BSN HESI 266 Med Surg Exam 2026/2027 |
Nightingale | Verified Questions & Answers |
100% Correct | Grade A
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.
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."
A. "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant."
Rationale
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.
,After checking the urinary drainage system for kinks in the tubing, the nurse determines that a
client who has returned from the post-anesthesia care has a dark, concentrated urinary output
of 54 ml for the last 2 hours. What priority nursing action should be implemented?
A. Report the findings to the surgeon.
B. Irrigate the indwelling urinary catheter.
C. Apply manual pressure to the bladder.
D. Increase the IV flow rate for 15 minutes.
A. Report the findings to the surgeon.
Rationale
An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly (1
ml/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the
surgeon.
A male client who smokes two packs of cigarettes a day states he understands that smoking
cigarettes is contributing to the difficulty that he and his wife are having in getting pregnant and
wants to know if other factors could be contributing to their difficulty. What information is best
for the nurse to provide? (Select all that apply.)
Select all that apply
A. Marijuana cigarettes do not affect sperm count.
B. Alcohol consumption can cause erectile dysfunction.
C. Low testosterone levels affect sperm production.
D. Cessation of smoking improves general health and fertility.
E. Obesity has no effect on sperm production.
B, C and D
Rationale
Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively
affected by low testerone levels and obesity.
,A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux
during sleep. Which recommendation by the nurse is most effective to assist the client?
A. Losing weight.
B. Decreasing caffeine intake.
C. Avoiding large meals.
D. Raising the head of the bed on blocks.
D. Raising the head of the bed on blocks.
Rationale
Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce reflux and
subsequent aspiration is the most non-pharmacological effective recommendation for a client
experiencing severe gastroesophageal reflux during sleep.
A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30 pounds
overweight is diagnosed with having a gastric ulcer. What content is most important for the
nurse to include in the discharge teaching for this client?
A. Information about smoking cessation.
B. Diet instructions for a low-residue diet.
C. Instructions on a weight-loss program.
D. The importance of increasing milk in the diet.
A. Information about smoking cessation.
Rationale
Smoking has been associated with ulcer formation, and stopping or decreasing the number of
cigarettes smoked per day is an important aspect of ulcer management.
What types of medications should the nurse expect to administer to a client during an acute
respiratory distress episode?
A. Vasodilators and hormones.
B. Analgesics and sedatives.
, C. Anticoagulants and expectorants.
D. Bronchodilators and steroids.
D. Bronchodilators and steroids.
Rationale
Besides supplemental oxygen, this client with ARDS needs medications to widen air passages,
increase air space, and reduce alveolar membrane inflammation, such as bronchodilators and
steroids.
A female client is brought to the clinic by her daughter for a flu shot. She has lost significant
weight since the last visit. She has poor personal hygiene and inadequate clothing for the
weather. The client states that she lives alone and denies problems or concerns. What action
should the nurse implement?
A. Notify social services immediately of suspected elderly abuse.
B. Discuss the need for mental health counseling with the daughter.
C. Explain to the client that she needs to take better care of herself.
D. Collect further data to determine whether self-neglect is occurring.
D. Collect further data to determine whether self-neglect is occurring.
Rationale
Changes in weight and hygiene may be indicators of self-neglect or neglect by family members.
Further assessment is needed before notifying social services or discussing a need for
counseling.
The nurse is assisting a client out of bed for the first time after surgery. What action should the
nurse do first?
A. Place a chair at a right angle to the bedside.
B. Encourage deep breathing prior to standing.
C. Help the client to sit and dangle legs on the side of the bed.
D. Allow the client to sit with the bed in a high Fowler's position.
D. Allow the client to sit with the bed in a high Fowler's position.
Rationale
Nightingale | Verified Questions & Answers |
100% Correct | Grade A
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.
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."
A. "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant."
Rationale
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.
,After checking the urinary drainage system for kinks in the tubing, the nurse determines that a
client who has returned from the post-anesthesia care has a dark, concentrated urinary output
of 54 ml for the last 2 hours. What priority nursing action should be implemented?
A. Report the findings to the surgeon.
B. Irrigate the indwelling urinary catheter.
C. Apply manual pressure to the bladder.
D. Increase the IV flow rate for 15 minutes.
A. Report the findings to the surgeon.
Rationale
An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly (1
ml/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the
surgeon.
A male client who smokes two packs of cigarettes a day states he understands that smoking
cigarettes is contributing to the difficulty that he and his wife are having in getting pregnant and
wants to know if other factors could be contributing to their difficulty. What information is best
for the nurse to provide? (Select all that apply.)
Select all that apply
A. Marijuana cigarettes do not affect sperm count.
B. Alcohol consumption can cause erectile dysfunction.
C. Low testosterone levels affect sperm production.
D. Cessation of smoking improves general health and fertility.
E. Obesity has no effect on sperm production.
B, C and D
Rationale
Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively
affected by low testerone levels and obesity.
,A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux
during sleep. Which recommendation by the nurse is most effective to assist the client?
A. Losing weight.
B. Decreasing caffeine intake.
C. Avoiding large meals.
D. Raising the head of the bed on blocks.
D. Raising the head of the bed on blocks.
Rationale
Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce reflux and
subsequent aspiration is the most non-pharmacological effective recommendation for a client
experiencing severe gastroesophageal reflux during sleep.
A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30 pounds
overweight is diagnosed with having a gastric ulcer. What content is most important for the
nurse to include in the discharge teaching for this client?
A. Information about smoking cessation.
B. Diet instructions for a low-residue diet.
C. Instructions on a weight-loss program.
D. The importance of increasing milk in the diet.
A. Information about smoking cessation.
Rationale
Smoking has been associated with ulcer formation, and stopping or decreasing the number of
cigarettes smoked per day is an important aspect of ulcer management.
What types of medications should the nurse expect to administer to a client during an acute
respiratory distress episode?
A. Vasodilators and hormones.
B. Analgesics and sedatives.
, C. Anticoagulants and expectorants.
D. Bronchodilators and steroids.
D. Bronchodilators and steroids.
Rationale
Besides supplemental oxygen, this client with ARDS needs medications to widen air passages,
increase air space, and reduce alveolar membrane inflammation, such as bronchodilators and
steroids.
A female client is brought to the clinic by her daughter for a flu shot. She has lost significant
weight since the last visit. She has poor personal hygiene and inadequate clothing for the
weather. The client states that she lives alone and denies problems or concerns. What action
should the nurse implement?
A. Notify social services immediately of suspected elderly abuse.
B. Discuss the need for mental health counseling with the daughter.
C. Explain to the client that she needs to take better care of herself.
D. Collect further data to determine whether self-neglect is occurring.
D. Collect further data to determine whether self-neglect is occurring.
Rationale
Changes in weight and hygiene may be indicators of self-neglect or neglect by family members.
Further assessment is needed before notifying social services or discussing a need for
counseling.
The nurse is assisting a client out of bed for the first time after surgery. What action should the
nurse do first?
A. Place a chair at a right angle to the bedside.
B. Encourage deep breathing prior to standing.
C. Help the client to sit and dangle legs on the side of the bed.
D. Allow the client to sit with the bed in a high Fowler's position.
D. Allow the client to sit with the bed in a high Fowler's position.
Rationale
