BSN 266 HESI MEDICAL-SURGICAL EXAM –
NIGHTINGALE COLLEGE 2025–2026 | 60 VERIFIED
NGN-STYLE QUESTIONS AND ANSWERS
While completing a health assessment for a client with migraine headaches, the nurse assesses bilateral
weakness in the clients hand grips. The client reports joint pain and trouble twisting a door knob due to
weaknesses. Which action should the nurses take in response to these figures?
a. Implement fall precautions to reduce the clients risk of injury.
b. Explain that relief of the migraine pain will reduce related symptoms.
c. Gather additional assessment data about the pain and weakness.
d. Consult with the occupational therapist for a functional assessment - CORRECT ANSWERS-
c. Gather additional assessment data about the pain and weakness.
A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. A
triple-lumen catheter for the continuous bladder
irrigation with normal saline is infused and the nurse observes dark-pink tinged outflow with blood clots
in the tubing collection bag.
Which action should the nurse take?
a. Monitoring catheter drainage (pic one says this)
b. irrigation the catheter manually.
c. Decreasing the flow rate.
,d. Discounting infusing solution. - CORRECT ANSWERS-a. Monitoring catheter drainage (pic
one says this)
The nurse is preparing a client for surgery who was admitted to the emergency center following a motor
vehicle collision. The client has an open
fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative
assessment, the nurse determines that the client currently receives heparin sodium 5,000 units
subcutaneously daily.
What is the priority nursing action?
a. Notify the healthcare provider of the client's medication history.
b. Observe the heparin injections sites for signs of bruising.
c. Have the client sign the surgical and transfusion permits.
d. Ensure that the potential for bleeding is explained to the client - CORRECT ANSWERS-a.
Notify the healthcare provider of the client's medication history.
The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving psoralen and ultraviolet
A light (PUVA) treatment.
Which assessment finding indicates that the client has been overexposed to the treatment?
a. Thick skin plaques topped by silvery white scales
b. Tenderness upon palpation and generalized erythema
c. Brown, rough, greasy, wart-like papules on the face
d. Requires sunglasses because sunlight hurts eyes - CORRECT ANSWERS-b. Tenderness upon
palpation and generalized erythema
, An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis
leakage. The client's abdomen is tender to touch, and the vital signs are temperature 101* F (38 3* C).
heart rate 130 beats/minute, Respiratory rate 26 breaths/minute, and blood pressure 100/50 mmHg.
Which intervention is most important for the nurse to include in the client's plan of care?
a. Encourage regular turning.
b. Monitor skin for breakdown.
c. Strict IV fluid replacement
d. Assess wound drainage daily - CORRECT ANSWERS-c. Strict IV fluid replacement
A client experiences an AOB incompatibility reaction after multiple blood transfusions. Which finding
should the nurse report immediately to the health care provider?
a. low back pain and hypotension
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
d. arthritic joint changes and chronic pain - CORRECT ANSWERS-a. low back pain and
hypotension
ANSWER: (A) LOW BACK PAIN AND HYPOTENSTION
When conducting discharge teaching for a client
NIGHTINGALE COLLEGE 2025–2026 | 60 VERIFIED
NGN-STYLE QUESTIONS AND ANSWERS
While completing a health assessment for a client with migraine headaches, the nurse assesses bilateral
weakness in the clients hand grips. The client reports joint pain and trouble twisting a door knob due to
weaknesses. Which action should the nurses take in response to these figures?
a. Implement fall precautions to reduce the clients risk of injury.
b. Explain that relief of the migraine pain will reduce related symptoms.
c. Gather additional assessment data about the pain and weakness.
d. Consult with the occupational therapist for a functional assessment - CORRECT ANSWERS-
c. Gather additional assessment data about the pain and weakness.
A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. A
triple-lumen catheter for the continuous bladder
irrigation with normal saline is infused and the nurse observes dark-pink tinged outflow with blood clots
in the tubing collection bag.
Which action should the nurse take?
a. Monitoring catheter drainage (pic one says this)
b. irrigation the catheter manually.
c. Decreasing the flow rate.
,d. Discounting infusing solution. - CORRECT ANSWERS-a. Monitoring catheter drainage (pic
one says this)
The nurse is preparing a client for surgery who was admitted to the emergency center following a motor
vehicle collision. The client has an open
fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative
assessment, the nurse determines that the client currently receives heparin sodium 5,000 units
subcutaneously daily.
What is the priority nursing action?
a. Notify the healthcare provider of the client's medication history.
b. Observe the heparin injections sites for signs of bruising.
c. Have the client sign the surgical and transfusion permits.
d. Ensure that the potential for bleeding is explained to the client - CORRECT ANSWERS-a.
Notify the healthcare provider of the client's medication history.
The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving psoralen and ultraviolet
A light (PUVA) treatment.
Which assessment finding indicates that the client has been overexposed to the treatment?
a. Thick skin plaques topped by silvery white scales
b. Tenderness upon palpation and generalized erythema
c. Brown, rough, greasy, wart-like papules on the face
d. Requires sunglasses because sunlight hurts eyes - CORRECT ANSWERS-b. Tenderness upon
palpation and generalized erythema
, An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis
leakage. The client's abdomen is tender to touch, and the vital signs are temperature 101* F (38 3* C).
heart rate 130 beats/minute, Respiratory rate 26 breaths/minute, and blood pressure 100/50 mmHg.
Which intervention is most important for the nurse to include in the client's plan of care?
a. Encourage regular turning.
b. Monitor skin for breakdown.
c. Strict IV fluid replacement
d. Assess wound drainage daily - CORRECT ANSWERS-c. Strict IV fluid replacement
A client experiences an AOB incompatibility reaction after multiple blood transfusions. Which finding
should the nurse report immediately to the health care provider?
a. low back pain and hypotension
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
d. arthritic joint changes and chronic pain - CORRECT ANSWERS-a. low back pain and
hypotension
ANSWER: (A) LOW BACK PAIN AND HYPOTENSTION
When conducting discharge teaching for a client
