Page |1
MED SURG HESI BSN 266 EXAM 2025 ACTUAL
EXAM QUESTIONS WITH 100% CORRECT
SOLUTIONS | GUARANTEED SUCCESS.
A newly graduated and licensed registered nurse (RN) is in the
second day of orientation to the hospital unit. The education director
tells the charge nurse that the new graduate should be assigned to
care for one client. Which client is best for the nurse to assign to this
new graduate?
A client who is 4-days post myocardial infarction
A female who was admitted for alcohol detoxification is nauseated
and describes feeling like roaches are crawling all over her. She is
tremulous, and her blood pressure is 146/92; her pulse rate is 94
beats/minute; and her temperature is 100.8oF. Which PRN medication
should the nurse administer first?
Lorazepam (Ativan)
A male client with bipolar disorder has difficulty concentrating and
plans to attend group for the first time. He tells the nurse that he will
try to stay for the music relaxation group. After 20 minutes in the
group, he becomes restless and begins to leave. What should the
nurse do
Allow the client to leave the group
A 60 yr old male with type 2 DM tells the nurse that he is going to join
a gym and start working out. Which information is most important for
the nurse to obtain?
Exercise tolerance test with EKG results
A client is receiving an IV infusion of regular insulin, 75 units in 100
ml of normal saline at 9 units per hr. The nurse should program the
pump to deliver how many ml/hr?
12
, Page |2
Which technique(s) should the nurse use to administer an intradermal
(ID) injection for a Mantoux test to screen for tuberculosis (TB)?
Ensure that the needle is inserted into the skin with the bevel up
Use a 25 gauge ½ inch needle on a 1 ml calibrated syringe
Assess skin for a bleb when injecting the tuberculin antigen (ID)
Following rectal surgery, a female client seems very anxious about
the pain that she may experience during defecation. The nurse should
collaborate with HCP to administer which type of medication?
stool softener
Which nursing entry to the client record best reflects significant data
on a male client who admitted with complaints of chest pain?
Client states he will notify the nurse if chest pain returns
A 37 year old client diagnosed with chronic kidney disease (CKD) is
being treated for renal osteodystrophy. Which nursing diagnosis is
most likely to be included in this client's plan of care?
High risk for injury related to ambulation
To assess for the presence of diaphragmatic breathing, what action
should the nurse take
Observe the movement of the abdomen
The nurse and a social worker are talking when a male client with
psychosis angrily shouts at the nurse, "Stop talking about me." The
nurse should document the client is exhibiting which symptom
Ideas of reference
Before administering a parenteral nutrition solution through a central
vein, the nurse should confirm information from which sources
Client’s identification band
Healthcare provider’s prescription
Solution label
Medication administration record
, Page |3
A male client with chronic asthma tells the nurse that he is having
more episodes of bronchoconstiction and increased mucous
production. Which action should the nurse implement?
Determine if rescue inhaler is being used first during an acute episode
The nurse plans to administer 5,000 units of heparin, an
anticoagulant. Which procedure should the nurse implement when
administering this drug?
Assess all needle insertion sites daily for hematoma and signs of
inflammation
A frail, elderly female with rheumatoid arthritis (RA) complains to the
nurse that the weight of the sheets on her legs hurts all the time.
Which action should the nurse implement ?
Use a bed cradle to keep linens off her legs
After administering a proton pump inhibitor (PPI), which action
should the nurse take to evaluate the effectiveness of the medication?
Ask the client about gastrointestinal pain
The nurse on a busy surgical unit is assigning client care to a
registered nurse (RN) and a practical nurse (PN). Which client is best
to assign to the PN?
A preoperative client who has developed urinary retention and needs a
urinary catheter inserted
Nurse overhears 2 employees discussing confidential pt info in
cafeteria. Breach of which ethical principle?
fidelity
Preparing to administer liter of IV solution to toddler with
gastroenteritis who is dehydrated. Which action to prevent overload?
Attached a volume-control device below the primary infusion
Teaching using a Holter monitor, which statement indicates
understanding the procedure?
“I must record any symptoms occurring with my activity”
, Page |4
Female diagnosed with major depression admitted to psych unit.
Refuses to take a bath, dress, eat, and wants to sleep during day.
Which intervention?
Provide and maintain a safe, structured daily routine
Pt with chronic controlled A-fib develops symptoms of PE. What
intervention?
Monitor O2 saturation via pulse Ox
School-aged child with OM receives Rx for Azithromycin 300mg once,
then 150 mg daily for 4 days. Med is avail in solution containing
200mg/5ml. How many mls should nurse administer on the 1st day of
Tx?
7.5ml
Which assessment is most important for the nurse to perform before
ambulating a client with a history of syncope?
Blood pressure
A male client with schizophrenia is jerking his neck and smacking his
lips. Which finding indicates to the nurse that he is experiencing an
irreversible side effect of antipsychotic agents?
Worming movements of tongue
What assessment data should lead the nurse to suspect that a client
has progressed from HIV infection to AIDS?
Recent history of recurrent pneumonia
Which assessment finding is most indicative of deep vein thrombosis
(DVT) in a client's right leg
Right calf is 3 cm larger in circumference than the left
The nurse is caring for a client with jaundice. Which serum laboratory
value is likely to be elevated for this client?
bilirubin
MED SURG HESI BSN 266 EXAM 2025 ACTUAL
EXAM QUESTIONS WITH 100% CORRECT
SOLUTIONS | GUARANTEED SUCCESS.
A newly graduated and licensed registered nurse (RN) is in the
second day of orientation to the hospital unit. The education director
tells the charge nurse that the new graduate should be assigned to
care for one client. Which client is best for the nurse to assign to this
new graduate?
A client who is 4-days post myocardial infarction
A female who was admitted for alcohol detoxification is nauseated
and describes feeling like roaches are crawling all over her. She is
tremulous, and her blood pressure is 146/92; her pulse rate is 94
beats/minute; and her temperature is 100.8oF. Which PRN medication
should the nurse administer first?
Lorazepam (Ativan)
A male client with bipolar disorder has difficulty concentrating and
plans to attend group for the first time. He tells the nurse that he will
try to stay for the music relaxation group. After 20 minutes in the
group, he becomes restless and begins to leave. What should the
nurse do
Allow the client to leave the group
A 60 yr old male with type 2 DM tells the nurse that he is going to join
a gym and start working out. Which information is most important for
the nurse to obtain?
Exercise tolerance test with EKG results
A client is receiving an IV infusion of regular insulin, 75 units in 100
ml of normal saline at 9 units per hr. The nurse should program the
pump to deliver how many ml/hr?
12
, Page |2
Which technique(s) should the nurse use to administer an intradermal
(ID) injection for a Mantoux test to screen for tuberculosis (TB)?
Ensure that the needle is inserted into the skin with the bevel up
Use a 25 gauge ½ inch needle on a 1 ml calibrated syringe
Assess skin for a bleb when injecting the tuberculin antigen (ID)
Following rectal surgery, a female client seems very anxious about
the pain that she may experience during defecation. The nurse should
collaborate with HCP to administer which type of medication?
stool softener
Which nursing entry to the client record best reflects significant data
on a male client who admitted with complaints of chest pain?
Client states he will notify the nurse if chest pain returns
A 37 year old client diagnosed with chronic kidney disease (CKD) is
being treated for renal osteodystrophy. Which nursing diagnosis is
most likely to be included in this client's plan of care?
High risk for injury related to ambulation
To assess for the presence of diaphragmatic breathing, what action
should the nurse take
Observe the movement of the abdomen
The nurse and a social worker are talking when a male client with
psychosis angrily shouts at the nurse, "Stop talking about me." The
nurse should document the client is exhibiting which symptom
Ideas of reference
Before administering a parenteral nutrition solution through a central
vein, the nurse should confirm information from which sources
Client’s identification band
Healthcare provider’s prescription
Solution label
Medication administration record
, Page |3
A male client with chronic asthma tells the nurse that he is having
more episodes of bronchoconstiction and increased mucous
production. Which action should the nurse implement?
Determine if rescue inhaler is being used first during an acute episode
The nurse plans to administer 5,000 units of heparin, an
anticoagulant. Which procedure should the nurse implement when
administering this drug?
Assess all needle insertion sites daily for hematoma and signs of
inflammation
A frail, elderly female with rheumatoid arthritis (RA) complains to the
nurse that the weight of the sheets on her legs hurts all the time.
Which action should the nurse implement ?
Use a bed cradle to keep linens off her legs
After administering a proton pump inhibitor (PPI), which action
should the nurse take to evaluate the effectiveness of the medication?
Ask the client about gastrointestinal pain
The nurse on a busy surgical unit is assigning client care to a
registered nurse (RN) and a practical nurse (PN). Which client is best
to assign to the PN?
A preoperative client who has developed urinary retention and needs a
urinary catheter inserted
Nurse overhears 2 employees discussing confidential pt info in
cafeteria. Breach of which ethical principle?
fidelity
Preparing to administer liter of IV solution to toddler with
gastroenteritis who is dehydrated. Which action to prevent overload?
Attached a volume-control device below the primary infusion
Teaching using a Holter monitor, which statement indicates
understanding the procedure?
“I must record any symptoms occurring with my activity”
, Page |4
Female diagnosed with major depression admitted to psych unit.
Refuses to take a bath, dress, eat, and wants to sleep during day.
Which intervention?
Provide and maintain a safe, structured daily routine
Pt with chronic controlled A-fib develops symptoms of PE. What
intervention?
Monitor O2 saturation via pulse Ox
School-aged child with OM receives Rx for Azithromycin 300mg once,
then 150 mg daily for 4 days. Med is avail in solution containing
200mg/5ml. How many mls should nurse administer on the 1st day of
Tx?
7.5ml
Which assessment is most important for the nurse to perform before
ambulating a client with a history of syncope?
Blood pressure
A male client with schizophrenia is jerking his neck and smacking his
lips. Which finding indicates to the nurse that he is experiencing an
irreversible side effect of antipsychotic agents?
Worming movements of tongue
What assessment data should lead the nurse to suspect that a client
has progressed from HIV infection to AIDS?
Recent history of recurrent pneumonia
Which assessment finding is most indicative of deep vein thrombosis
(DVT) in a client's right leg
Right calf is 3 cm larger in circumference than the left
The nurse is caring for a client with jaundice. Which serum laboratory
value is likely to be elevated for this client?
bilirubin
