BSN HESI 266 Med Surg Exam – Nightingale Actual
Exam Questions & Verified Answers | 100% Correct
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Cardiovascular & Respiratory Disorders
Q1: The nurse is caring for a client admitted with heart failure who reports shortness of
breath while lying flat. Which action should the nurse take first?
A. Administer the scheduled IV furosemide (Lasix).
B. Place the client in a high Fowler’s position.
C. Check the client’s oxygen saturation level.
D. Auscultate lung sounds for crackles.
Correct Answer: B
Rationale: The best answer is placing the client in a high Fowler’s position because this
immediately uses gravity to decrease venous return to the heart and reduce the
workload of breathing, which relieves the dyspnea caused by orthopnea. While
checking vitals and giving meds are important, positioning is the quickest intervention to
improve comfort and gas exchange.
Q2: A client with hypertension is prescribed Lisinopril. Which instruction should the
nurse include in the discharge teaching plan?
A. Avoid taking potassium supplements or salt substitutes.
B. Rise slowly from a sitting or lying position.
C. Take the medication at bedtime to prevent morning dizziness.
D. Monitor your pulse rate daily before taking the pill.
Correct Answer: A
Rationale: The best answer is to avoid taking potassium supplements or salt substitutes
because ACE inhibitors like Lisinopril cause the kidneys to retain potassium, leading to
potentially dangerous hyperkalemia if extra potassium is ingested.
Q3: [DATA SNIPPET]
The nurse receives the morning shift report for four clients. Based on the following
assessment data, which client should the nurse assess first?
,Client Vital Signs Assessment
Post-op Day 2 hip repair, pain
Client A BP 110/70, HR 88
4/10
Pneumonia, productive cough,
Client B BP 138/82, HR 76
SaO2 95% on 2L
New onset atrial fibrillation,
Client C BP 88/54, HR 122
complains of dizziness
Client D BP 128/78, HR 64 COPD, stable, receiving Duoneb
A. Client A
, B. Client B
C. Client C
D. Client D
Correct Answer: C
Rationale: The best answer is Client C because
this client is showing signs of hemodynamic
instability with hypotension and dizziness, likely
due to the loss of the atrial kick in new atrial
fibrillation. On a med-surg unit, priority goes to
the patient who is unstable over those who are
stable or recovering.
Exam Questions & Verified Answers | 100% Correct
| Grade A | Pass Guaranteed - A+ Graded
Cardiovascular & Respiratory Disorders
Q1: The nurse is caring for a client admitted with heart failure who reports shortness of
breath while lying flat. Which action should the nurse take first?
A. Administer the scheduled IV furosemide (Lasix).
B. Place the client in a high Fowler’s position.
C. Check the client’s oxygen saturation level.
D. Auscultate lung sounds for crackles.
Correct Answer: B
Rationale: The best answer is placing the client in a high Fowler’s position because this
immediately uses gravity to decrease venous return to the heart and reduce the
workload of breathing, which relieves the dyspnea caused by orthopnea. While
checking vitals and giving meds are important, positioning is the quickest intervention to
improve comfort and gas exchange.
Q2: A client with hypertension is prescribed Lisinopril. Which instruction should the
nurse include in the discharge teaching plan?
A. Avoid taking potassium supplements or salt substitutes.
B. Rise slowly from a sitting or lying position.
C. Take the medication at bedtime to prevent morning dizziness.
D. Monitor your pulse rate daily before taking the pill.
Correct Answer: A
Rationale: The best answer is to avoid taking potassium supplements or salt substitutes
because ACE inhibitors like Lisinopril cause the kidneys to retain potassium, leading to
potentially dangerous hyperkalemia if extra potassium is ingested.
Q3: [DATA SNIPPET]
The nurse receives the morning shift report for four clients. Based on the following
assessment data, which client should the nurse assess first?
,Client Vital Signs Assessment
Post-op Day 2 hip repair, pain
Client A BP 110/70, HR 88
4/10
Pneumonia, productive cough,
Client B BP 138/82, HR 76
SaO2 95% on 2L
New onset atrial fibrillation,
Client C BP 88/54, HR 122
complains of dizziness
Client D BP 128/78, HR 64 COPD, stable, receiving Duoneb
A. Client A
, B. Client B
C. Client C
D. Client D
Correct Answer: C
Rationale: The best answer is Client C because
this client is showing signs of hemodynamic
instability with hypotension and dizziness, likely
due to the loss of the atrial kick in new atrial
fibrillation. On a med-surg unit, priority goes to
the patient who is unstable over those who are
stable or recovering.
