BSN HESI 266 Med Surg Exam V2 Questions and Answers and
Explanations | Latest For Nightingale
1. A nurse is assessing a patient with left-sided heart failure. Which of the
following clinical manifestations should the nurse expect to find?
A. Jugular vein distention
B. Peripheral edema
C. Crackles in the lungs
D. Abdominal distention
Answer: C
Explanation: Left-sided heart failure leads to pulmonary congestion, resulting in
symptoms like crackles, dyspnea, and cough. Options A, B, and D are signs of right-sided
heart failure.
2. A patient with Type 1 Diabetes Mellitus presents with diaphoresis, shakiness,
and a blood glucose level of 55 mg/dL. Which action should the nurse take first?
A. Administer 15g of fast-acting carbohydrates
B. Check the patient’s A1C level
C. Administer 10 units of regular insulin
D. Provide a complex carbohydrate and protein snack
Answer: A
,Explanation: The patient is experiencing hypoglycemia. The first action is to provide 15g
of simple carbohydrates to raise the blood glucose level quickly.
3. Which arterial blood gas (ABG) result indicates respiratory acidosis?
A. pH 7.30, PaCO2 50, HCO3 24
B. pH 7.50, PaCO2 30, HCO3 22
C. pH 7.32, PaCO2 35, HCO3 18
D. pH 7.48, PaCO2 40, HCO3 30
Answer: A
Explanation: Respiratory acidosis is characterized by a low pH (<7.35) and an elevated
PaCO2 (>45). Option A meets these criteria.
4. A patient who underwent an abdominal surgery 3 days ago reports a
‘popping’ sensation after coughing, and the nurse observes a loop of bowel
protruding from the wound. What is the nurse’s priority action?
A. Attempt to push the bowel back into the abdomen
B. Place the patient in a High-Fowler’s position
C. Apply a tight pressure dressing
D. Apply a sterile dressing moistened with normal saline
Answer: D
Explanation: This is wound evisceration. The nurse must cover the protruding organ with
sterile, saline-soaked gauze to keep it moist and minimize infection risk until surgery.
,5. The nurse is caring for a patient with Chronic Obstructive Pulmonary Disease
(COPD). Which oxygen delivery rate is generally most appropriate for this
patient?
A. 6-10 L/min via simple face mask
B. 10-15 L/min via non-rebreather mask
C. 12 L/min via Venturi mask
D. 1-2 L/min via nasal cannula
Answer: D
Explanation: In COPD patients, high oxygen concentrations can suppress the hypoxic drive
to breathe. Low-flow oxygen (1-2 L/min) is typically preferred unless the patient is in acute
distress.
6. A patient with cirrhosis and an elevated ammonia level is prescribed
lactulose. What is the expected therapeutic effect of this medication?
A. Decreased abdominal girth
B. Improved level of consciousness
C. Reduced jaundice
D. Lowered blood pressure
Answer: B
Explanation: Lactulose helps excrete ammonia through the stool, which reduces hepatic
encephalopathy and improves neurological status/level of consciousness.
, 7. During a blood transfusion, the patient complains of chills, low back pain, and
itching. What should the nurse do first?
A. Slow the infusion rate
B. Stop the transfusion immediately
C. Administer diphenhydramine
D. Notify the healthcare provider
Answer: B
Explanation: The patient is showing signs of a transfusion reaction. The first and most
critical step is to stop the transfusion to prevent further exposure to the blood product.
8. A patient is 2 hours post-operative from a total hip arthroplasty. Which
position should the nurse maintain for the affected extremity?
A. Adduction with internal rotation
B. Internal rotation with 90-degree flexion
C. Full flexion at the hip
D. Abduction with an wedge pillow
Answer: D
Explanation: To prevent dislocation of the new hip joint, the leg should be kept in an
abducted position, often using an abduction pillow or wedge.
Explanations | Latest For Nightingale
1. A nurse is assessing a patient with left-sided heart failure. Which of the
following clinical manifestations should the nurse expect to find?
A. Jugular vein distention
B. Peripheral edema
C. Crackles in the lungs
D. Abdominal distention
Answer: C
Explanation: Left-sided heart failure leads to pulmonary congestion, resulting in
symptoms like crackles, dyspnea, and cough. Options A, B, and D are signs of right-sided
heart failure.
2. A patient with Type 1 Diabetes Mellitus presents with diaphoresis, shakiness,
and a blood glucose level of 55 mg/dL. Which action should the nurse take first?
A. Administer 15g of fast-acting carbohydrates
B. Check the patient’s A1C level
C. Administer 10 units of regular insulin
D. Provide a complex carbohydrate and protein snack
Answer: A
,Explanation: The patient is experiencing hypoglycemia. The first action is to provide 15g
of simple carbohydrates to raise the blood glucose level quickly.
3. Which arterial blood gas (ABG) result indicates respiratory acidosis?
A. pH 7.30, PaCO2 50, HCO3 24
B. pH 7.50, PaCO2 30, HCO3 22
C. pH 7.32, PaCO2 35, HCO3 18
D. pH 7.48, PaCO2 40, HCO3 30
Answer: A
Explanation: Respiratory acidosis is characterized by a low pH (<7.35) and an elevated
PaCO2 (>45). Option A meets these criteria.
4. A patient who underwent an abdominal surgery 3 days ago reports a
‘popping’ sensation after coughing, and the nurse observes a loop of bowel
protruding from the wound. What is the nurse’s priority action?
A. Attempt to push the bowel back into the abdomen
B. Place the patient in a High-Fowler’s position
C. Apply a tight pressure dressing
D. Apply a sterile dressing moistened with normal saline
Answer: D
Explanation: This is wound evisceration. The nurse must cover the protruding organ with
sterile, saline-soaked gauze to keep it moist and minimize infection risk until surgery.
,5. The nurse is caring for a patient with Chronic Obstructive Pulmonary Disease
(COPD). Which oxygen delivery rate is generally most appropriate for this
patient?
A. 6-10 L/min via simple face mask
B. 10-15 L/min via non-rebreather mask
C. 12 L/min via Venturi mask
D. 1-2 L/min via nasal cannula
Answer: D
Explanation: In COPD patients, high oxygen concentrations can suppress the hypoxic drive
to breathe. Low-flow oxygen (1-2 L/min) is typically preferred unless the patient is in acute
distress.
6. A patient with cirrhosis and an elevated ammonia level is prescribed
lactulose. What is the expected therapeutic effect of this medication?
A. Decreased abdominal girth
B. Improved level of consciousness
C. Reduced jaundice
D. Lowered blood pressure
Answer: B
Explanation: Lactulose helps excrete ammonia through the stool, which reduces hepatic
encephalopathy and improves neurological status/level of consciousness.
, 7. During a blood transfusion, the patient complains of chills, low back pain, and
itching. What should the nurse do first?
A. Slow the infusion rate
B. Stop the transfusion immediately
C. Administer diphenhydramine
D. Notify the healthcare provider
Answer: B
Explanation: The patient is showing signs of a transfusion reaction. The first and most
critical step is to stop the transfusion to prevent further exposure to the blood product.
8. A patient is 2 hours post-operative from a total hip arthroplasty. Which
position should the nurse maintain for the affected extremity?
A. Adduction with internal rotation
B. Internal rotation with 90-degree flexion
C. Full flexion at the hip
D. Abduction with an wedge pillow
Answer: D
Explanation: To prevent dislocation of the new hip joint, the leg should be kept in an
abducted position, often using an abduction pillow or wedge.
