stress response and a cascade of harmful effects system wide.
b. decreased tumor growth and longevity
c. large tidal volumes and decreased lung capacity
d. decreased carbohydrate, protein, and fat destruction
A
Pain triggers a number of physiologic stress responses in the human body.
Unrelieved pain can prolong the stress response and produce a cascade of
harmful effects in all body systems. The stress response causes the endocrine
system to release excessive amounts of hormones, such as cortisol,
catecholamines, and glucagon. Insulin and testosterone levels decrease.
Increased endocrine activity in turn initiates a number of metabolic processes, in
particular, accelerated carbohydrate, protein, and fat destruction, whcih can
result in weight loss, tachycardia, increased respiratory rate, shock, and even
death. The immune system is also affected by pain as demonstrated by research
showing a link between unrelieved pain and a higher incidence of nosocomial
infections and increased tumor growth. Large tidal volumes are not associated
with pain while decreased lung capacity is associated with unrelieved pain.
Decreased tumor growth and longevity are not associated with unrelieved pain.
Decreased carbs, protein, and fat are not associated with pain or stress
response.
, 1/24/26, 10:33 AM HESI - Medical Surgical Nursing
When describing patient education approaches, the nurse educator would
explain that informal teaching is an approach that
a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs
C. Informal teaching is individualized one on one teaching which represents the
majority of patient education done by nurses that occurs when an intervention is
explained or a question is answered. Group needs are often the focus of formal
patient education courses or classes. Informal teaching does not necessarily
follow a specific formalized plan. It may be planned with specific content, but it
is individualized responses to patient needs. Formal teaching involves the use of
a curriculum/course plan with standardized content.
A patient expresses a strong interest in returning to their work, family, and
hobbies after having a stroke. Which theory type would the nurse use to develop
a plan of care for the best results of this patient's motivation style?
a. field
b. biological
c. cognitive
d. sociologic
C. Cognitive theorists believe that attention, relevance, confidence, and
satisfaction (ARCS) are the conditions that, when integrated, motivate someone
to learn. Field theorists place significance on how achievement, power, the need
for affiliation, and avoidance motives influence individual behavior. Sociologic
theories are not involved in motivation.
/ 2/123
complete questions and correct detailed answers \verified 100%
\Actual Exam 2026-2027 \Graded A+ Nightingale College
The nurse is working at a first aid booth for a spring training game on a hot day. A
spectator comes in, reporting that he is not feeling well. Vital signs are temp 104.1
F, pulse 132 BPM, respirs 26 breaths/min, and blood pressure 106/66 mm Hg. He
trips over his feet as the nurse leads him to a cot. What is the priory action of the
nurse?
a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the victim with cool water and remove his shirt
d. encourage drinking of cool water or sports drink
C
The spectator shows signs of heat stroke, which is a medical emergency. The
spectator should be transported to the ED ASAP. The nurs should take actions to
lower his body temp in teh meantime by removing his shirt and sponging his
body with cool water. Lowering body temp by drinking cool fluids or taking
acetaminophen is not as effective in an emergency situation. The client needs to
be cooled quickly and is a priority for treatment
,The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL solution
of dextrose 5% in 0.45% saline. The client states that the area around the IV site
burns. What intervention does the nurse perform first?
a. assess for a blood return
b. notify the physician
c. document the finding
d. stop the IV infusion
D
Potassium is a severe tissue irritant. The safest action is to discontinue the solution
that contains the potassium and discontinue the IV altogether, in which case the
client would need another site started. Assessing for a blood return may or may
not be successful. The solution could be diluted (less potassium) and the rate
could be slowed once it is determined that the needle is in the vein.
A nurse is caring for an older adult client who lives alone. Which economic
situation presents the most serious problem for this client?
a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income
D
Older adults on fixed incomes are unable to adjust their income to meet rising
costs associated with meeting basic needs
,Controlling pain is important to promoting wellness. Unrelieved pain has been
associated with
a. prolonged stress response and a cascade of harmful effects system wide.
b. decreased tumor growth and longevity
c. large tidal volumes and decreased lung capacity
d. decreased carbohydrate, protein, and fat destruction
A
Pain triggers a number of physiologic stress responses in the human body.
Unrelieved pain can prolong the stress response and produce a cascade of
harmful effects in all body systems. The stress response causes the endocrine
system to release excessive amounts of hormones, such as cortisol,
catecholamines, and glucagon. Insulin and testosterone levels decrease.
Increased endocrine activity in turn initiates a number of metabolic processes, in
particular, accelerated carbohydrate, protein, and fat destruction, whcih can
result in weight loss, tachycardia, increased respiratory rate, shock, and even
death. The immune system is also affected by pain as demonstrated by research
showing a link between unrelieved pain and a higher incidence of nosocomial
infections and increased tumor growth. Large tidal volumes are not associated
with pain while decreased lung capacity is associated with unrelieved pain.
Decreased tumor growth and longevity are not associated with unrelieved pain.
Decreased carbs, protein, and fat are not associated with pain or stress
response.
, 1/24/26, 10:33 AM HESI - Medical Surgical Nursing
When describing patient education approaches, the nurse educator would
explain that informal teaching is an approach that
a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs
C. Informal teaching is individualized one on one teaching which represents the
majority of patient education done by nurses that occurs when an intervention is
explained or a question is answered. Group needs are often the focus of formal
patient education courses or classes. Informal teaching does not necessarily
follow a specific formalized plan. It may be planned with specific content, but it
is individualized responses to patient needs. Formal teaching involves the use of
a curriculum/course plan with standardized content.
A patient expresses a strong interest in returning to their work, family, and
hobbies after having a stroke. Which theory type would the nurse use to develop
a plan of care for the best results of this patient's motivation style?
a. field
b. biological
c. cognitive
d. sociologic
C. Cognitive theorists believe that attention, relevance, confidence, and
satisfaction (ARCS) are the conditions that, when integrated, motivate someone
to learn. Field theorists place significance on how achievement, power, the need
for affiliation, and avoidance motives influence individual behavior. Sociologic
theories are not involved in motivation.
/ 2/123
