NIGHTINGALE BSN 266 HESI MED SURG
EXAMS 3 VERSIONS (V4, V5 & V6) EACH
VERSION WITH 100 QUESTIONS AND
CORRECT ANSWERS/ HESI MED SURG BSN
266 EXAMS 2025 300 QS & AS( NEW!)
BSN 266 VERSION 4
After surgery for gastric cancer, a client is scheduled to undergo radiation therapy.
It will be most important for the nurse to include information about which of the
following in the client's teaching plan?
A. Nutritional intake.
B. Management of alopecia.
C. Exercise and activity levels.
D. Access to community resources. - ANSWER-A. Nutritional intake
NGN CASE STUDY: 24YO F presents to ED w/abdominal pain. The client
reports that she was vacuuming in her home approximately 1 hours prior to arrival
when she had a sudden onset of abdominal pain. She also reports nausea and
vomiting. The client has a prior medical history of anxiety and constipation. The
stool soft and formed. There are no known diagnosed allergies.
Her last menstrual period was reported to be 1 weeks ago. She is not currently
sexually active. Her partner was two years ago.
a. SELECT 4 ASSESSMENT FINDINGS THAT REQUIRE IMMEDIATE
FOLLOW UP:
i. Respirations 28 breaths/minute with shallow breathing.
ii. Feels anxious.
iii. Radial and Pedal pulses +2
iv. Blood Pressure 115/76 mm Hg
v. Heart Rate 121 beats/ minute
vi. Capillary refill 2 seconds.
pg. 1
,vii. Severe abdominal pain in right lower quadrant
viii. Temperature 100.8 F
ix. Vomiting small amounts of green bile
The four assessment findings that require immediate follow-up are:
1. Respirations 28 breaths/minute with shallow breathing - This is
above the normal range of 12-20 breaths per minute for adults and
indicates that the patient may be experiencing respiratory distress.
2. Heart Rate 121 beats/ minute - This is also above the normal range
of 60-100 beats per minute for adults and could indicate a response to
pain, anxiety, or other underlying conditions.
3. Severe abdominal pain in right lower quadrant - This could indicate a
number of serious conditions such as appendicitis, especially when
combined with the patient's other symptoms.
4. Vomiting small amounts of green bile - This could indicate a blockage
in the digestive tract or other serious gastrointestinal issues.
Which instruction should the nurse delegate to an unlicensed assistive
personnel (UAP)?
A.
Call the pharmacy to obtain a client's next antibiotic dose.
B.
Observe a client's gait to determine the need for assistance.
C.
Bring a sterile chest drainage unit from central supply to the unit.
D.
Evaluate a client's urinary catheter for proper drainage.
C. Bring a sterile chest drainage unit from central supply to the unit.
The nurse is providing teaching to a client admitted with a blood glucose level of
580 mg/dL about preventing complications related to diabetes mellitus. Which
information stated by the client indicates understanding? Reference Range Glucose
[Reference Range: 0 to 50 years: less than 140 mg/dL or less than 7.8 mmol/L]
pg. 2
,A. Do not take take diabetes medication when feeling sick
B. Obtain an A1C blood test every year to monitor glucose control.
C. Have some form of rapid acting glucose easily accessible
D. Using salt, herbs, and spices will improve the flavor of foods.
C. Have some form of rapid acting glucose easily accessible.
Rationale: Having a source of rapid acting glucose on hand is important for
treating hypoglycemia which can be a side effect of diabetes mellitus.
Client is transferred from the operating room to the post anesthesia care unit
(PACU) with vial signs of T 99.8, HR 62, RR
8, BP 95/54, and O2 94% on 2L. Which medication should the nurse administer?
A. Acetaminophen
B. Morphine
C. Milrinone
D. Naloxone
D. Naloxone
Rationale: The client's vital signs indicate that they are experiencing respiratory
depression, as evidenced by the low respiratory rate of 8 breaths/minute. The
normal respiratory rate for an adult is typically between 12 and 20 breaths per
minute.
The nurse observes an unlicensed assistive personnel (UAP) applying in alcohol-
based hand rub while leaving the client's room after taking vital signs. What action
should the nurse take?
A. Instruct the UAP to return to the client's room to perform handwashing
B. Supervise the UAP and the next client's room to evaluate hand hygiene
C. Remind the UAP to continue rubbing the hands together until they are dry
D. Advise the UAP to wear gloves when obtaining vital signs for all clients
C. Remind the UAP to continue rubbing the hands together until they are dry
The nurse is caring for an immobile client after spinal surgery. Which action is
most important for the nurse to take to prevent postoperative complications?
a. Apply intermittent pneumatic compression devices.
b. Maintain intervascular infusion rate.
c. Obtain frequent pain level assessments.
d. Progress diet slowly from ice chips to clear liquids.
pg. 3
, a. Apply pneumatic compression devices
RATIONALE: The most important action for the nurse to take to prevent
postoperative
complications in an immobile client after spinal surgery is to apply intermittent
pneumatic compression devices.
The nurse is using a straight urinary catheter kit to collect a sterile urine specimen
from a female client. After positioning an preparing the client, rank the actions in
the sequence they should be
implemented. (Place the first action at the top with the last action at the bottom.)
a. Cleanse the urinary meatus using the solution, swabs, and forceps provided.
b. Open the sterile catheter kit close to the client's perineum.
c. Done sterile gloves and prepare the sterile field.
d. Place distal end of the catheter in sterile specimen cup and insert catheter into
meatus.
1.) Open the sterile catheter kit close to the client's perineum.
2.) Done sterile gloves and prepare the sterile field.
3.) Cleanse the urinary meatus using the solution, swabs, and forceps provided.
4.) Place distal end of the catheter in sterile specimen cup and insert catheter into
meatus.
After receiving report on an inpatient acute care unit, which client should the nurse
assess first?
a. The client with a small bowel obstruction who has a nasogastric tube that is
draining greenish fluid.
b. The client who has surgery yesterday and is experiencing a paralytic ileus with
absent bowel sounds.
c. The client with an obstruction of the large intestine who is experiencing
abdominal distention.
d. The client with a bowel obstruction due to a volvulus who is experiencing
abdominal rigidity.
a. The client with a small bowel obstruction who has a nasogastric tube that is
draining greenish fluid.
RATIONALE: A small bowel obstruction is a potentially serious condition, and
the drainage of green fluid through the nasogastric tube may indicate a possible
bowel perforation or compromised blood supply. This situation requires immediate
pg. 4
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