Question 2
Spring 2026 BSN 266- RN Medical/surgical. The nurse reviews the client’s symptoms and assessment findings. Click to highlight the findings requiring follow-up by the nurse.
Client remembers being at home and dropped dishes in the kitchen. Spouse was present and transported the client for emergency care. She is unable to remember being transported and wants to go home. Has weak left-hand grasp and unable to bear weight on left leg. Denies falling. Client unable to feel palpation of the left upper arm and upper and lower left leg. She informs had a mild headache around the eyes was present upon waking up in the morning but denies it now. Apical heart rate 82 and regular. Blood pressure 168/96 mm Hg. Peripheral pulses present. No jugular vein distension. No shortness of breath; has a productive cough. Client says back is “uncomfortable” on the examination table and asks to sit with the legs dependent.
Question 3
The nurse reviews the assessment findings to determine the most likely condition. Click to indicate which findings are associated with an ischemic stroke or a ruptured cerebral aneurysm. Each column must have at least one response option selected.
| Clinical Finding | Ischemic Stroke | Ruptured Cerebral Aneurysm |
| Confusion | X | X |
| Headache | X | |
| Left-sided weakness, paralysis | X | X |
| CT scan results | X | X |
| Treatment for atherosclerosis | X | |
| Elevated blood pressure | X | X |
Question 4
The nurse determines the client’s most immediate risk. Drag from the Word Choices to complete the sentence.
Based on the client’s symptoms and assessment findings, the nurse determines the priority to address for the client now is:
- Perfusion
- Sensory perception
- Mobility
- Cognition Spring 2026 BSN 266- RN Medical/surgical
Question 5
The nurse determines the most appropriate focus of care based on the client’s symptoms, assessment findings, and imaging test results. Select the 3 potential interventions the nurse would anticipate including in the plan of care.
- A. Monitor neurological status every hour
- B. Apply oxygen via nasal cannula
- C. Prepare for alteplase therapy
- D. Administer antihypertensive medication
- E. Ambulate in the hallway
- F. Administer antibiotics
Question 6
The nurse carries out interventions to support the client’s condition. For each intervention, click to indicate if the action is appropriate or not appropriate for the client receiving fibrinolytic therapy with alteplase. Each row must have one response option selected.
| Intervention | Appropriate | Not Appropriate |
| Conduct neurological assessment at 2-hour intervals | X | |
| Provide the total alteplase dose over 5 minutes | X | |
| Monitor vital signs every 15 minutes | X | |
| Prepare for a CT scan after alteplase therapy | X | |
| Limit venipunctures when possible | X | |
| Prepare for discharge in 24 hours | X |
Question 7
The nurse is evaluating care provided to the client recovering from fibrinolytic therapy. Which findings indicate that the client’s condition is improved? Select all that apply.
- A. Moving fingers on the left hand
- B. Blood pressure 132/88 mm Hg
- C. Oriented to person, place, and time
- D. Bends left leg at the knee
- E. Reports having a frontal headache
- F. Swallows sips of water
- G. NIH stroke scale rating 4
- H. Blood oozing from the intravenous site
Question 8
A male client who reports feeling chronically fatigued has a hemoglobin of 11 g/dL (110 g/L), hematocrit of 34% (0.34 volume fraction), and both microcytic and hypochromic red blood cells (RBC). Based on these findings, which dinner selection should the nurse suggest to the client?
- A. Broiled white fish with a baked sweet potato.
- B. Beef steak with steamed broccoli and orange slices.
- C. Cheese pasta and a lettuce and tomato salad.
- D. Grilled shrimp and seasoned rice with asparagus salad.
Question 9
A client with a closed head injury demonstrates signs of syndrome of inappropriate antidiuretic hormone (SIADH). Which additional finding should the nurse expect to obtain?
- A. Weight gain of 2 lb (0.91 kg) in one day.
- B. Urine specific gravity of 1.004.
- C. Fremitus over the chest wall.
- D. Serum sodium of 150 mEq/L (150 mmol/L).
Question 10
An older adult client recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. Which action should the nurse take?
- A. Prepare to transfer the client to a critical care unit.
- B. Assist the client to a high Fowler’s position in bed.
- C. Instruct the client in pursed lip breathing techniques.
- D. Observe the client for the presence of a barrel chest. Spring 2026 BSN 266- RN Medical/surgical
Question 11
A client with an external fixation device for a fractured left femur is troubled with left foot pain. Which intervention should the nurse implement first?
- A. Observe the leg for swelling.
- B. Auscultate blood pressure.
- C. Administer PRN pain medication.
- D. Assess peripheral pulses.
Question 12
The nurse reviews the client’s symptoms and assessment findings. Click to highlight the findings that warrant follow-up by the nurse.
“It’s been hard to catch my breath.” Crackles are heard in the bases of bilateral lungs. Heart rate is 118 beats/minute. Bilateral peripheral pitting edema of 2+ is present in both legs.
Question 13
The nurse reviews the assessment findings to determine the most likely condition. Click to indicate which findings are associated with heart failure, pneumonia, or pulmonary embolism. Each column must have at least one response option selected.
| Clinical Finding | Heart Failure | Pneumonia | Pulmonary Embolism |
| Shortness of breath | X | X | X |
| Crackles in the lungs | X | X | |
| Peripheral edema | X | ||
| Oxygen saturation 83% | X | X | X |
| Heart rate 118 beats/minute | X | X | X |
| History of smoking | X | X | X |
Question 14
The nurse determines the client’s most immediate risk. Drag from the Word Choices to complete the sentence.
Based on the client’s symptoms and assessment findings, the nurse determines the priority to address for the client now is:
- Oxygenation
- Perfusion
- Infection
- Nutrition
Question 15
The nurse determines the most appropriate focus of care based on the client’s symptoms, assessment findings, and imaging test results. Select the 3 potential interventions the nurse would anticipate including in the plan of care.
- A. Administer furosemide
- B. Monitor daily weight
- C. Encourage fluid intake
- D. Restrict dietary sodium
- E. Administer a beta-blocker
- F. Prepare for a chest X-ray Spring 2026 BSN 266- RN Medical/surgical
Question 16
The nurse carries out interventions to support the client’s condition. For each intervention, click to indicate if the action is appropriate or not appropriate. Each row must have one response option selected.
| Intervention | Appropriate | Not Appropriate |
| Administer high-flow oxygen | X | |
| Place the client in a high Fowler’s position | X | |
| Change the prescription for IV fluids to 50 mL/hour | X | |
| Weigh the client every shift | X | |
| Assess the client’s lung sounds every 2 hours | X | |
| Encourage the client to increase oral fluid intake | X |
Question 17
The nurse is evaluating care provided to the client. Which findings indicate that the client’s condition is improved? Select all that apply. Spring 2026 BSN 266- RN Medical/surgical
- A. Oxygen saturation 96% on 2 L/min via nasal cannula
- B. Weight decrease of 3 lb (1.36 kg) in 24 hours
- C. Heart rate 92 beats/minute
- D. Crackles heard only in the bases of the lungs
- E. Urine output of 600 mL over the last 8 hours
- F. Denies having any pain
- G. Pitting edema 2+ in the lower extremities
Question 18
The nurse is planning care for a client who is at risk for developing deep vein thrombosis (DVT). Which intervention should the nurse include in the plan of care? Spring 2026 BSN 266- RN Medical/surgical
- A. Ensure the client’s legs are dependent when in bed.
- B. Encourage the client to use an incentive spirometer.
- C. Place the client in a side-lying position.
- D. Elevate the client’s legs on two pillows.
Question 19
The nurse is assessing a client who is receiving a unit of packed red blood cells. Which finding should the nurse identify as a potential hemolytic transfusion reaction?
- A. Respiratory rate 12 breaths/minute.
- B. Temperature 98.4°F (36.9°C).
- C. Heart rate 110 beats/minute.
- D. Blood pressure 120/80 mm Hg.
Question 20 of 60
The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?
- A Teach importance of medication regimen and follow up protocol.
- B Clarify that all STIs are transmitted through sexual intercourse.
- C Discuss that partners without similar symptoms may not be infected.
- D Emphasize that using safe sex practices removes the risk of STIs.
Question 21 of 60
The nurse is assessing a client’s arteriovenous (AV) fistula. Which finding provides evidence of its normal function?
- A Pulselessness.
- B Redness.
- C Ecchymotic area.
- D Enlarged vein.
Question 22 of 60
The nurse is caring for a client with urolithiasis who reports severe flank and abdominal pain. Which action should the nurse implement?
- A Encourage a high-calcium diet.
- B Strain all urine.
- C Limit fluid intake.
- D Maintain client on strict bedrest.
Question 23 of 60
The healthcare provider prescribed 2 liters of 5% Dextrose in water (D5W) to infuse in 24 hours. The IV administration set delivers 15 gtt/mL. How many mL/hour should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
- 83
Question 24 of 60
A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching?
- A Encourage active range of motion to limit stiffness.
- B Use electric heating pad when pain is at its worse.
- C Drink at least 8 cups (1,920 mL) of water per day.
- D Eat high protein foods to achieve ideal body weight.
Question 25 of 60
A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?
- A Take sedatives prior to sleep.
- B Sleep with the head of the bed flat.
- C Drink 1 to 2 glasses of wine at bedtime.
- D Begin a weight loss program.
Question 33 of 60
65-year-old female presents to the emergency department from home reporting fatigue and progressive shortness of breath over 5 days. Past medical history: Hypertension, myocardial infarction with stent placement 6 years ago. Social history: Smokes one pack of cigarettes per day for the last 20 years. Drinks one or two glasses of wine per day. Retired retail worker. Lives at home with her spouse and adult child. Medications: Lisinopril 20 mg daily, metoprolol 50 mg daily, aspirin 81 mg, hydrochlorothiazide 50 mg daily.
The emergency department nurse conducted an initial assessment. Click to highlight the findings from the nurse’s assessment that warrant follow-up.
0125 Client is alert and oriented to person, place, time, and situation. Client states, “It’s been hard to catch my breath.” Crackles are heard in the bases of bilateral lungs. S1 and S2 heart sounds noted. Heart rate is 118 beats/minute with a regular rhythm. Bilateral peripheral pitting edema of 2+ is present in both legs. Client denies pain. Reports voiding prior to coming to hospital.
(Note: Additional follow-up findings from the Flow Sheet include: Respirations: 26 breaths/minute, Blood pressure: 165/86 mm Hg, and Oxygen saturation via room air: 83%.)
Question 34 of 60
The nurse reviews the client’s assessment data and test results. For each client finding, click to indicate if the data is consistent with heart failure, pulmonary embolism, or myocardial infarction. Each column must have at least one response option selected.
- Chest pain: Myocardial Infarction, Pulmonary Embolism
- Weight gain: Heart Failure
- Heart rate: Heart Failure, Pulmonary Embolism, Myocardial Infarction Spring 2026 BSN 266- RN Medical/surgical
- Cardiac laboratory results: Heart Failure, Myocardial Infarction
- Shortness of breath: Heart Failure, Pulmonary Embolism, Myocardial Infarction
- Chest x-ray results: Heart Failure, Pulmonary Embolism
Question 35 of 60
The nurse determines the highest priority concerns for the client. Choose the most likely option to complete the sentence.
The nurse recognizes that the most immediate concern for the client is to improve her:
- Oxygen saturation
- Potassium level
- Blood pressure
- Pain level
Question 36 of 60
The nurse has received initial prescriptions for the client and is planning nursing care. Select 2 outcomes that would be appropriate for the nurse to include for the client’s plan of care.
- A BNP level will decrease
- B Potassium level will decrease
- C Lung sounds will remain unchanged
- D Weight will remain unchanged
- E Urine output will increase
- F Oxygen demands will increase
Question 37 of 60
The nurse is implementing new prescriptions. Click to indicate if each nursing action is appropriate or not appropriate for the client at the current time. Each row must have one response option selected.
- Ambulate the client in the hallway: Not Appropriate
- Encourage the client to drink 2 liters of fluids per day: Not Appropriate
- Administer daily potassium supplement: Appropriate
- Discuss the client’s readiness to quit smoking cigarettes: Appropriate
- Increase oxygen by nasal cannula: Appropriate
- Request a prescription for opioid pain medication: Not Appropriate
Question 38 of 60
The morning shift nurse reviews the client’s laboratory results and performs a shift assessment. Which findings indicate that treatment has been effective? Select all that apply.
- A BNP level
- B Potassium level
- C Creatinine level
- D Blood pressure
- E Urine output
- F Edema assessment
- G Oxygen saturation
- H Weight
- I Pain score
Question 39 of 60
The healthcare provider prescribes streptomycin 300 mg IM every 12 hours for a client with tuberculosis. The available vial is labeled, Streptomycin 1 gram/2.5 mL. How many milliliters should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
- 0.8
Question 43 of 60
Based on the diagnosis of meningitis for this client, the healthcare provider has written specific medication prescriptions. Select the two newly prescribed drugs that will first decrease inflammation and second, aid in diuresis.
- A Cefuroxime 2 gm IVPB every 4 hours
- B Dexamethasone 10 mg IVP daily
- C Mannitol IV 1 to 2 grams/kg, then 0.25 to 1 grams/kg every 4 hours
- D Phenytoin 225 mg by mouth (PO) daily
- E Codeine 30 mg by mouth (PO) every 4 hours as needed (PRN) headache
Question 44 of 60
A client with an external fixation device for a fractured left femur is troubled with left foot pain. Which intervention should the nurse implement first?
- A Administer PRN pain medication.
- B Auscultate blood pressure.
- C Observe the leg for swelling.
- D Assess peripheral pulses.
Question 54 of 60
Following a total thyroidectomy, the nurse plans to observe a client for complications. Which finding indicates that the client developed a complication?
- A Troubled with back and joint tenderness and pain.
- B Diaphoretic, but denies any headache.
- C Denies muscle spasms in extremities.
- D Reports of muscle twitching in hands and feet.
Question 55 of 60
A client who had a laparoscopic adrenalectomy for Cushing’s syndrome is admitted to the post-anesthesia care unit. Which assessment finding warrants immediate intervention by the nurse?
- A Purple marks on the client’s abdomen.
- B Irregular apical heart rate.
- C Quarter size blood spot on the dressing.
- D Pitting ankle edema.
Question 56 of 60
The nurse is caring for an older adult client with a history of chronic obstructive pulmonary disease (COPD) who is leaning over a bedside table and using accessory muscles to breathe. What action should the nurse take?
- A Prepare for a transfer to the critical care unit.
- B Instruct the client in pursed lip breathing techniques.
- C Observe the client for a barrel chest.
- D Position the client in high Fowler’s position.
Question 60 of 60
Complete the diagram by dragging from the choices to identify the condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s response to the actions.
- Potential Condition: Exercise induced asthma
- Actions to Take: Administer bronchodilator
- Actions to Take: Provide education on management of asthma
- Parameters to Monitor: Resolution of symptoms
- Parameters to Monitor: Lung sounds
