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BSN 266 Hesi || Complete Comprehensive Questions 2026-2027
BANK QUESTIONS WITH DETAILED VERIFIED ANSWERS
EXAM QUESTIONS WILL COME FROM HERE (100%
CORRECT ANSWERS A+ GRADED
1. A nurse is assessing a client with left-sided heart failure. Which
finding should the nurse expect?
A. Jugular venous distention
B. Dependent edema
C. Crackles in the lung bases
D. Hepatomegaly
Answer: C. Crackles in the lung bases
Rationale: Left-sided heart failure results in pulmonary congestion due
to the left ventricle's inability to effectively pump blood forward into
the systemic circulation. Blood backs up into the pulmonary
vasculature, causing fluid to leak into the alveoli, which manifests as
crackles on auscultation. Jugular venous distention, dependent edema,
and hepatomegaly are characteristic of right-sided heart failure, which
results from systemic venous congestion.
2. A client is receiving intravenous heparin for a deep vein thrombosis.
The nurse should have which antidote available?
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A. Vitamin K
B. Protamine sulfate
C. Naloxone
D. Flumazenil
Answer: B. Protamine sulfate
Rationale: Protamine sulfate is the specific reversal agent for heparin. It
binds to heparin, forming a stable complex that neutralizes the
anticoagulant effect. Vitamin K is the antidote for warfarin. Naloxone
reverses opioid effects, and flumazenil is the benzodiazepine
antagonist.
3. A client reports crushing substernal chest pain radiating to the left
arm. The nurse administers one nitroglycerin tablet sublingually. After
five minutes, the pain is unrelieved. What is the priority nursing action?
A. Administer a second nitroglycerin tablet
B. Obtain a 12-lead electrocardiogram
C. Notify the healthcare provider immediately
D. Administer morphine sulfate as prescribed
Answer: A. Administer a second nitroglycerin tablet
Rationale: Current American Heart Association guidelines recommend
administering up to three doses of sublingual nitroglycerin at five-
minute intervals for ongoing chest pain, provided the client remains
hemodynamically stable and blood pressure is adequate. If pain persists
after the first dose, administering a second dose is appropriate. The
healthcare provider should be notified if pain persists after three doses.
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An ECG should be obtained promptly, but pain relief is the immediate
priority.
RESPIRATORY
4. A nurse is caring for a client with a chest tube connected to a water-
seal drainage system. Continuous bubbling is observed in the water-
seal chamber. What does this finding indicate?
A. Normal functioning of the system
B. Tracheobronchial obstruction
C. A leak in the drainage system
D. Subcutaneous emphysema resolving
Answer: C. A leak in the drainage system
Rationale: Continuous bubbling in the water-seal chamber indicates an
air leak in the chest tube system. Bubbling in this chamber should be
intermittent, occurring with exhalation or coughing when the lung has
not yet fully re-expanded. Continuous bubbling suggests air is entering
the system somewhere between the client and the drainage chamber.
The nurse should systematically check connections and the insertion
site. Gentle, continuous bubbling in the suction control chamber is
normal and indicates that suction is functioning.
5. A client with status asthmaticus is receiving albuterol via nebulizer.
The nurse should monitor for which adverse effect?
A. Bradycardia
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B. Tremors and tachycardia
C. Drowsiness
D. Hypotension
Answer: B. Tremors and tachycardia
Rationale: Albuterol is a short-acting beta-2 adrenergic agonist, but it
also produces some beta-1 stimulation. Expected adverse effects
include tachycardia, palpitations, tremors, and nervousness due to
sympathetic nervous system activation. Bradycardia, drowsiness, and
hypotension are not typical adverse effects of albuterol.
6. A client with a pulmonary embolism suddenly develops severe
dyspnea, tachypnea, and cyanosis. The nurse auscultates crackles and a
new S3 heart sound. What complication does the nurse suspect?
A. Tension pneumothorax
B. Acute respiratory distress syndrome
C. Right ventricular failure
D. Pulmonary fibrosis
Answer: C. Right ventricular failure
Rationale: A massive pulmonary embolism increases pulmonary
vascular resistance, forcing the right ventricle to pump against elevated
pressures. The right ventricle can acutely fail under this strain, leading
to decreased cardiac output. Signs include severe dyspnea, cyanosis,
jugular venous distention, an S3 gallop, and eventually shock. This
condition, known as acute cor pulmonale, is life-threatening and
requires immediate intervention.
BSN 266 Hesi || Complete Comprehensive Questions 2026-2027
BANK QUESTIONS WITH DETAILED VERIFIED ANSWERS
EXAM QUESTIONS WILL COME FROM HERE (100%
CORRECT ANSWERS A+ GRADED
1. A nurse is assessing a client with left-sided heart failure. Which
finding should the nurse expect?
A. Jugular venous distention
B. Dependent edema
C. Crackles in the lung bases
D. Hepatomegaly
Answer: C. Crackles in the lung bases
Rationale: Left-sided heart failure results in pulmonary congestion due
to the left ventricle's inability to effectively pump blood forward into
the systemic circulation. Blood backs up into the pulmonary
vasculature, causing fluid to leak into the alveoli, which manifests as
crackles on auscultation. Jugular venous distention, dependent edema,
and hepatomegaly are characteristic of right-sided heart failure, which
results from systemic venous congestion.
2. A client is receiving intravenous heparin for a deep vein thrombosis.
The nurse should have which antidote available?
,2|Page
A. Vitamin K
B. Protamine sulfate
C. Naloxone
D. Flumazenil
Answer: B. Protamine sulfate
Rationale: Protamine sulfate is the specific reversal agent for heparin. It
binds to heparin, forming a stable complex that neutralizes the
anticoagulant effect. Vitamin K is the antidote for warfarin. Naloxone
reverses opioid effects, and flumazenil is the benzodiazepine
antagonist.
3. A client reports crushing substernal chest pain radiating to the left
arm. The nurse administers one nitroglycerin tablet sublingually. After
five minutes, the pain is unrelieved. What is the priority nursing action?
A. Administer a second nitroglycerin tablet
B. Obtain a 12-lead electrocardiogram
C. Notify the healthcare provider immediately
D. Administer morphine sulfate as prescribed
Answer: A. Administer a second nitroglycerin tablet
Rationale: Current American Heart Association guidelines recommend
administering up to three doses of sublingual nitroglycerin at five-
minute intervals for ongoing chest pain, provided the client remains
hemodynamically stable and blood pressure is adequate. If pain persists
after the first dose, administering a second dose is appropriate. The
healthcare provider should be notified if pain persists after three doses.
,3|Page
An ECG should be obtained promptly, but pain relief is the immediate
priority.
RESPIRATORY
4. A nurse is caring for a client with a chest tube connected to a water-
seal drainage system. Continuous bubbling is observed in the water-
seal chamber. What does this finding indicate?
A. Normal functioning of the system
B. Tracheobronchial obstruction
C. A leak in the drainage system
D. Subcutaneous emphysema resolving
Answer: C. A leak in the drainage system
Rationale: Continuous bubbling in the water-seal chamber indicates an
air leak in the chest tube system. Bubbling in this chamber should be
intermittent, occurring with exhalation or coughing when the lung has
not yet fully re-expanded. Continuous bubbling suggests air is entering
the system somewhere between the client and the drainage chamber.
The nurse should systematically check connections and the insertion
site. Gentle, continuous bubbling in the suction control chamber is
normal and indicates that suction is functioning.
5. A client with status asthmaticus is receiving albuterol via nebulizer.
The nurse should monitor for which adverse effect?
A. Bradycardia
, 4|Page
B. Tremors and tachycardia
C. Drowsiness
D. Hypotension
Answer: B. Tremors and tachycardia
Rationale: Albuterol is a short-acting beta-2 adrenergic agonist, but it
also produces some beta-1 stimulation. Expected adverse effects
include tachycardia, palpitations, tremors, and nervousness due to
sympathetic nervous system activation. Bradycardia, drowsiness, and
hypotension are not typical adverse effects of albuterol.
6. A client with a pulmonary embolism suddenly develops severe
dyspnea, tachypnea, and cyanosis. The nurse auscultates crackles and a
new S3 heart sound. What complication does the nurse suspect?
A. Tension pneumothorax
B. Acute respiratory distress syndrome
C. Right ventricular failure
D. Pulmonary fibrosis
Answer: C. Right ventricular failure
Rationale: A massive pulmonary embolism increases pulmonary
vascular resistance, forcing the right ventricle to pump against elevated
pressures. The right ventricle can acutely fail under this strain, leading
to decreased cardiac output. Signs include severe dyspnea, cyanosis,
jugular venous distention, an S3 gallop, and eventually shock. This
condition, known as acute cor pulmonale, is life-threatening and
requires immediate intervention.
