BSN HESI 266 MED SURG
ACTUAL EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS GRADED
A+ LATEST EXAM UPDATE
Question 11 of 55
The nurse is providing discharge teaching to an older adult client hospitalized
for treatment of venous leg ulcers. Which instruction(s) should the nurse include
in the teaching plan? (Select all that apply.)
- A Inspect ankles daily for areas of darkening skin.
- B Apply intermittent cold compresses four times daily.
- C Keep legs elevated when sitting or lying down.
- D Maintain bed rest as much as possible.
- E Eat a diet that is high in protein and vitamins A and C. - ✔✔✔
Correct Answer > - A: Inspect ankles daily for areas of darkening skin.
Regular inspection can help detect any changes or worsening of the condition
early.
- C: Keep legs elevated when sitting or lying down.
Elevation can help reduce swelling and improve blood circulation.
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,- E: Eat a diet that is high in protein and vitamins A and C.
A nutritious diet can support wound healing and overall health.
The nurse should not include the following instructions:
B: Apply intermittent cold compresses four times daily. There is no evidence
from the search results that cold compresses are beneficial for venous leg ulcers.
- D: Maintain bed rest as much as possible. On the contrary, physical
activity, such as walking, can promote blood circulation and aid in wound
healing.
Question 12 of 55
An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with
possible anastomosis leakage. The client's abdomen is tender to touch, and the
vital signs are: temperature 101° F (38.3° C), heart rate 130 beats/minute,
respiratory rate 26 breaths/minute, and blood pressure 100/50 mm Hg. Which
intervention is most important for the nurse to include in the client's plan of
care?
- A Encourage regular turning.
- B Assess wound drainage daily.
- C Monitor skin for breakdown.
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,- D Strict intravenous (IV) fluid replacement. - ✔✔✔ Correct Answer > -
D Strict intravenous (IV) fluid replacement.
The most important intervention for the nurse to include in the client's plan of
care, who is suspected of anastomosis leakage post gastric bypass surgery, is D:
Strict intravenous (IV) fluid replacement. This is crucial as the client's vital
signs indicate possible sepsis due to infection, which can lead to severe
dehydration. IV fluid replacement can help maintain the client's blood pressure
and prevent further complications.
While interventions A, B, and C (Encourage regular turning, Assess wound
drainage daily, Monitor skin for breakdown) are generally important in
postoperative care, they are not the most critical in this specific situation of
suspected anastomotic leakage.
Question 13 of 55
A client receives a prescription for 1 liter of 0.9% sodium chloride, USP
intravenously (IV) to be infused over 4 hours. The IV administration set
delivers 10 gtt/mL. How many gtt/min should the nurse regulate the infusion?
(Enter numerical value only. If rounding is required, round to the nearest whole
number) - ✔✔✔ Correct Answer > 42
Question 14 of 55
A client arrives to the emergency department reporting an intermittent fever and
night sweats for the past 3 weeks and has developed a productive cough
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, containing small amounts of blood. Which intervention should the nurse
prioritize?
- A Collect specimens for blood cultures.
B Obtain a sputum sample.
- C Arrange transport for radiographic imaging.
- D Move into airborne isolation. - ✔✔✔ Correct Answer > - D Move into
airborne isolation.
Airborne - think MTV: Measles, TB, Varicella
Question 15 of 55
A client presents to the emergency department reporting chest pain that is
radiating to the left arm, shortness of breath, and diaphoresis. Which medication
should the nurse anticipate being prescribed by the healthcare provider?
- A Fentanyl.
- B Oxycodone.
- C Morphine.
- D Hydromorphone. - ✔✔✔ Correct Answer > - C Morphine.
Question 16 of 55
Page 4 of 71
ACTUAL EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS GRADED
A+ LATEST EXAM UPDATE
Question 11 of 55
The nurse is providing discharge teaching to an older adult client hospitalized
for treatment of venous leg ulcers. Which instruction(s) should the nurse include
in the teaching plan? (Select all that apply.)
- A Inspect ankles daily for areas of darkening skin.
- B Apply intermittent cold compresses four times daily.
- C Keep legs elevated when sitting or lying down.
- D Maintain bed rest as much as possible.
- E Eat a diet that is high in protein and vitamins A and C. - ✔✔✔
Correct Answer > - A: Inspect ankles daily for areas of darkening skin.
Regular inspection can help detect any changes or worsening of the condition
early.
- C: Keep legs elevated when sitting or lying down.
Elevation can help reduce swelling and improve blood circulation.
Page 1 of 71
,- E: Eat a diet that is high in protein and vitamins A and C.
A nutritious diet can support wound healing and overall health.
The nurse should not include the following instructions:
B: Apply intermittent cold compresses four times daily. There is no evidence
from the search results that cold compresses are beneficial for venous leg ulcers.
- D: Maintain bed rest as much as possible. On the contrary, physical
activity, such as walking, can promote blood circulation and aid in wound
healing.
Question 12 of 55
An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with
possible anastomosis leakage. The client's abdomen is tender to touch, and the
vital signs are: temperature 101° F (38.3° C), heart rate 130 beats/minute,
respiratory rate 26 breaths/minute, and blood pressure 100/50 mm Hg. Which
intervention is most important for the nurse to include in the client's plan of
care?
- A Encourage regular turning.
- B Assess wound drainage daily.
- C Monitor skin for breakdown.
Page 2 of 71
,- D Strict intravenous (IV) fluid replacement. - ✔✔✔ Correct Answer > -
D Strict intravenous (IV) fluid replacement.
The most important intervention for the nurse to include in the client's plan of
care, who is suspected of anastomosis leakage post gastric bypass surgery, is D:
Strict intravenous (IV) fluid replacement. This is crucial as the client's vital
signs indicate possible sepsis due to infection, which can lead to severe
dehydration. IV fluid replacement can help maintain the client's blood pressure
and prevent further complications.
While interventions A, B, and C (Encourage regular turning, Assess wound
drainage daily, Monitor skin for breakdown) are generally important in
postoperative care, they are not the most critical in this specific situation of
suspected anastomotic leakage.
Question 13 of 55
A client receives a prescription for 1 liter of 0.9% sodium chloride, USP
intravenously (IV) to be infused over 4 hours. The IV administration set
delivers 10 gtt/mL. How many gtt/min should the nurse regulate the infusion?
(Enter numerical value only. If rounding is required, round to the nearest whole
number) - ✔✔✔ Correct Answer > 42
Question 14 of 55
A client arrives to the emergency department reporting an intermittent fever and
night sweats for the past 3 weeks and has developed a productive cough
Page 3 of 71
, containing small amounts of blood. Which intervention should the nurse
prioritize?
- A Collect specimens for blood cultures.
B Obtain a sputum sample.
- C Arrange transport for radiographic imaging.
- D Move into airborne isolation. - ✔✔✔ Correct Answer > - D Move into
airborne isolation.
Airborne - think MTV: Measles, TB, Varicella
Question 15 of 55
A client presents to the emergency department reporting chest pain that is
radiating to the left arm, shortness of breath, and diaphoresis. Which medication
should the nurse anticipate being prescribed by the healthcare provider?
- A Fentanyl.
- B Oxycodone.
- C Morphine.
- D Hydromorphone. - ✔✔✔ Correct Answer > - C Morphine.
Question 16 of 55
Page 4 of 71
