BSN 266 / NEWEST ACTUAL EXAM COMPLETE 100+ QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES(REAL DEAL) GRADE A+ ASSURED.
Question 1
A client is recovering from a transurethral resection of the prostate (TURP). Which activity
should be limited until after the first postoperative visit with the healthcare provider?
A) Driving a car.
B) Drinking at least 2 L of fluid per day.
C) Walking short distances.
D) Performing Kegel exercises.
Correct Answer: A) Driving a car.
Rationale: After a TURP, clients are typically advised to avoid activities that can increase intra-
abdominal pressure and the risk of bleeding, such as strenuous exercise, heavy lifting, and
driving, until cleared by their surgeon at the follow-up appointment.
Question 2
A client with stage IV bone cancer is admitted to the hospital with a pain rating of 8 on a 1-10
scale. Which intervention should the nurse implement for pain management?
A) Administer a PRN opioid medication only when the pain is severe.
B) Alternate doses of opioid and non-opioid medications.
C) Administer opioid and non-opioid medications simultaneously.
D) Use only non-pharmacological methods for pain relief.
Correct Answer: C) Administer opioid and non-opioid medications simultaneously.
Rationale: For severe cancer pain, a multimodal approach is most effective. Combining an
opioid (for severe pain) with a non-opioid analgesic (like acetaminophen or an NSAID) works
on different pain pathways and can provide better pain relief with potentially lower doses of
opioids.
Question 3
A client experiences an acute hemolytic transfusion reaction. Which finding should the nurse
report immediately to the health care provider?
A) Low back pain and hypotension.
,B) Rhinitis and nasal stuffiness.
C) A delayed painful rash with urticaria.
D) Arthritic joint changes and chronic pain.
Correct Answer: A) Low back pain and hypotension.
Rationale: An acute hemolytic reaction is a life-threatening ABO incompatibility reaction. The
destruction of red blood cells causes hemoglobinuria (leading to low back/flank pain) and a
systemic inflammatory response leading to hypotension, fever, chills, and tachycardia.
Question 4
When conducting discharge teaching for a client diagnosed with diverticulosis, which diet
instruction should the nurse include?
A) "Have small frequent meals and sit up for at least two hours after meals."
B) "Eat a bland diet and avoid spicy foods."
C) "Eat a high-fiber diet and increase fluid intake."
D) "Eat a soft diet with an increased intake of milk and milk products."
Correct Answer: C) "Eat a high-fiber diet and increase fluid intake."
Rationale: For diverticulosis (the presence of diverticula), a high-fiber diet is recommended to
increase stool bulk, prevent constipation, and decrease intraluminal pressure, which can help
prevent the formation of new diverticula and the inflammation seen in diverticulitis.
Question 5
The nurse observes an increased number of blood clots in the drainage tubing of a client with
continuous bladder irrigation (CBI) following a TURP. What is the best initial nursing action?
A) Provide additional oral fluid intake.
B) Measure the client's intake and output.
C) Increase the flow of the bladder irrigation.
D) Administer a PRN dose of an antispasmodic agent.
Correct Answer: C) Increase the flow of the bladder irrigation.
Rationale: The purpose of CBI is to prevent the formation of blood clots that can obstruct the
catheter. If clots are observed, the immediate action is to increase the irrigation flow rate to
flush them out and prevent obstruction.
,Question 6
A client with lung cancer who wears a fentanyl patch for pain is found to be short of breath and
difficult to arouse. The nurse discovers four analgesic patches on the client's back. What is the
priority nursing action?
A) Administer naloxone.
B) Remove all fentanyl patches.
C) Obtain a set of vital signs.
D) Notify the healthcare provider.
Correct Answer: B) Remove all fentanyl patches.
Rationale: The client is experiencing an opioid overdose. The immediate priority is to stop the
source of the drug absorption. Removing all the patches is the first step to prevent further
overdose, followed by assessing vital signs, administering naloxone, and notifying the
provider.
Question 7
A client is brought to the ED after a fall. X-rays confirm a fractured right leg, and a cast is
applied. Which assessment finding warrants immediate intervention by the nurse?
A) A pain report of 5 on a 0-10 scale.
B) Edema of the right toes.
C) The right foot is pale with a capillary refill of 4 seconds.
D) Increased warmth of the right lower extremity.
Correct Answer: C) The right foot is pale with a capillary refill of 4 seconds.
Rationale: Pallor and a prolonged capillary refill are signs of impaired arterial perfusion. This
could indicate that the cast is too tight and is causing a neurovascular compromise (like
compartment syndrome), which is a medical emergency.
Question 8
An overweight young adult recently diagnosed with type 2 diabetes is admitted for surgery. He
reports feeling weak and jittery. Which actions should the nurse implement? (Select all that
apply.)
A) Check fingerstick glucose.
, B) Assess skin temperature and moisture.
C) Measure pulse and blood pressure.
D) Administer a dose of regular insulin.
E) Offer the client a glass of orange juice.
Correct Answer: A) Check fingerstick glucose., B) Assess skin temperature and moisture., C)
Measure pulse and blood pressure.
Rationale: Weakness and feeling jittery, along with changes in skin (cool, moist) and vital signs
(tachycardia), are classic signs of hypoglycemia. The first step is to confirm this by checking
the blood glucose level and performing a rapid assessment.
Question 9
A client who underwent cardiac stent placement four days ago presents to the ED with a sudden
onset of chest pressure and shortness of breath. Which action should the nurse take next?
A) Listen for extra heart sounds.
B) Evaluate extremities for perfusion.
C) Schedule troponin level assessments.
D) Obtain a 12-lead electrocardiogram (ECG).
Correct Answer: D) Obtain a 12-lead electrocardiogram (ECG).
Rationale: These symptoms are highly suggestive of an acute coronary syndrome, possibly
from stent thrombosis. Obtaining a 12-lead ECG is the immediate priority to diagnose a
potential ST-elevation MI (STEMI), which requires emergent intervention.
Question 10
While assessing a client with migraines, the nurse notes bilateral weakness in the hand grips
and the client reports joint pain. Which action should the nurse take?
A) Implement fall precautions.
B) Explain that the symptoms are related to the migraine.
C) Gather additional assessment data about the pain and weakness.
D) Consult with an occupational therapist.
Correct Answer: C) Gather additional assessment data about the pain and weakness.
Rationale: The nursing process begins with assessment. The new findings of bilateral
DETAILED ANSWERS WITH RATIONALES(REAL DEAL) GRADE A+ ASSURED.
Question 1
A client is recovering from a transurethral resection of the prostate (TURP). Which activity
should be limited until after the first postoperative visit with the healthcare provider?
A) Driving a car.
B) Drinking at least 2 L of fluid per day.
C) Walking short distances.
D) Performing Kegel exercises.
Correct Answer: A) Driving a car.
Rationale: After a TURP, clients are typically advised to avoid activities that can increase intra-
abdominal pressure and the risk of bleeding, such as strenuous exercise, heavy lifting, and
driving, until cleared by their surgeon at the follow-up appointment.
Question 2
A client with stage IV bone cancer is admitted to the hospital with a pain rating of 8 on a 1-10
scale. Which intervention should the nurse implement for pain management?
A) Administer a PRN opioid medication only when the pain is severe.
B) Alternate doses of opioid and non-opioid medications.
C) Administer opioid and non-opioid medications simultaneously.
D) Use only non-pharmacological methods for pain relief.
Correct Answer: C) Administer opioid and non-opioid medications simultaneously.
Rationale: For severe cancer pain, a multimodal approach is most effective. Combining an
opioid (for severe pain) with a non-opioid analgesic (like acetaminophen or an NSAID) works
on different pain pathways and can provide better pain relief with potentially lower doses of
opioids.
Question 3
A client experiences an acute hemolytic transfusion reaction. Which finding should the nurse
report immediately to the health care provider?
A) Low back pain and hypotension.
,B) Rhinitis and nasal stuffiness.
C) A delayed painful rash with urticaria.
D) Arthritic joint changes and chronic pain.
Correct Answer: A) Low back pain and hypotension.
Rationale: An acute hemolytic reaction is a life-threatening ABO incompatibility reaction. The
destruction of red blood cells causes hemoglobinuria (leading to low back/flank pain) and a
systemic inflammatory response leading to hypotension, fever, chills, and tachycardia.
Question 4
When conducting discharge teaching for a client diagnosed with diverticulosis, which diet
instruction should the nurse include?
A) "Have small frequent meals and sit up for at least two hours after meals."
B) "Eat a bland diet and avoid spicy foods."
C) "Eat a high-fiber diet and increase fluid intake."
D) "Eat a soft diet with an increased intake of milk and milk products."
Correct Answer: C) "Eat a high-fiber diet and increase fluid intake."
Rationale: For diverticulosis (the presence of diverticula), a high-fiber diet is recommended to
increase stool bulk, prevent constipation, and decrease intraluminal pressure, which can help
prevent the formation of new diverticula and the inflammation seen in diverticulitis.
Question 5
The nurse observes an increased number of blood clots in the drainage tubing of a client with
continuous bladder irrigation (CBI) following a TURP. What is the best initial nursing action?
A) Provide additional oral fluid intake.
B) Measure the client's intake and output.
C) Increase the flow of the bladder irrigation.
D) Administer a PRN dose of an antispasmodic agent.
Correct Answer: C) Increase the flow of the bladder irrigation.
Rationale: The purpose of CBI is to prevent the formation of blood clots that can obstruct the
catheter. If clots are observed, the immediate action is to increase the irrigation flow rate to
flush them out and prevent obstruction.
,Question 6
A client with lung cancer who wears a fentanyl patch for pain is found to be short of breath and
difficult to arouse. The nurse discovers four analgesic patches on the client's back. What is the
priority nursing action?
A) Administer naloxone.
B) Remove all fentanyl patches.
C) Obtain a set of vital signs.
D) Notify the healthcare provider.
Correct Answer: B) Remove all fentanyl patches.
Rationale: The client is experiencing an opioid overdose. The immediate priority is to stop the
source of the drug absorption. Removing all the patches is the first step to prevent further
overdose, followed by assessing vital signs, administering naloxone, and notifying the
provider.
Question 7
A client is brought to the ED after a fall. X-rays confirm a fractured right leg, and a cast is
applied. Which assessment finding warrants immediate intervention by the nurse?
A) A pain report of 5 on a 0-10 scale.
B) Edema of the right toes.
C) The right foot is pale with a capillary refill of 4 seconds.
D) Increased warmth of the right lower extremity.
Correct Answer: C) The right foot is pale with a capillary refill of 4 seconds.
Rationale: Pallor and a prolonged capillary refill are signs of impaired arterial perfusion. This
could indicate that the cast is too tight and is causing a neurovascular compromise (like
compartment syndrome), which is a medical emergency.
Question 8
An overweight young adult recently diagnosed with type 2 diabetes is admitted for surgery. He
reports feeling weak and jittery. Which actions should the nurse implement? (Select all that
apply.)
A) Check fingerstick glucose.
, B) Assess skin temperature and moisture.
C) Measure pulse and blood pressure.
D) Administer a dose of regular insulin.
E) Offer the client a glass of orange juice.
Correct Answer: A) Check fingerstick glucose., B) Assess skin temperature and moisture., C)
Measure pulse and blood pressure.
Rationale: Weakness and feeling jittery, along with changes in skin (cool, moist) and vital signs
(tachycardia), are classic signs of hypoglycemia. The first step is to confirm this by checking
the blood glucose level and performing a rapid assessment.
Question 9
A client who underwent cardiac stent placement four days ago presents to the ED with a sudden
onset of chest pressure and shortness of breath. Which action should the nurse take next?
A) Listen for extra heart sounds.
B) Evaluate extremities for perfusion.
C) Schedule troponin level assessments.
D) Obtain a 12-lead electrocardiogram (ECG).
Correct Answer: D) Obtain a 12-lead electrocardiogram (ECG).
Rationale: These symptoms are highly suggestive of an acute coronary syndrome, possibly
from stent thrombosis. Obtaining a 12-lead ECG is the immediate priority to diagnose a
potential ST-elevation MI (STEMI), which requires emergent intervention.
Question 10
While assessing a client with migraines, the nurse notes bilateral weakness in the hand grips
and the client reports joint pain. Which action should the nurse take?
A) Implement fall precautions.
B) Explain that the symptoms are related to the migraine.
C) Gather additional assessment data about the pain and weakness.
D) Consult with an occupational therapist.
Correct Answer: C) Gather additional assessment data about the pain and weakness.
Rationale: The nursing process begins with assessment. The new findings of bilateral
