1|Page
BSN HESI 266 Concepts of Nursing Test Bank: A
Comprehensive Study Guide with Actual Exam
Questions and Detailed Rationales.
A client with a completed ischemic stroke has a blood pressure of
180/90 mm Hg. Which action should the nurse implement?
A. Position the head of the bed (HOB) flat.
B. Withhold intravenous fluids.
C. Administer a bolus of IV fluids.
D. Give an antihypertensive medication. - ANSWER-D. Give an
antihypertensive medication.
Rationale
Most ischemic strokes occur during sleep when baseline blood pressure
declines or blood viscosity increases due to minimal fluid intake.
Completed strokes usually produce neurologic deficits within an hour,
and the client's current elevated blood pressure requires antihypertensive
medication.
A client who is receiving chemotherapy asks the nurse, "Why is so much
of my hair falling out each day?" Which response by the nurse best
explains the reason for alopecia?
A. "Chemotherapy affects the cells of the body that grow rapidly, both
normal and malignant."
B. "Alopecia is a common side effect you will experience during long-
term steroid therapy."
C. "Your hair will grow back completely after your course of
chemotherapy is completed."
,2|Page
D. "The chemotherapy causes permanent alterations in your hair follicles
that lead to hair loss." - ANSWER-A. "Chemotherapy affects the cells of
the body that grow rapidly, both normal and malignant."
Rationale
The common adverse effects of chemotherapy (nausea, vomiting,
alopecia, bone marrow depression) are due to chemotherapy's effect on
the rapidly reproducing cells, both normal and malignant.
After checking the urinary drainage system for kinks in the tubing, the
nurse determines that a client who has returned from the post-anesthesia
care has a dark, concentrated urinary output of 54 ml for the last 2 hours.
What priority nursing action should be implemented?
A. Report the findings to the surgeon.
B. Irrigate the indwelling urinary catheter.
C. Apply manual pressure to the bladder.
D. Increase the IV flow rate for 15 minutes. - ANSWER-A. Report the
findings to the surgeon.
Rationale
An adult who weighs 132 pounds (60 kg) should produce about 60 ml of
urine hourly (1 ml/kg/hour). Dark, concentrated, and low volume of
urine output should be reported to the surgeon.
A male client who smokes two packs of cigarettes a day states he
understands that smoking cigarettes is contributing to the difficulty that
he and his wife are having in getting pregnant and wants to know if
other factors could be contributing to their difficulty. What information
is best for the nurse to provide? (Select all that apply.)
Select all that apply
A. Marijuana cigarettes do not affect sperm count.
B. Alcohol consumption can cause erectile dysfunction.
C. Low testosterone levels affect sperm production.
D. Cessation of smoking improves general health and fertility.
E. Obesity has no effect on sperm production. - ANSWER-B, C and D
Rationale
,3|Page
Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm
count is also negatively affected by low testerone levels and obesity.
A client with gastroesophageal reflux disease (GERD) has been
experiencing severe reflux during sleep. Which recommendation by the
nurse is most effective to assist the client?
A. Losing weight.
B. Decreasing caffeine intake.
C. Avoiding large meals.
D. Raising the head of the bed on blocks. - ANSWER-D. Raising the
head of the bed on blocks.
Rationale
Raising the head of the bed on blocks (reverse Trendelenburg position)
to reduce reflux and subsequent aspiration is the most non-
pharmacological effective recommendation for a client experiencing
severe gastroesophageal reflux during sleep.
A 51-year-old truck driver who smokes two packs of cigarettes a day
and is 30 pounds overweight is diagnosed with having a gastric ulcer.
What content is most important for the nurse to include in the discharge
teaching for this client?
A. Information about smoking cessation.
B. Diet instructions for a low-residue diet.
C. Instructions on a weight-loss program.
D. The importance of increasing milk in the diet. - ANSWER-A.
Information about smoking cessation.
Rationale
Smoking has been associated with ulcer formation, and stopping or
decreasing the number of cigarettes smoked per day is an important
aspect of ulcer management.
What types of medications should the nurse expect to administer to a
client during an acute respiratory distress episode?
A. Vasodilators and hormones.
B. Analgesics and sedatives.
, 4|Page
C. Anticoagulants and expectorants.
D. Bronchodilators and steroids. - ANSWER-D. Bronchodilators and
steroids.
Rationale
Besides supplemental oxygen, this client with ARDS needs medications
to widen air passages, increase air space, and reduce alveolar membrane
inflammation, such as bronchodilators and steroids.
A female client is brought to the clinic by her daughter for a flu shot.
She has lost significant weight since the last visit. She has poor personal
hygiene and inadequate clothing for the weather. The client states that
she lives alone and denies problems or concerns. What action should the
nurse implement?
A. Notify social services immediately of suspected elderly abuse.
B. Discuss the need for mental health counseling with the daughter.
C. Explain to the client that she needs to take better care of herself.
D. Collect further data to determine whether self-neglect is occurring. -
ANSWER-D. Collect further data to determine whether self-neglect is
occurring.
Rationale
Changes in weight and hygiene may be indicators of self-neglect or
neglect by family members. Further assessment is needed before
notifying social services or discussing a need for counseling.
The nurse is assisting a client out of bed for the first time after surgery.
What action should the nurse do first?
A. Place a chair at a right angle to the bedside.
B. Encourage deep breathing prior to standing.
C. Help the client to sit and dangle legs on the side of the bed.
D. Allow the client to sit with the bed in a high Fowler's position. -
ANSWER-D. Allow the client to sit with the bed in a high Fowler's
position.
Rationale
The first step is to raise the head of the bed to a high Fowler's position,
which allow venous return to compensate from lying flat and the
BSN HESI 266 Concepts of Nursing Test Bank: A
Comprehensive Study Guide with Actual Exam
Questions and Detailed Rationales.
A client with a completed ischemic stroke has a blood pressure of
180/90 mm Hg. Which action should the nurse implement?
A. Position the head of the bed (HOB) flat.
B. Withhold intravenous fluids.
C. Administer a bolus of IV fluids.
D. Give an antihypertensive medication. - ANSWER-D. Give an
antihypertensive medication.
Rationale
Most ischemic strokes occur during sleep when baseline blood pressure
declines or blood viscosity increases due to minimal fluid intake.
Completed strokes usually produce neurologic deficits within an hour,
and the client's current elevated blood pressure requires antihypertensive
medication.
A client who is receiving chemotherapy asks the nurse, "Why is so much
of my hair falling out each day?" Which response by the nurse best
explains the reason for alopecia?
A. "Chemotherapy affects the cells of the body that grow rapidly, both
normal and malignant."
B. "Alopecia is a common side effect you will experience during long-
term steroid therapy."
C. "Your hair will grow back completely after your course of
chemotherapy is completed."
,2|Page
D. "The chemotherapy causes permanent alterations in your hair follicles
that lead to hair loss." - ANSWER-A. "Chemotherapy affects the cells of
the body that grow rapidly, both normal and malignant."
Rationale
The common adverse effects of chemotherapy (nausea, vomiting,
alopecia, bone marrow depression) are due to chemotherapy's effect on
the rapidly reproducing cells, both normal and malignant.
After checking the urinary drainage system for kinks in the tubing, the
nurse determines that a client who has returned from the post-anesthesia
care has a dark, concentrated urinary output of 54 ml for the last 2 hours.
What priority nursing action should be implemented?
A. Report the findings to the surgeon.
B. Irrigate the indwelling urinary catheter.
C. Apply manual pressure to the bladder.
D. Increase the IV flow rate for 15 minutes. - ANSWER-A. Report the
findings to the surgeon.
Rationale
An adult who weighs 132 pounds (60 kg) should produce about 60 ml of
urine hourly (1 ml/kg/hour). Dark, concentrated, and low volume of
urine output should be reported to the surgeon.
A male client who smokes two packs of cigarettes a day states he
understands that smoking cigarettes is contributing to the difficulty that
he and his wife are having in getting pregnant and wants to know if
other factors could be contributing to their difficulty. What information
is best for the nurse to provide? (Select all that apply.)
Select all that apply
A. Marijuana cigarettes do not affect sperm count.
B. Alcohol consumption can cause erectile dysfunction.
C. Low testosterone levels affect sperm production.
D. Cessation of smoking improves general health and fertility.
E. Obesity has no effect on sperm production. - ANSWER-B, C and D
Rationale
,3|Page
Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm
count is also negatively affected by low testerone levels and obesity.
A client with gastroesophageal reflux disease (GERD) has been
experiencing severe reflux during sleep. Which recommendation by the
nurse is most effective to assist the client?
A. Losing weight.
B. Decreasing caffeine intake.
C. Avoiding large meals.
D. Raising the head of the bed on blocks. - ANSWER-D. Raising the
head of the bed on blocks.
Rationale
Raising the head of the bed on blocks (reverse Trendelenburg position)
to reduce reflux and subsequent aspiration is the most non-
pharmacological effective recommendation for a client experiencing
severe gastroesophageal reflux during sleep.
A 51-year-old truck driver who smokes two packs of cigarettes a day
and is 30 pounds overweight is diagnosed with having a gastric ulcer.
What content is most important for the nurse to include in the discharge
teaching for this client?
A. Information about smoking cessation.
B. Diet instructions for a low-residue diet.
C. Instructions on a weight-loss program.
D. The importance of increasing milk in the diet. - ANSWER-A.
Information about smoking cessation.
Rationale
Smoking has been associated with ulcer formation, and stopping or
decreasing the number of cigarettes smoked per day is an important
aspect of ulcer management.
What types of medications should the nurse expect to administer to a
client during an acute respiratory distress episode?
A. Vasodilators and hormones.
B. Analgesics and sedatives.
, 4|Page
C. Anticoagulants and expectorants.
D. Bronchodilators and steroids. - ANSWER-D. Bronchodilators and
steroids.
Rationale
Besides supplemental oxygen, this client with ARDS needs medications
to widen air passages, increase air space, and reduce alveolar membrane
inflammation, such as bronchodilators and steroids.
A female client is brought to the clinic by her daughter for a flu shot.
She has lost significant weight since the last visit. She has poor personal
hygiene and inadequate clothing for the weather. The client states that
she lives alone and denies problems or concerns. What action should the
nurse implement?
A. Notify social services immediately of suspected elderly abuse.
B. Discuss the need for mental health counseling with the daughter.
C. Explain to the client that she needs to take better care of herself.
D. Collect further data to determine whether self-neglect is occurring. -
ANSWER-D. Collect further data to determine whether self-neglect is
occurring.
Rationale
Changes in weight and hygiene may be indicators of self-neglect or
neglect by family members. Further assessment is needed before
notifying social services or discussing a need for counseling.
The nurse is assisting a client out of bed for the first time after surgery.
What action should the nurse do first?
A. Place a chair at a right angle to the bedside.
B. Encourage deep breathing prior to standing.
C. Help the client to sit and dangle legs on the side of the bed.
D. Allow the client to sit with the bed in a high Fowler's position. -
ANSWER-D. Allow the client to sit with the bed in a high Fowler's
position.
Rationale
The first step is to raise the head of the bed to a high Fowler's position,
which allow venous return to compensate from lying flat and the
