BSN 266 MED SURG EXAM: Latest Update (2025/2026) Medical-
Surgical Nursing | Q&A | Grade A | 100% Correct (Verified Answers) –
Nightingale College
Subject: BSN 266 Med Surg – TURP, Pain Management, Blood Transfusion Reaction,
Diverticulosis, Cancer, Diabetes, Crohn's, Raynaud's, COPD, GERD, Glaucoma, AKI, Cirrhosis,
Pheochromocytoma, Stroke, ALS, Meningitis, Burns, and more.
Source: HESI BSN 266 Comprehensive Review / Nightingale College Med Surg Blueprint
Format: Q&A Guide with Clinical Rationale | 100% Verified
1: Client is recovering from a transurethral prostatectomy. Which activity should be limited
until after the first postoperative visit with the healthcare provider?
Correct Answer: Drink 3L of fluids (strenuous activity, heavy lifting, and driving are typically limited;
excessive fluid intake may be problematic but 3L is often encouraged. The question as written
suggests the answer is drinking 3L - but typically after TURP, driving and heavy lifting are limited.
Based on provided answer key: "Drink 3L" is listed as correct though clinically this is usually
encouraged.)
1. After TURP, patients are encouraged to drink large amounts of fluid to flush the bladder.
2. The limitation is typically on driving, heavy lifting, and sexual activity.
2: A client with stage IV bone cancer is admitted for pain (1-10 scale). Which intervention
should the nurse implement?
Correct Answer: Administer opioid and non-opioid medications simultaneously
1. Multimodal analgesia provides better pain control with lower opioid doses.
2. Combination of opioid + NSAID or acetaminophen addresses different pain mechanisms.
3: A client experiences an ABO incompatibility reaction after multiple blood transfusions.
Which finding should the nurse report immediately?
Correct Answer: a. low back pain and hypotension
1. Low back pain and hypotension are classic signs of acute hemolytic transfusion reaction.
2. Stop transfusion immediately, maintain IV line, notify provider.
4: For a client diagnosed with diverticulosis, which diet instruction should the nurse
include?
Correct Answer: c. Eat a high fiber diet and increase fluid intake
1. High fiber softens stool and reduces intraluminal pressure.
2. Fluid intake (8-10 glasses daily) helps fiber work effectively.
5: The nurse observes increased blood clots in drainage tubing of a client with continuous
bladder irrigation after TURP. What is the best initial nursing action?
Correct Answer: c. Increase the flow of the bladder irrigation
1. Increased flow helps flush clots and maintain catheter patency.
2. Monitor for outflow obstruction; manual irrigation if needed.
, 6: A client with lung cancer who wears a subcutaneous morphine sulfate patch is short of
breath and difficult to arouse. The nurse discovers four analgesic patches on the client.
What action should the nurse take?
Correct Answer: Remove all morphine patches
1. Overdose of opioid patches causes respiratory depression and altered mental status.
2. Remove all patches immediately; prepare for naloxone administration.
7: Coming down the basement steps, a client is brought to the ER. After cast application,
which assessment finding warrants immediate intervention?
Correct Answer: Right foot pale with sluggish capillary refill
1. Pallor and sluggish cap refill suggest compartment syndrome or vascular compromise.
2. Immediate notification required; possible cast splitting.
8: An overweight young adult with new type 2 DM is admitted for hernia repair. He
reports feeling weak and jittery. Which actions should the nurse implement? (SATA)
Correct Answer: a. Check finger stick glucose; b. Assess skin temperature and moisture; c. Measure
pulse and blood pressure
1. Weakness and jittery may indicate hypoglycemia.
2. Immediate glucose check; cold/clammy skin and tachycardia support hypoglycemia.
9: A client with cardiac stent placement 4 days ago reports sudden chest pressure and
shortness of breath. Which action should the nurse take next?
Correct Answer: d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring
1. Suspect acute coronary syndrome or stent thrombosis.
2. ECG is priority to identify ischemia or infarction.
10: A client with migraine headaches has bilateral hand grip weakness, joint pain, and
trouble twisting door knobs. Which action should the nurse take?
Correct Answer: c. Gather additional assessment data about the pain and weakness
1. Weakness with joint pain suggests possible autoimmune or inflammatory condition.
2. Collect more data before implementing interventions.
11: A client with psoriasis vulgaris receiving PUVA treatment. Which finding indicates
overexposure?
Correct Answer: b. Tenderness upon palpation and generalized erythema
1. Erythema and tenderness indicate phototoxic reaction from PUVA.
2. May require treatment interruption and dose adjustment.
12: An adult client 2 weeks post-gastric bypass with suspected anastomosis leakage
(tender abdomen, fever 101°F, HR 130, RR 26, BP 100/50). Which intervention is most
important?
Correct Answer: c. Strict IV fluid replacement
1. Hypotension and tachycardia indicate septic shock from leakage.
2. Fluid resuscitation is priority to maintain perfusion.
Surgical Nursing | Q&A | Grade A | 100% Correct (Verified Answers) –
Nightingale College
Subject: BSN 266 Med Surg – TURP, Pain Management, Blood Transfusion Reaction,
Diverticulosis, Cancer, Diabetes, Crohn's, Raynaud's, COPD, GERD, Glaucoma, AKI, Cirrhosis,
Pheochromocytoma, Stroke, ALS, Meningitis, Burns, and more.
Source: HESI BSN 266 Comprehensive Review / Nightingale College Med Surg Blueprint
Format: Q&A Guide with Clinical Rationale | 100% Verified
1: Client is recovering from a transurethral prostatectomy. Which activity should be limited
until after the first postoperative visit with the healthcare provider?
Correct Answer: Drink 3L of fluids (strenuous activity, heavy lifting, and driving are typically limited;
excessive fluid intake may be problematic but 3L is often encouraged. The question as written
suggests the answer is drinking 3L - but typically after TURP, driving and heavy lifting are limited.
Based on provided answer key: "Drink 3L" is listed as correct though clinically this is usually
encouraged.)
1. After TURP, patients are encouraged to drink large amounts of fluid to flush the bladder.
2. The limitation is typically on driving, heavy lifting, and sexual activity.
2: A client with stage IV bone cancer is admitted for pain (1-10 scale). Which intervention
should the nurse implement?
Correct Answer: Administer opioid and non-opioid medications simultaneously
1. Multimodal analgesia provides better pain control with lower opioid doses.
2. Combination of opioid + NSAID or acetaminophen addresses different pain mechanisms.
3: A client experiences an ABO incompatibility reaction after multiple blood transfusions.
Which finding should the nurse report immediately?
Correct Answer: a. low back pain and hypotension
1. Low back pain and hypotension are classic signs of acute hemolytic transfusion reaction.
2. Stop transfusion immediately, maintain IV line, notify provider.
4: For a client diagnosed with diverticulosis, which diet instruction should the nurse
include?
Correct Answer: c. Eat a high fiber diet and increase fluid intake
1. High fiber softens stool and reduces intraluminal pressure.
2. Fluid intake (8-10 glasses daily) helps fiber work effectively.
5: The nurse observes increased blood clots in drainage tubing of a client with continuous
bladder irrigation after TURP. What is the best initial nursing action?
Correct Answer: c. Increase the flow of the bladder irrigation
1. Increased flow helps flush clots and maintain catheter patency.
2. Monitor for outflow obstruction; manual irrigation if needed.
, 6: A client with lung cancer who wears a subcutaneous morphine sulfate patch is short of
breath and difficult to arouse. The nurse discovers four analgesic patches on the client.
What action should the nurse take?
Correct Answer: Remove all morphine patches
1. Overdose of opioid patches causes respiratory depression and altered mental status.
2. Remove all patches immediately; prepare for naloxone administration.
7: Coming down the basement steps, a client is brought to the ER. After cast application,
which assessment finding warrants immediate intervention?
Correct Answer: Right foot pale with sluggish capillary refill
1. Pallor and sluggish cap refill suggest compartment syndrome or vascular compromise.
2. Immediate notification required; possible cast splitting.
8: An overweight young adult with new type 2 DM is admitted for hernia repair. He
reports feeling weak and jittery. Which actions should the nurse implement? (SATA)
Correct Answer: a. Check finger stick glucose; b. Assess skin temperature and moisture; c. Measure
pulse and blood pressure
1. Weakness and jittery may indicate hypoglycemia.
2. Immediate glucose check; cold/clammy skin and tachycardia support hypoglycemia.
9: A client with cardiac stent placement 4 days ago reports sudden chest pressure and
shortness of breath. Which action should the nurse take next?
Correct Answer: d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring
1. Suspect acute coronary syndrome or stent thrombosis.
2. ECG is priority to identify ischemia or infarction.
10: A client with migraine headaches has bilateral hand grip weakness, joint pain, and
trouble twisting door knobs. Which action should the nurse take?
Correct Answer: c. Gather additional assessment data about the pain and weakness
1. Weakness with joint pain suggests possible autoimmune or inflammatory condition.
2. Collect more data before implementing interventions.
11: A client with psoriasis vulgaris receiving PUVA treatment. Which finding indicates
overexposure?
Correct Answer: b. Tenderness upon palpation and generalized erythema
1. Erythema and tenderness indicate phototoxic reaction from PUVA.
2. May require treatment interruption and dose adjustment.
12: An adult client 2 weeks post-gastric bypass with suspected anastomosis leakage
(tender abdomen, fever 101°F, HR 130, RR 26, BP 100/50). Which intervention is most
important?
Correct Answer: c. Strict IV fluid replacement
1. Hypotension and tachycardia indicate septic shock from leakage.
2. Fluid resuscitation is priority to maintain perfusion.
