BSN HESI 266 Med Surg Exam V3 | 2026/2027 | Nightingale | Verified Questions & Answers | 100% Correct | Grade A

BSN HESI 266 Med Surg Exam V3 | 2026/2027 | Nightingale | Verified Questions & Answers | 100% Correct | Grade A An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? A. Administer a prescribed sedative B. Assist client to an upright position C. Encourage client to drink water D. Apply a high flow venturi mask B. Assist client to an upright position A client with multiple sclerosis (MS) is admitted to the medical unit, The client reports fatigue, muscle weakness, and diplopia. Which action should the nurse implement to reduce the clients risk for falls? SATA A. Provide assistance to bedside commode B. Provide frequent rest periods. C. Offer to assist with warm baths in the morning D. Monitor pulse ox during activities E. Teach to patch one eye while walking A. Provide assistance to bedside commode C. Schedule frequent rest periods. E. Teach to patch one eye while walking A client arrives to the ED following a motor vehicle collision, The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side, which procedure should the nurse prepare for the client? A. Bronchoscopy B. Chest tube insertion C. Endotracheal intubation D. Pulmonary function test B. Chest tube insertion Following a transurethral resection of the prostate (TURP) a client is discharged from the hospital with an indwelling urinary catheter, Which instruction is most important for the nurse to include in the discharge teaching plan? A. Eliminate all spicy foods from your diet B. Drink 3 liters of water each day C. Clamp the catheter when taking a shower D. Avoid driving a car for 2 weeks B. Drink 3 liters of water each day An adult woman with Graves disease is admitted with severe dehydration and malnutrition, She is currently restless and refusing to eat. Which action is most important for the nurse to implement? A. Teach client relaxation techniques B. Determine the clients food preferences C. Maintain a patent Intravenous site D. Keep room temperature cool C. Maintain a paten intravenous site A client tells the clinic nurse about experiencing burning on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was a casual acquaintance, Which action should the nurse implement? A. Obtain a specimen of urethral drainage for culture B. Observe the perineal area for a chancre like lesion C. Identify all sexual partners in the last four days. D. Assess for perineal itching erythema and excoriation A. Obtain a specimen of urethral drainage for culture The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis, which diagnostic procedure should the nurse prepare the client for? A. Lumbar puncture B. Skull radiography C. MRI D. CT A Lumbar puncture An older adult client with long term type 2 DM is seen in the clinic for a routine health assessment, which assessment would the nurse complete to determine if a patient with type 2 DM is experiencing long term complications? SATA A. Sensation in feet and legs B. Skin condition of lower extremities C. Visual acuity D Serum creatinine and blood urea nitrogen (BUN) E. Signs of respiratory tract infection A. Sensation in feet and legs B. Skin condition of lower extremities C. Visual acuity D. Serum Creatinine and blood urea nitrogen (BUN) The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites, Which mechanism contributes to edema and ascites in a client with cirrhosis? A. Decreased portacaval pressure with greater collateral circulation B. Hypoalbuminemia that results in decreased colloidal oncotic pressure C. Decreased renin angiotensin response related to an increase in renal blood flow D. Hyperaldosteronism causing an increased sodium absorption in renal tubes B. Hypoalbuminemia that results in decreased colloidal oncotic pressure Hypoalbuminemia that results in a decreased colloidal oncotic pressure, this is correct, in cirrhosis liver damage leads to decreased synthesis of albumin, Albumin plays a crucial role in maintaining colloidal oncotic pressure and when it is decreased (hypoalbuminemia) fluid is more likely to leak out of blood vessels resulting n edema, the same mechanism contributes to the development of ascites in the abdominal cavity. D: Incorrect hyperaldosteronism is characterized by an excess of aldosterone a hormone that regulates sodium and water balance in cirrhosis sodium retention is often related to other mechanisms such as portal hypertension and hypoalbuminemia rather than hyperaldosteronism. C. Cirrhosis is more commonly associated with an activated renin angiotensin aldosterone system, leading to increased sodium and water retention, the increased renin angiotensin response is a compensatory mechanism to maintain perfusion in the setting o cirrhosis and does not contribute to decreased renal blood flow The nurse is planning care for an older adult client who experiences a cerebrovascular accident several weeks ago. The client has expressive aphasia (Broca's aphasia) and often becomes frustrated with the nursing staff. Which intervention should the nurse implement? A. Encourage clients use of picture charts B. Speak slowly to the client C. Ask the client simple questions D, Teach the client use of basic sign language A. Encourage the clients use of picture charts. which client has the highest risk for developing skin cancer? A. A 70 year old fair skinned client who works as a secretary. B, A 65 year old fair skinned client who works as a construction worker C. a 25 year old dark skinned client whose mother had skin cancer D. A 16 year old dark skinned client who tans in tanning beds once a week. B. A 65 year old fair skinned client who works as a construction worker which intervention should the nurse include in the teaching plan for a client with pruritis? A. Explain the importance of not taking any type of tub bath B Discourage the use of any type of skin lubricant C. Encourage the client to keep warm sleeping environment D. Instruct client to keep fingernails trimmed short D. Instruct the client to keep fingernails trimmed short One hour after major abdominal surgery a client in the post anesthesia care unit (PACU) has a BP of 136/80. Fifteen minutes later it is 114/72 which actions should the nurse take first? A. Increase frequency of BP assessments B. Encourage the client to breathe deeply C. Check abdominal surgical dressing D. Review the clients baseline BP trends C. Check the abdominal surgical dressing When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary teaching? A. select a protein rich food daily B. Restrict sodium intake C. Eat high potassium foods D. Avoid foods high in carbohydrates B. Restrict sodium intake Two days after a nephrectomy the client reports abdominal pressure and nausea. which assessment should the nurse implement? A. Auscultate bowel sounds B. Ambulate the client in the hallway C. Palpate the abdomen D. Measure hourly urine output A. Auscultate bowel sounds A client with urolithiasis is preparing for discharge after lithotripsy. which intervention should the nurse include in the clients postoperative discharge instructions? A. Report when hematuria becomes pink tinged B. Use an incentive spirometer C, Monitor urinary stream for decrease in output C. Monitor urinary stream for decrease in output A male client who had abdominal surgery 5 days ago and hospitalized because of a surgical wound infection, tells the nurse that he feels like insides just spilled out when he coughed. What action should the nurse take first? A. Visualize the abdominal incision B. Notify the healthcare provider C. Obtain sterile towels soaked in saline D. Assure the client that such feelings occur with wound infections. A. Visualize the abdominal incision A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions how should the nurse respond? A. Describe the use of an elimination diet to find trigger foods. B. Instruct the client to avoid foods with gluten such as wheat bread C. Explain that the need to restrict fluids is the primary limitation D. Advise the client to limit foods that are high in calcium and iron A. Describe the use of an elimination diet to find trigger foods A client with pheochromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic which assessment data should the nurse obtain next? A. Blood pressure B. Capillary glucose C. Oxygen saturation D. Body temperature A. Blood pressure A client with type 1 diabetes mellitus reports blood glucose levels between 180 and 210 upon wakening each time also reports experiencing an increase in disturbing dreams and diaphoresis during the night. Which instruction should the nurse include for the client? A. Check blood glucose during the night B. Have the glucose monitor recalibrated C. Eat a high carbohydrate snack before bed D. Report to the clinic for a fasting serum glucose A. Check blood glucose during the night which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers? A. Lean beef, salads, and baked potatoes B. Chicken, rice, and wheat products, C. Potatoes, low fat breads and applesauce D. Oatmeal, raisins, and fruit with skin D. Oatmeal, raisins, and fruit with skin A client is newly diagnosed with type 2 diabetes mellitus. The nurse is educating the client about self monitoring blood glucose (SMBG) and hemoglobin A1C. which statement by the client indicates teaching has been effective? A. I will use a lancing device on the center of my finger pad for a drop of blood B. I will inform the healthcare provider (HCP) of my average HbA1C results weekly. C. I will wash my hands with warm soapy water before sticking my finger D. I will document my HbA1C results from SMBG monitor every morning, C. I will wash my hands with warm soapy water before sticking my finger Which instruction should the nurse include in the discharge teaching plan of a client who has started treatment for a newly diagnosed diabetes insipidus? A. weigh yourself every day at the same time B. Check your blood sugar prior to each meal C. Keep legs elevated to reduce swelling D. Restrict fluids to half the volume of urine output A. weight yourself everyday at the same time While performing a neurovascular assessment distal to a clients fracture site the nurse determines that the clients pulse is present, regular and full. Which nursing action should be taken next? A. Notify the healthcare provider of assessment finding B. Document the neurovascular assessment as normal C. Discontinue elevating the clients affected extremity D. Assess for color, feeling, discomfort, and movement D. Assess for color, feeling, discomfort and movement Two hours before a clients scheduled surgery the nurse is completing the preoperative checklist. Which information requires the most immediate actin by the nurse Reference range 3.5-5.0 A. Surgical consent form is not signed B. Clients pulse oximeter reading is 96% C. Preoperative chest xray report is not available D. Preoperative serum potassium level 2.8 D. Preoperative serum potassium level 2.8 The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting a sputum? A. Breathe deeply followed by coughing up the sputum B. Restrict fluids before expectorating the sputum specimen C, Obtain the specimen before bedtime D. Avoid mouth care prior to collecting the sputum. A. Breath deeply followed by coughing up the sputum The nurse is obtaining the admission history for a client with suspected ulcer disease (PUD) which objective data reported by the client supports this medical diagnosis? A. Severe abdominal cramps and diarrhea after eating spicy foods B. Frequent use of chewable and liquid antacids for indigestion C. Upper and mid abdominal pain is described as gnawing and burning D. Marked loss of weight and appetite over the last 3 or 4 months A. Upper and mid abdominal pain is described as gnawing and burning Five months following treatment for herpes zoster (shingles) an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. which action should the nurse A. Complete an assessment of the clients pain B. Determine if the client has had a shingles vaccination C. Teach the client about phantom pain symptoms D. Perform a complete mental status exam A. Complete an assessment of the clients pain The nurse calls the health care provider because a client diagnosed with an aortic aneurysm (AAA) is reporting of low back pain Which additional information about the client would be important for the nurse to tell the health care provider? A. Calcium level and skin condition B. Serum amylase and level of consciousness C. Hematocrit and blood pressure D. White blood cell count and heart rate C. Hematocrit and blood pressure A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI which parameters are most important for the nurse to plan to carefully monitor? A. Elevated creatinine and blood urea nitrogen (BUN) B. Side effects of total parenteral nutrition (TPN) and intralipids C. Uremic irritation of mucous membranes and skin surfaces D. Hypovolemia and ECG Changes D. Hypovolemia and ECH changes An adult woman with primary Raynaud's phenomenon develops pallor and then cyanosis of her fingers. After warming her hands the fingers turn red and the client reports burning sensation. What action should the nurse take? A, Report the finding to the healthcare provider as soon as possible B. Continue to monitor the fingers until color returns to normal C. Secure a pulse oximeter to clients oxygen saturation D. Apply a cool compress to the affected fingers for 20 minutes B. Continue to monitor the fingers until color returns to normal Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant? A. Administer a stool softener B. Observe pupil response of the right eye C. Turn, cough and deep breathe every 2 hours D. Sleep flat in a supine position A. Administer a stool softner A client receives a prescription for ciprofloxacin 400 mg intravenously (IV) every 12 hours to be infused over an hour. The IV bag contains ciprofloxacin 400 mg in dextrose 5% in water (DW) 200 mL. The nurse should program the infusion pump to deliver how many mL/hr? 200 while assessing a client with degenerative joint disease the nurse observes Heberden's nodes, large prominences on the clients fingers that are reddened the client reports that the nodes are painful which action should the nurse take? A. Discuss approaches to chronic pain control with the client B. Review the clients dietary intake of high protein foods. C Notify the healthcare provider of the finding immediately D. Assess the clients radial pulses and capillary refill time A. Discuss approaches to chronic pain control with the client A nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following finding should the nurse associate with SLE? SATA A. Arthralgia B. Hirutism C. Light tan stools D. Proteinuria E. Thrombocytopenia A. Arthralgia D. Proteinuria E. Thrombocytopenia A client with a right ulnar fracture and cast placement reports an increase in arm pain. which action should the nurse take next? A. Implement distraction techniques B. Assess right radial pulse volume C. Administer a PRN analgesic D. Measured the blood pressure B. Assess radial pulse volume A client tells the clinic nurse about experiencing burning on urination and assessment reveals that the client had sexual intercourse four days ago with a person who was a casual acquaintance, which action should the nurse implement? A. Observe the perineal area for chancroid like lesion B. Assess for perineal itching, erythema, and excoriation C. Identify all sexual partners in the last four days D. Obtain a specimen of urethral drainage for culture D. Obtain a specimen of urethral drainage for culture The nurse observes that a client with Parkinson's disease (PD) has a mask like face. Which follow up assessment is most important for the nurse to implement? A. Note the frequency of drooling B. Observe the appearance of oral mucosa C. Assess patterns of speech D. Determine the ability to chew and swallow D. Determine the ability to chew and swallow A client is admitted with a history of hypertension and an acute myocardial infarction 2 years ago. The client reports I am feeling weak and tired so I cannot exercise at all I feel out of breath when I walk even a short distance Since I cannot exercise I am gaining weight My shoes are even getting tight the cardiac monitor displays sinus tachycardia which cue should lead the nurse to further assess the client for other symptoms of right sided heart failure? A. Breathlessness B. Report of tight shoes C. Lack of exercise D. Weakness B. Report of tight shoes A client with orthopnea expresses concern about the ability to get enough air during a scheduled thoracentesis. On which information should the nurses response be based? A. Extra pillows can be used if needed to elevate the clients head B. The procedure is performed with the client in an upright position C. A thoracentesis is a brief procedure that has minimal discomfort D. Orthopnea is frequently caused by a clients uncontrolled anxiety B. The procedure is performed with the client in an upright position A client is to receive progesterone 10mg IM Daily The medication is labeled progesterone 50 mg/mL how many mL should the nurse administer 0.2 When caring for a client with a cervical spinal cord injury which intervention is the most important for the nurse to implement? A. Assess the extremity reflexes B. Logroll to change positions C. Immobilize the head in anatomical alignment D. Obtain hourly neurological assessments C. Immobilize the head in anatomical alignment NGN A 52 year old male is brought to the emergency department by his partner after noting he had a yellow tinge to his skin and eyes. Is alert but disorientated and not able to provide a history at this time, Currently has slurred speech and balance disturbance and the partner reports that the client has had about 12 beers today and also informs of alcohol use of approximately 12-16 beers Highlight nursing assessment Cardiovascular: Tachycardia, 2_ radial and pedal pulses. 2 second cap refill Respiratory: Clear breath sounds throughout bilateral lungs Gastrointestinal: Distended abdomen, reported diarrhea, denies nausea Genitourinary: Within normal limits (WL) per report of client Integumentary: Jaundice. Spider angiomas to the chest and abdominal generalized bruising in various states of healing Cardiovascular: Tachycardia Gastrointestinal: Distended abdomen Reports diarrhea Integumentary: Jaundice, spider angiomas to the chest and abdominal generalized bruising in various states of healing NGN A 52 year old male is brought to the emergency department (ED) by his partner after for each assessment finding click to indicate whehter findings from the clients assessment are associated with cerebral vascular accident, liver disorder or thrombocytopenia. Symptom or finding Thrombocytopenia Liver disorder Cerebral vascular accident Jaundice Generalized bruising Disorientation Hepatomegaly Slurred speech Jaundice: Liver disorder Generalized bruising: Liver disorder and thrombocytopenia Disorientation: CVA and liver disorder Hepatomegaly: liver disorder Slurred speech: CVA NGN: A 52 year old male is brought to the emergency department (ED) by his partner after For each potential nursing action click to indicate whether the action is indicated or contraindicated for this clients plan of care. Each row must have one response Assist with ambulation with 1 person assist Prepare to insert an esophageal balloon tamponade tube: Monitor for bleeding: Encourage a high calorie diet: Assess level of consciousness: Assist with ambulation with 1 person assist: Indicated Prepare to insert an esophageal balloon tamponade tube Indicated Monitor for bleeding: Indicated Encourage a high calorie diet: Contraindicated Assess level of consciousness: Indicated A 52 year old male is brought to the emergency department by his partner after The client is receiving care on the medical unit for two days the nurse completes a physical assessment and record the clients vital signs the client is evaluated to determine his response to treatment. which indicates that the client is responding to care SATA A. Jaundice of sclera B. Blood pressure 136/80 C. 180 mL clear amber urine in 4 hours D. Mild intermittent headaches e. Medium bowel movement that is soft brown F. Alert and orientated to person, place, time, and situation G. Nausea with meals H Mild dyspnea with exertion B: BP 136/81 C. 180 mL clear amber urine in 4 hrs E. Medium bowel movement that is soft brown F. Alert and orientated to person, place, time, and situation NGN: A 52 year old male is brought to the emergency by his partner after the health care provider places prescriptions for further diagnostics click to indicate if the listed symptoms are consistent with angina, myocardial, infarction or both Feeling of fear Pain only relieved by opioids Pain relieved by nitroglycerin Epigastric distress Occurring without cause Chest pain radiating down arm Feeling of fear: Both Pain only relieved by opioids: MI Pain relieved by nitroglycerin: Angina Epigastric distress: MI Occurring without cause : both Chest pain radiating down arm: MI NGN 36 year old female For each body system clinc to Hight light the findings that require follow up Neurological: Alert and orientated to person place time and situation Report generalized fatigue Mild headache Ringing in described as roaring Cardiovascular: Normal heart tones Denies chest pain Pulses 3_ Pedal pulses 2_ Dorsalis pedis 2_ Capillary n seconds Gastrointestinal: Denies nausea, vomiting and diarrhea, anorexia with 8lbs unintentional Weight loss over 2 m denies blood in stool Genitourinary: Reported chronic dysmenorrhea with menstrual bleeding Denies pain with urination Denies urine Uterus is palpated one finger breadth above symphysis Neurological: reported generalized fatigue Mild headache Ringing in ears described as roaring Gastrointestinal: Anorexia with 8lbs unintentional weight loss over 2 months Genitourinary: Chronic dysmenorrhea with menstrual bleeding NGN: 36 year old female Each column must have a least one response option selected. Statement Iron deficiency anemia Folic acid deficiency Vitamin B12 deficiency Often associated with chronic alcoholism Can be caused by malabsorption syndrome Uptake often impeded by medications Result of dietary deficiency Decreased hemoglobin and hematocrit levels Often associated with chronic alcoholism: Folic acid, vitamin b12 can be caused by malabsorption syndrome: Folic acid, vitamin b12 Uptake often impeded by medications: Iron deficiency, folic acid, vitamin b12 Result of dietary deficiency: Iron deficiency, folic acid, Vitamin b12 Decreased hemoglobin and hematocrit levels: Iron deficiency, folic acid, vitamin b12 NGN: 36 year old female The nurse reviews the results of the testing and is preparing a plan of care for the client Choose the most likely option for the information missing from the statement by selecting from the list of options provided. The nurse recognizes that the client is most at risk for Select response (Drop down) anemia as evidenced by increased mean corpuscular volume and decreased folate Folic acid deficiency NGN: 36 year old female Select 5 foods that the nurse should encourage the client to integrate into her diet to best address the diagnosis of folic acid deficiency anemia A. Potatoes B. Beef C. Vegetable oil D. Enriched grains E. Peanuts F. Avocado G. Green leafy vegetables H. Orange juice D. Enriched grains E. Peanuts F. Avocado G. Green leafy vegetables H. Orange juice NGN: 36 year old female Which findings indicate that the client is adhering to the treatment plan? SATA A. Complete blood count B. Subjective report from client C.. Vital signs D. Body mass index E. Record of medication administration F. Physical assessment G. Meal diary B. Subjective report client E. Record of medication administration G. Meal diary A 76 year old female was brought to the ED by ambulance, She had been receiving home health care due to decreased mobility and poorly controlled type 2 diabetes BOWTIE Condition the client is most likely experiencing two actions the nurse should take to address that condition and two parameters the nurse should monitor to assess the clients progress Actions to take: Consult diabetic education Encourage ambulation Draw blood for STAT laboratory Prescriptions Educate on foot care Potential conditions: DVT Diabetic neuropathy Vascular disease Pulmonary embolism Parameters to monitor: Foot ulcer development Blood glucose Heparin therapy lung sounds Telemetry Actions to take: Draw blood for stat laboratory prescriptions Consult diabetic educator Potential conditions DVT Parameters to monitor Blood glucose Lung sounds A 78 year old male visits his primary healthcare provider reporting an increase in urinary urgency and frequency Choose the most likely options for the information missing from the statment by selecting from the lists of options provided The nurse recognizes that the client has _______ and________incontinence which may be caused by benign prostate hyperplasia (BPH) Stress Bladder retention Decreased urine production Overflow UTI functional overflow functional a 43 year old female arrives to the emergency department reporting pain in her abdomen BOWTIE Condition the client is most likely experiencing two actions the nurse should take to address that condition two parameters the nurse should monitor to assess the clients progress Actions to take Prepare for surgery Apply an abdominal binder Order low fat diet Transfer to high risk level of care Educate on Potential conditions Abdominal hernia Gallstones GERD Peptic ulcer disease Parameters to monitor: Surgical site signs and symptoms of abdominal perforation reflux pain Actions to take: Prepare for surgery Order low fat diet Potential conditions Gallstones Parameters to monitor Pain Signs and symptoms of abdominal perforation