Med-Surg II HESI Test Bank_
Retake on September 2022, all answers verified Correct.
A – A nurse is collecting data from a client who has a possible cataract. Which of the
following manifestations should the nurse expect the client to report?
1) Decreased color perception
2) Loss of peripheral vision
3) Bright flashes of light
4) Eyestrain
A, B – A nurse is assisting with the care of a client immediately following a lumbar
puncture. Which of the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
3) Insert a urinary catheter.
4) Elevate the client’s head of bed.
5) Apply a cervical collar to the client.
A, B, C – A nurse is caring for a client who has Cushing’s syndrome. Which of the
following clinical manifestations should the nurse expect to observe? (Select all that
apply.)
1) Buffalo hump
2) Purple striations
3) Moon face
4) Tremors
5) Obese extremities
A, B, C, D – A nurse is collecting data from a client who has an exacerbation of gout.
Which of the following findings should the nurse expect? (Select all that apply.)
1) Edema
2) Erythema
3) Tophi
4) Tight skin
5) Symmetrical joint pain
A, B, C, D – A nurse is collecting data from a client who has emphysema. Which of the
following findings should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
5) Bradycardia
A, B, E – A nurse is reinforcing pre-operative teaching for a client who is scheduled for
surgery and is to take hydroxyzine preoperatively. Which of the following effects of the
medication should the nurse include in the teaching? (Select all that apply.)
1) Decreasing anxiety 2) Controlling emesis
3) Relaxing skeletal muscles
4) Preventing surgical site infections
5) Reducing the amount of narcotics needed for pain relief
A, D – A nurse is caring for a client who is 12 hours postoperative following a
transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with
continuous irrigation. The nurse notes there has not been any urinary output in the last
hour. Which of the following actions should the nurse perform first?
1) Notify the provider.
2) Administer a prescribed analgesic.
3) Offer oral fluids.
4) Determine the patency of the tubing.
A. – A nurse in a provider’s office is reinforcing teaching with a client who has anemia
and has been taking ferrous gluconate for several weeks. Which of the following
instructions should the nurse include?
1) Take this medication between meals.
2) Limit intake of Vitamin C while taking this medication.
3) Take this medication with milk.
4) Limit intake of whole grains while taking this medication.
A. – A nurse in a provider’s office is reinforcing teaching with a client who has anemia
and has been taking ferrous gluconate for several weeks. Which of the following
instructions should the nurse include?
1) Take this medication between meals.
2) Limit intake of Vitamin C while taking this medication.
3) Take this medication with milk.
4) Limit intake of whole grains while taking this medication.
A. – A nurse is assisting in the care of a client who is 2 hours postoperative following a
wedge resection of the left lung and has a chest tube to suction. Which of the following
is the priority finding the nurse should report to the provider?
1) Abdomen is distended
2) Chest tube drainage of 70 mL in the last hour
3) Subcutaneous emphysema is noted to the left chest wall
4) Pain level of 6 on a 0 to 10 scale
A. – A nurse is assisting with the care of a client who has diabetes insipidus. The nurse
should monitor the client for which of the following manifestations?
1) Hypotension
2) Polyphagia
3) Hyperglycemia
4) Bradycardia
A. – A nurse is assisting with the care of a client who is postoperative and has a closedwound drainage system in place. Which of the following actions should the nurse take?
1) Fully recollapse the reservoir after emptying it.
2) Empty the reservoir once per day.
3) Replace the drainage plug after releasing hand pressure on the device.
4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr.
A. – A nurse is caring for a client during the immediate postoperative period following
thoracic surgery. When administering an opioid analgesic for pain, the nurse should
explain that the medication should have which of the following effects?
1) Reducing anxiety
2) Increasing blood pressure
3) Increasing coughing
4) Increasing the client’s respiratory rate
A. – A nurse is caring for a client following an open reduction and internal fixation of a
fractured femur. Which of the following findings is the nurse’s priority?
1) Altered level of consciousness
2) Oral temperature of 37.7° C (100° C)
3) Muscle spasms
4) Headache
A. – A nurse is caring for a client immediately following a cardiac catheterization with a
femoral artery approach. Which of the following actions should the nurse take?
1) Check pedal pulses every 15 min.
2) Perform passive range-of-motion for the affected extremity.
3) Remind the client not to turn from side to side.
4) Keep the client in high-Fowler’s position for 6 hr.
A. – A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the
following reactions from the client should the nurse initially expect?
1) Denial
2) Bargaining
3) Acceptance
4) Anger
A. – A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a
prescription for a hypothermia blanket. The nurse should monitor the client for which of
the following adverse effects of the hypothermia blanket?
A. Shivering
B. Infection
C. Burns
D. Hypervolemia
HESI RN MED SURG EXAM
PACK-EXAM MEREGED FROM
2019/2020/2021 ACTUAL
EXAMs
BEST FOR 2022 NEXT GEN
ACTUAL EXAM REVIEW
MED SURG EXAM PACK
HESI RN MED SURG
- A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the
best initial nursing action?
Answer: Administer the first dose of prescribed antibiotic therapy - A client is brought to the Emergency Department by ambulation in cardiac arrest with cardiopulmonary
resuscitation (CPR) in progress. The client is intubated and receiving 100% oxygen per self‐inflating (ambu)
bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most
important for the nurse to obtain?
Answer: deep tendon reflexes. - After hospitalization for Syndrome of Inappropriate Antidiuretic hormone (SIADH), a client develops
myelinolysis. Which intervention should the nurse implement first?
Answer: Reorient client to hisroom. - A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because
they are too tight. Which additional information should the nurse obtain?
Answer: Has his weight changed in the last several days? - An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a
persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse
implement?
Answer: Apply a high‐flow venturi mask. - A client with a history of asthma and bronchitis arrives at the clinic with SOB, productive cough with
thickened, tenacious mucous, and the inability to walk up flight of stairs without experiencing
breathlessness. Which action is most important for the nurse to instruct the client about self‐care?
Answer: Increase the daily intake of oral fluids to liquefy secretions. - A cardiac catheterization of a client with heart disease indicates the following blockages: 95% LAD, 99%
proximal circumflex, and 95% proximal RCA. The client later asks the nurse “what does all that mean for
me?”
Answer: Three main arteries have major blockage with only 1 to 5% of the blood flow getting through to
the heart muscle. - A client who weighs 175 pounds is receiving an IV bolus dose of heparin 80 units/kg. The heparin is
available in a 2 mL vial, labeled 10,000 units/mL. How many mL should the nurse administer? (enter
numeric value only. If rounding, round to nearest tenth.)
Answer: 1.3 mL
after calculations: the calculator will show 1.272727272727273, but you must round to the nearest tenth.
So, the answer is 1.3 mL. - What information should the nurse include in the teaching plan of a client diagnosed with
gastroesophageal reflux disease (GERD)?
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Answer: minimize symptoms by wearing loose, comfortable clothing.
- The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse
instruct the client to maintain?
Answer: Left Lateral. - A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink
without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare
provider?
Answer: Yellow Sclera - While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological
assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
Answer: Increasing anxiety. - The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft to
promote burn healing. Which information should the nurse provide this client?
Answer: The xenograft is taken from nonhuman sources. - A male client who had colon surgery 3 days ago is anxious and request assistance to reposition. The
wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and palaces it over
the wound. Which intervention should the nurse implement next?
answer: prepare the client to return to the operating room. - A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117
mEq/L. Which nursing problem should the nurse include in this client’s plan of care?
answer: fluid volume excess
16.A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heart
beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare provider
suspects hyperthyroidism. Which action should the nurse implement?
answer:space the client’s care to provide periods of rest - The nurse is teaching a client with glomerulonephritis about self‐care. Which dietary recommendations
should the nurse encourage the client to follow?
answer: restrict intake by limiting meats and other high‐protein foods. - An overweight, young adult male who has recently diagnosed with type diabetes mellitus is admitted for a
hernia repair. He tells the nurse he is feeling very weak and jittery. Which actions should the nurse
implement? (select all that apply).
☒Assess hisskin temperature and moisture.
☒Document anxiety on the surgical checklist.
☒Administer a PRN dose of regular insulin
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assessment finding warrants immediate intervention by the nurse?
answer: irregular apical pulse - An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers.
After warming her hands, the fingers turn red and the client reports a burning sensation. What action
should the nurse take?
answer:secure a pulse oximeter to monitor the client’s oxygen saturation. - A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right
foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital
signs are temperature 101° F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood
pressure 122/82, which intervention is most important for the nurse to implement first?
Answer: assess lower extremity circulation.
22.The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic
cholecystectomy under general anesthesia. Which finding warrants notification ofthe healthcare provider
prior to proceeding with the scheduled procedure?
answer: the client’s blood pressure is 184/88 mm Hg. - A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which
additional finding warrants the most immediate action by the nurse?
answer: hematocrit of 30% - Following surgical repair of the bladder, a female client is being discharged from the hospital to home
with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this
client?
answer: keep the drainage bag lower than the level of the bladder - Which client has the highest risk for developing skin cancer?
answer: a 65‐year‐old fairskinned male who is a construction worker. - When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to
obtain?
answer: level of consciousness - A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which
is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF).
(select all that apply).
☒Verify pedal pulses using a doppler pulse device.
☒Monitor left leg for pain, pallor, paresthesia, paralysis, pressure.
☒Evaluate the application of the splint to the left leg. - A male client with herpeszoster (shingles) on his thorax tellsthe nurse that he is having difficulty sleeping.
What is the probably etiology of this problem?
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