BSN 266 HESI Exam Med-Surg Exam 5 100+
Verified Q&A ACTUAL EXAM 2026/2027 |
BSN 266 HESI Med Surg 5 | Verified Q&A |
Pass Guaranteed - A+ Graded
Section 1: Cardiovascular Disorders (Questions 1–20)
Q1: A nurse is caring for a client 24 hours after an acute anterior ST-segment elevation myocardial
infarction (STEMI). The client reports sudden shortness of breath and auscultation reveals crackles
bilaterally to the mid-scapular area. Vital signs: HR 118, BP 158/90, RR 28, SpO2 89% on 2L nasal
cannula. Which action should the nurse take first?
A. Reposition the client to high-Fowler's position [CORRECT]
B. Administer sublingual nitroglycerin 0.4 mg
C. Increase oxygen to 4L via nasal cannula
D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: High-Fowler's positioning reduces venous return and preload, decreasing pulmonary
congestion and improving ventilation-perfusion matching in acute decompensated heart failure post-
STEMI.
Q2: A client with heart failure is receiving furosemide 40 mg IV push daily. The nurse notes a potassium
level of 3.1 mEq/L. Which action is the priority?
A. Administer the scheduled furosemide dose
B. Hold the furosemide and notify the provider [CORRECT]
C. Increase oral fluid intake
D. Administer potassium supplement without provider order
Correct Answer: B
,Rationale: Hypokalemia below 3.5 mEq/L increases the risk of life-threatening dysrhythmias, and loop
diuretics further deplete potassium; the nurse must hold the diuretic and notify the provider for
potassium replacement orders.
Q3: A client with atrial fibrillation is receiving warfarin 5 mg daily. The INR is 4.2, and the client reports
dark tarry stools. Which intervention is the priority?
A. Administer vitamin K 10 mg orally
B. Hold the warfarin and notify the provider immediately [CORRECT]
C. Continue warfarin at a reduced dose
D. Apply pressure to any bleeding sites
Correct Answer: B
Rationale: An INR above 4.0 with signs of gastrointestinal bleeding indicates supratherapeutic
anticoagulation with active hemorrhage, requiring immediate warfarin discontinuation and provider
notification for potential reversal agents.
Q4: A client with third-degree AV block has a heart rate of 34 bpm, BP 72/48 mmHg, and altered mental
status. Which intervention should the nurse prepare for?
A. Administer atropine 0.5 mg IV
B. Initiate transcutaneous pacing [CORRECT]
C. Begin dopamine infusion
D. Prepare for cardioversion
Correct Answer: B
Rationale: Third-degree AV block with hemodynamic compromise requires immediate transcutaneous
pacing per ACLS guidelines, as atropine is ineffective for blocks below the AV node and the client is
unstable.
Q5: A client post-cardiac catheterization with a femoral sheath in place reports increased back pain and
a feeling of warmth at the insertion site. The nurse notes a hematoma extending to the flank. Which
action is the priority?
A. Apply manual pressure and notify the provider immediately [CORRECT]
B. Remove the sheath independently
C. Elevate the head of the bed
,D. Administer pain medication
Correct Answer: A
Rationale: Retroperitoneal bleeding is a serious complication of femoral catheterization presenting with
back pain, flank hematoma, and hypotension; manual pressure and immediate provider notification are
essential to prevent hemorrhagic shock.
Q6: A client with acute pericarditis reports sharp chest pain that worsens with inspiration and lying flat.
Which positioning provides the most relief?
A. Supine with legs elevated
B. Sitting upright and leaning forward [CORRECT]
C. Left lateral decubitus
D. Prone position
Correct Answer: B
Rationale: Sitting upright and leaning forward reduces pressure on the pericardium and minimizes
friction between inflamed pericardial layers, which is the characteristic pain-relieving position for
pericarditis.
Q7: A client with a history of heart failure has a BNP of 2,400 pg/mL. Which clinical finding supports this
result?
A. Clear lung sounds bilaterally
B. Jugular venous distension and peripheral edema [CORRECT]
C. Blood pressure 110/70 mmHg
D. Heart rate 72 bpm
Correct Answer: B
Rationale: BNP levels above 400 pg/mL indicate severe heart failure decompensation, and jugular
venous distension with peripheral edema are classic signs of fluid overload consistent with elevated
BNP.
Q8: A client with hypertensive emergency has a BP of 220/130 mmHg and reports a severe headache
with visual changes. Which medication is most appropriate for initial management?
A. Oral lisinopril 10 mg
B. IV labetalol or nicardipine [CORRECT]
, C. Sublingual nifedipine
D. Oral metoprolol 50 mg
Correct Answer: B
Rationale: Hypertensive emergency with target organ damage requires controlled reduction using IV
agents such as labetalol or nicardipine to prevent cerebral hypoperfusion from overly rapid correction
while reducing blood pressure safely.
Q9: A client with dilated cardiomyopathy has an ejection fraction of 20%. Which teaching point is most
important for discharge?
A. Increase sodium intake to maintain blood pressure
B. Weigh daily and report weight gain greater than 3 pounds in 2 days [CORRECT]
C. Discontinue ACE inhibitors if dizziness occurs
D. Exercise vigorously to strengthen cardiac muscle
Correct Answer: B
Rationale: Daily weight monitoring is essential for heart failure self-management because a weight gain
of 2 to 3 pounds in 24 hours indicates fluid retention and impending decompensation requiring early
intervention.
Q10: A client with acute MI develops a new loud holosystolic murmur at the apex, pulmonary edema,
and hypotension on day 3 post-infarction. Which complication is most likely?
A. Ventricular septal defect
B. Papillary muscle rupture with acute mitral regurgitation [CORRECT]
C. Left ventricular aneurysm
D. Dressler syndrome
Correct Answer: B
Rationale: Papillary muscle rupture is a catastrophic mechanical complication of acute MI occurring 2 to
7 days post-infarction, presenting with acute severe mitral regurgitation, pulmonary edema, and
cardiogenic shock requiring emergent surgical intervention.
Q11: A client receiving digoxin 0.25 mg daily has a potassium of 2.9 mEq/L and reports nausea and visual
disturbances. Which action is the priority?
A. Administer the scheduled digoxin dose
Verified Q&A ACTUAL EXAM 2026/2027 |
BSN 266 HESI Med Surg 5 | Verified Q&A |
Pass Guaranteed - A+ Graded
Section 1: Cardiovascular Disorders (Questions 1–20)
Q1: A nurse is caring for a client 24 hours after an acute anterior ST-segment elevation myocardial
infarction (STEMI). The client reports sudden shortness of breath and auscultation reveals crackles
bilaterally to the mid-scapular area. Vital signs: HR 118, BP 158/90, RR 28, SpO2 89% on 2L nasal
cannula. Which action should the nurse take first?
A. Reposition the client to high-Fowler's position [CORRECT]
B. Administer sublingual nitroglycerin 0.4 mg
C. Increase oxygen to 4L via nasal cannula
D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: High-Fowler's positioning reduces venous return and preload, decreasing pulmonary
congestion and improving ventilation-perfusion matching in acute decompensated heart failure post-
STEMI.
Q2: A client with heart failure is receiving furosemide 40 mg IV push daily. The nurse notes a potassium
level of 3.1 mEq/L. Which action is the priority?
A. Administer the scheduled furosemide dose
B. Hold the furosemide and notify the provider [CORRECT]
C. Increase oral fluid intake
D. Administer potassium supplement without provider order
Correct Answer: B
,Rationale: Hypokalemia below 3.5 mEq/L increases the risk of life-threatening dysrhythmias, and loop
diuretics further deplete potassium; the nurse must hold the diuretic and notify the provider for
potassium replacement orders.
Q3: A client with atrial fibrillation is receiving warfarin 5 mg daily. The INR is 4.2, and the client reports
dark tarry stools. Which intervention is the priority?
A. Administer vitamin K 10 mg orally
B. Hold the warfarin and notify the provider immediately [CORRECT]
C. Continue warfarin at a reduced dose
D. Apply pressure to any bleeding sites
Correct Answer: B
Rationale: An INR above 4.0 with signs of gastrointestinal bleeding indicates supratherapeutic
anticoagulation with active hemorrhage, requiring immediate warfarin discontinuation and provider
notification for potential reversal agents.
Q4: A client with third-degree AV block has a heart rate of 34 bpm, BP 72/48 mmHg, and altered mental
status. Which intervention should the nurse prepare for?
A. Administer atropine 0.5 mg IV
B. Initiate transcutaneous pacing [CORRECT]
C. Begin dopamine infusion
D. Prepare for cardioversion
Correct Answer: B
Rationale: Third-degree AV block with hemodynamic compromise requires immediate transcutaneous
pacing per ACLS guidelines, as atropine is ineffective for blocks below the AV node and the client is
unstable.
Q5: A client post-cardiac catheterization with a femoral sheath in place reports increased back pain and
a feeling of warmth at the insertion site. The nurse notes a hematoma extending to the flank. Which
action is the priority?
A. Apply manual pressure and notify the provider immediately [CORRECT]
B. Remove the sheath independently
C. Elevate the head of the bed
,D. Administer pain medication
Correct Answer: A
Rationale: Retroperitoneal bleeding is a serious complication of femoral catheterization presenting with
back pain, flank hematoma, and hypotension; manual pressure and immediate provider notification are
essential to prevent hemorrhagic shock.
Q6: A client with acute pericarditis reports sharp chest pain that worsens with inspiration and lying flat.
Which positioning provides the most relief?
A. Supine with legs elevated
B. Sitting upright and leaning forward [CORRECT]
C. Left lateral decubitus
D. Prone position
Correct Answer: B
Rationale: Sitting upright and leaning forward reduces pressure on the pericardium and minimizes
friction between inflamed pericardial layers, which is the characteristic pain-relieving position for
pericarditis.
Q7: A client with a history of heart failure has a BNP of 2,400 pg/mL. Which clinical finding supports this
result?
A. Clear lung sounds bilaterally
B. Jugular venous distension and peripheral edema [CORRECT]
C. Blood pressure 110/70 mmHg
D. Heart rate 72 bpm
Correct Answer: B
Rationale: BNP levels above 400 pg/mL indicate severe heart failure decompensation, and jugular
venous distension with peripheral edema are classic signs of fluid overload consistent with elevated
BNP.
Q8: A client with hypertensive emergency has a BP of 220/130 mmHg and reports a severe headache
with visual changes. Which medication is most appropriate for initial management?
A. Oral lisinopril 10 mg
B. IV labetalol or nicardipine [CORRECT]
, C. Sublingual nifedipine
D. Oral metoprolol 50 mg
Correct Answer: B
Rationale: Hypertensive emergency with target organ damage requires controlled reduction using IV
agents such as labetalol or nicardipine to prevent cerebral hypoperfusion from overly rapid correction
while reducing blood pressure safely.
Q9: A client with dilated cardiomyopathy has an ejection fraction of 20%. Which teaching point is most
important for discharge?
A. Increase sodium intake to maintain blood pressure
B. Weigh daily and report weight gain greater than 3 pounds in 2 days [CORRECT]
C. Discontinue ACE inhibitors if dizziness occurs
D. Exercise vigorously to strengthen cardiac muscle
Correct Answer: B
Rationale: Daily weight monitoring is essential for heart failure self-management because a weight gain
of 2 to 3 pounds in 24 hours indicates fluid retention and impending decompensation requiring early
intervention.
Q10: A client with acute MI develops a new loud holosystolic murmur at the apex, pulmonary edema,
and hypotension on day 3 post-infarction. Which complication is most likely?
A. Ventricular septal defect
B. Papillary muscle rupture with acute mitral regurgitation [CORRECT]
C. Left ventricular aneurysm
D. Dressler syndrome
Correct Answer: B
Rationale: Papillary muscle rupture is a catastrophic mechanical complication of acute MI occurring 2 to
7 days post-infarction, presenting with acute severe mitral regurgitation, pulmonary edema, and
cardiogenic shock requiring emergent surgical intervention.
Q11: A client receiving digoxin 0.25 mg daily has a potassium of 2.9 mEq/L and reports nausea and visual
disturbances. Which action is the priority?
A. Administer the scheduled digoxin dose
