BSN HESI 266 Med Surg PREDICTOR Actual Exam
(Latest ) Verified Questions & Correct
Answers With Detailed Rationales, 100%
Guaranteed Pass || Complete A+ Guide -
Nightingale
A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action
should the nurse implement?
A. Position the head of the bed (HOB) flat.
B. Withhold intravenous fluids.
C. Administer a bolus of IV fluids.
D. Give an antihypertensive medication. - Correct Answer-D. Give an antihypertensive
medication.
Rationale
Most ischemic strokes occur during sleep when baseline blood pressure declines or blood
viscosity increases due to minimal fluid intake. Completed strokes usually produce neurologic
deficits within an hour, and the client's current elevated blood pressure requires
antihypertensive medication.
A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out
each day?" Which response by the nurse best explains the reason for alopecia?
A. "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant."
B. "Alopecia is a common side effect you will experience during long-term steroid therapy."
C. "Your hair will grow back completely after your course of chemotherapy is completed."
D. "The chemotherapy causes permanent alterations in your hair follicles that lead to hair loss."
- Correct Answer-A. "Chemotherapy affects the cells of the body that grow rapidly, both normal
and malignant."
Rationale
Page 1 of 103
,The common adverse effects of chemotherapy (nausea, vomiting, alopecia, bone marrow
depression) are due to chemotherapy's effect on the rapidly reproducing cells, both normal and
malignant.
A 57-year-old male client is scheduled to have a stress-thallium test the following morning and
is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food.
Which response is best for the nurse to provide to this client?
A. "I'm sorry sir, you have a prescription for nothing by mouth from midnight tonight."
B. "I will let you have one cracker, but that is all you can have for the rest of tonight."
C. "What did the healthcare provider tell you about the test you are having tomorrow?"
D. "The test you are having tomorrow requires that you have nothing by mouth tonight." -
Correct Answer-D. "The test you are having tomorrow requires that you have nothing by mouth
tonight."
Rationale
Being direct and explaining to the client that the test requires him to be NPO, is the most
therapeutic statement because the nurse is responding to the client's question and providing
him the reason why.
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not
moving. What action should the nurse take first?
A. Use a laryngoscope to check for a foreign body lodged in the esophagus.
B. Reposition the head to validate that the head is in the proper position to open the airway.
C. Turn the client to the side and administer three back blows.
D. Perform a finger sweep of the mouth to remove any vomitus. - Correct Answer-B. Reposition
the head to validate that the head is in the proper position to open the airway.
Rationale
The most frequent cause of inadequate aeration of the client's lungs during CPR is the improper
positioning of the head resulting in occlusion of the airway. The nurse should reposition the
client's head and attempt to ventilate again, looking for the rise and fall of the chest.
Page 2 of 103
,A client who was in a motor vehicle collision was admitted to the hospital and the right knee
was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's
medical record: "Potential for impairment of skin integrity related to immobility from traction."
Which nursing intervention is indicated based on this diagnosis statement?
A. Release the traction q4h to provide skin care.
B. Turn the client for back care while suspending traction.
C. Provide back and skin care while maintaining the traction.
D. Give back care after the client is released from traction. - Correct Answer-C. Provide back and
skin care while maintaining the traction.
Rationale
Maintaining skin integrity and providing back care is difficult when a client is in traction, but
must be performed and is the correct intervention to maintain the client's skin integrity.
A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the
nurse to ask the client?
A. "What dose of medication are you taking?"
B. "Are you eating foods rich in potassium?"
C. "Have you lost weight recently?"
D. "At what time do you take your medication?" - Correct Answer-D. "At what time do you take
your medication?"
Rationale
The nurse needs to first determine at what time of day the client takes the Lasix. Because of the
diuretic effect of Lasix, clients should take the medication in the morning to prevent nocturia
which may be the reason for the sleep difficulties.
Which postmenopausal client's complaint should the nurse refer to the healthcare provider?
A. Breasts feel lumpy when palpated.
B. History of white nipple discharge.
C. Episodes of vaginal bleeding.
D. Excessive diaphoresis occurs at night. - Correct Answer-C. Episodes of vaginal bleeding.
Page 3 of 103
, Rationale
Postmenopausal vaginal bleeding may be an indication of endometrial cancer, which should be
reported to the healthcare provider.
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which
assessment finding should the nurse expect this client to exhibit?
A. Lower left quadrant pain and a low-grade fever.
B. Severe pain at McBurney's point and nausea.
C. Abdominal pain and intermittent tenesmus.
D. Exacerbations of severe diarrhea. - Correct Answer-A. Lower left quadrant pain and a low-
grade fever.
Rationale
Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the most
common area for diverticula, and the inflammation of diverticula causes a low-grade fever.
A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for what
vitamin deficiency?
A. K.
B. B12.
C. B6.
D. C. - Correct Answer-A. K.
Rationale
This drug is administered to help lower the triglycerides levels. One of the side effects clients
should be monitored for an increased prothrombin time and prolonged bleeding times which
would alert the nurse to a vitamin K deficiency. These drugs reduce absorption of the fat
soluble (lipid) vitamins A, D, E, and K.
A client has undergone insertion of a permanent pacemaker. When developing a discharge
teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker
failure." Which symptoms are most important to teach the client?
Page 4 of 103
(Latest ) Verified Questions & Correct
Answers With Detailed Rationales, 100%
Guaranteed Pass || Complete A+ Guide -
Nightingale
A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action
should the nurse implement?
A. Position the head of the bed (HOB) flat.
B. Withhold intravenous fluids.
C. Administer a bolus of IV fluids.
D. Give an antihypertensive medication. - Correct Answer-D. Give an antihypertensive
medication.
Rationale
Most ischemic strokes occur during sleep when baseline blood pressure declines or blood
viscosity increases due to minimal fluid intake. Completed strokes usually produce neurologic
deficits within an hour, and the client's current elevated blood pressure requires
antihypertensive medication.
A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out
each day?" Which response by the nurse best explains the reason for alopecia?
A. "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant."
B. "Alopecia is a common side effect you will experience during long-term steroid therapy."
C. "Your hair will grow back completely after your course of chemotherapy is completed."
D. "The chemotherapy causes permanent alterations in your hair follicles that lead to hair loss."
- Correct Answer-A. "Chemotherapy affects the cells of the body that grow rapidly, both normal
and malignant."
Rationale
Page 1 of 103
,The common adverse effects of chemotherapy (nausea, vomiting, alopecia, bone marrow
depression) are due to chemotherapy's effect on the rapidly reproducing cells, both normal and
malignant.
A 57-year-old male client is scheduled to have a stress-thallium test the following morning and
is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food.
Which response is best for the nurse to provide to this client?
A. "I'm sorry sir, you have a prescription for nothing by mouth from midnight tonight."
B. "I will let you have one cracker, but that is all you can have for the rest of tonight."
C. "What did the healthcare provider tell you about the test you are having tomorrow?"
D. "The test you are having tomorrow requires that you have nothing by mouth tonight." -
Correct Answer-D. "The test you are having tomorrow requires that you have nothing by mouth
tonight."
Rationale
Being direct and explaining to the client that the test requires him to be NPO, is the most
therapeutic statement because the nurse is responding to the client's question and providing
him the reason why.
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not
moving. What action should the nurse take first?
A. Use a laryngoscope to check for a foreign body lodged in the esophagus.
B. Reposition the head to validate that the head is in the proper position to open the airway.
C. Turn the client to the side and administer three back blows.
D. Perform a finger sweep of the mouth to remove any vomitus. - Correct Answer-B. Reposition
the head to validate that the head is in the proper position to open the airway.
Rationale
The most frequent cause of inadequate aeration of the client's lungs during CPR is the improper
positioning of the head resulting in occlusion of the airway. The nurse should reposition the
client's head and attempt to ventilate again, looking for the rise and fall of the chest.
Page 2 of 103
,A client who was in a motor vehicle collision was admitted to the hospital and the right knee
was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's
medical record: "Potential for impairment of skin integrity related to immobility from traction."
Which nursing intervention is indicated based on this diagnosis statement?
A. Release the traction q4h to provide skin care.
B. Turn the client for back care while suspending traction.
C. Provide back and skin care while maintaining the traction.
D. Give back care after the client is released from traction. - Correct Answer-C. Provide back and
skin care while maintaining the traction.
Rationale
Maintaining skin integrity and providing back care is difficult when a client is in traction, but
must be performed and is the correct intervention to maintain the client's skin integrity.
A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the
nurse to ask the client?
A. "What dose of medication are you taking?"
B. "Are you eating foods rich in potassium?"
C. "Have you lost weight recently?"
D. "At what time do you take your medication?" - Correct Answer-D. "At what time do you take
your medication?"
Rationale
The nurse needs to first determine at what time of day the client takes the Lasix. Because of the
diuretic effect of Lasix, clients should take the medication in the morning to prevent nocturia
which may be the reason for the sleep difficulties.
Which postmenopausal client's complaint should the nurse refer to the healthcare provider?
A. Breasts feel lumpy when palpated.
B. History of white nipple discharge.
C. Episodes of vaginal bleeding.
D. Excessive diaphoresis occurs at night. - Correct Answer-C. Episodes of vaginal bleeding.
Page 3 of 103
, Rationale
Postmenopausal vaginal bleeding may be an indication of endometrial cancer, which should be
reported to the healthcare provider.
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which
assessment finding should the nurse expect this client to exhibit?
A. Lower left quadrant pain and a low-grade fever.
B. Severe pain at McBurney's point and nausea.
C. Abdominal pain and intermittent tenesmus.
D. Exacerbations of severe diarrhea. - Correct Answer-A. Lower left quadrant pain and a low-
grade fever.
Rationale
Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the most
common area for diverticula, and the inflammation of diverticula causes a low-grade fever.
A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for what
vitamin deficiency?
A. K.
B. B12.
C. B6.
D. C. - Correct Answer-A. K.
Rationale
This drug is administered to help lower the triglycerides levels. One of the side effects clients
should be monitored for an increased prothrombin time and prolonged bleeding times which
would alert the nurse to a vitamin K deficiency. These drugs reduce absorption of the fat
soluble (lipid) vitamins A, D, E, and K.
A client has undergone insertion of a permanent pacemaker. When developing a discharge
teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker
failure." Which symptoms are most important to teach the client?
Page 4 of 103
