BSN HESI 266 Med Surg Exam V3 Questions and Answers and
Explanations | Latest For Nightingale
1. A nurse is caring for a patient with Congestive Heart Failure (CHF). Which
assessment finding is most indicative of left-sided heart failure?
A. Crackles auscultated in the lungs
B. Peripheral edema in the lower extremities
C. Jugular venous distention
D. Hepatomegaly and right upper quadrant pain
Answer: A
Explantation:Left-sided heart failure causes blood to back up into the pulmonary system,
leading to pulmonary congestion and crackles. Options A, B, and D are signs of right-sided
heart failure.
2. A patient with Type 1 Diabetes Mellitus is found unconscious with a blood
glucose of 45 mg/dL. Which action should the nurse take first?
A. Administer 15g of oral carbohydrates
B. Call the healthcare provider for an insulin order
C. Re-check the blood glucose level in 15 minutes
D. Administer Glucagon IM or SQ per protocol
Answer: D
,Explantation:For an unconscious patient with hypoglycemia, oral intake is unsafe.
Glucagon or IV Dextrose is required immediately to raise blood glucose levels.
3. Which laboratory value is the most specific indicator of acute myocardial
infarction (MI)?
A. Troponin I
B. Creatine Kinase (CK-MB)
C. Myoglobin
D. C-reactive protein
Answer: A
Explantation:Troponin I is highly specific to cardiac muscle damage and remains elevated
longer than other markers, making it the gold standard for MI diagnosis.
4. A patient is diagnosed with Chronic Obstructive Pulmonary Disease (COPD).
The nurse should instruct the patient to use which breathing technique to
prevent airway collapse during exhalation?
A. Diaphragmatic breathing
B. Pursed-lip breathing
C. Deep chest breathing
D. Rapid, shallow breathing
Answer: B
,Explantation:Pursed-lip breathing creates positive pressure in the airways, preventing
collapse and promoting better gas exchange in COPD patients.
5. A patient with a history of cirrhosis presents with increased confusion and
flapping tremors of the hands (asterixis). Which medication does the nurse
expect to administer?
A. Lactulose
B. Spironolactone
C. Furosemide
D. Propranolol
Answer: A
Explantation:Lactulose is used to reduce ammonia levels in hepatic encephalopathy by
promoting its excretion through the stool.
6. Following a thyroidectomy, a patient reports numbness and tingling around
the mouth. Which assessment should the nurse perform?
A. Assess for Kernig’s sign
B. Assess for Homan’s sign
C. Check the surgical site for drainage
D. Check for Trousseau’s sign
Answer: D
, Explantation:Numbness and tingling indicate hypocalcemia, a risk after thyroid surgery
due to potential parathyroid damage. Trousseau’s sign tests for latent tetany caused by
hypocalcemia.
7. Which acid-base imbalance is most likely in a patient with a three-day history
of severe vomiting?
A. Metabolic alkalosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Respiratory acidosis
Answer: A
Explantation:Vomiting results in the loss of gastric acid (hydrogen ions), leading to an
increase in serum pH and bicarbonate, characteristic of metabolic alkalosis.
8. A patient is receiving a blood transfusion and begins to experience chills,
fever, and lower back pain. What is the nurse’s priority action?
A. Slow the infusion rate
B. Administer acetaminophen and continue the transfusion
C. Stop the transfusion immediately
D. Notify the blood bank
Answer: C
Explanations | Latest For Nightingale
1. A nurse is caring for a patient with Congestive Heart Failure (CHF). Which
assessment finding is most indicative of left-sided heart failure?
A. Crackles auscultated in the lungs
B. Peripheral edema in the lower extremities
C. Jugular venous distention
D. Hepatomegaly and right upper quadrant pain
Answer: A
Explantation:Left-sided heart failure causes blood to back up into the pulmonary system,
leading to pulmonary congestion and crackles. Options A, B, and D are signs of right-sided
heart failure.
2. A patient with Type 1 Diabetes Mellitus is found unconscious with a blood
glucose of 45 mg/dL. Which action should the nurse take first?
A. Administer 15g of oral carbohydrates
B. Call the healthcare provider for an insulin order
C. Re-check the blood glucose level in 15 minutes
D. Administer Glucagon IM or SQ per protocol
Answer: D
,Explantation:For an unconscious patient with hypoglycemia, oral intake is unsafe.
Glucagon or IV Dextrose is required immediately to raise blood glucose levels.
3. Which laboratory value is the most specific indicator of acute myocardial
infarction (MI)?
A. Troponin I
B. Creatine Kinase (CK-MB)
C. Myoglobin
D. C-reactive protein
Answer: A
Explantation:Troponin I is highly specific to cardiac muscle damage and remains elevated
longer than other markers, making it the gold standard for MI diagnosis.
4. A patient is diagnosed with Chronic Obstructive Pulmonary Disease (COPD).
The nurse should instruct the patient to use which breathing technique to
prevent airway collapse during exhalation?
A. Diaphragmatic breathing
B. Pursed-lip breathing
C. Deep chest breathing
D. Rapid, shallow breathing
Answer: B
,Explantation:Pursed-lip breathing creates positive pressure in the airways, preventing
collapse and promoting better gas exchange in COPD patients.
5. A patient with a history of cirrhosis presents with increased confusion and
flapping tremors of the hands (asterixis). Which medication does the nurse
expect to administer?
A. Lactulose
B. Spironolactone
C. Furosemide
D. Propranolol
Answer: A
Explantation:Lactulose is used to reduce ammonia levels in hepatic encephalopathy by
promoting its excretion through the stool.
6. Following a thyroidectomy, a patient reports numbness and tingling around
the mouth. Which assessment should the nurse perform?
A. Assess for Kernig’s sign
B. Assess for Homan’s sign
C. Check the surgical site for drainage
D. Check for Trousseau’s sign
Answer: D
, Explantation:Numbness and tingling indicate hypocalcemia, a risk after thyroid surgery
due to potential parathyroid damage. Trousseau’s sign tests for latent tetany caused by
hypocalcemia.
7. Which acid-base imbalance is most likely in a patient with a three-day history
of severe vomiting?
A. Metabolic alkalosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Respiratory acidosis
Answer: A
Explantation:Vomiting results in the loss of gastric acid (hydrogen ions), leading to an
increase in serum pH and bicarbonate, characteristic of metabolic alkalosis.
8. A patient is receiving a blood transfusion and begins to experience chills,
fever, and lower back pain. What is the nurse’s priority action?
A. Slow the infusion rate
B. Administer acetaminophen and continue the transfusion
C. Stop the transfusion immediately
D. Notify the blood bank
Answer: C
