HESI: Medical-Surgical Assignment
Exam and Rationale Correct and Verified Answers Graded A
- Which assessment finding should most concern the nurse who is monitoring a client two
hours after a thoracentesis?
A: New onset of coughing.
B: Low resting heart rate.
C: Distended neck veins.
D: Decreased shallow respirations.
Correct Answer: A: New onset of coughing.
- A client has been told that there is cataract formation over both eyes. Which finding
should the nurse expect when assessing the client?
A: Decreased color perception.
B: Presence of floaters.
C: Loss of central vision.
D: Reduced peripheral vision.
Correct Answer: A: Decreased color perception.
- A 40-year-old female client has a history of smoking. Which finding should the nurse
identify as a risk factor for myocardial infarction?
A: Oral contraceptives.
B: Senile osteopenia.
C: Levothyroxine therapy.
D: Pernicious anemia.
Correct Answer: A: Oral contraceptives.
- The nurse is teaching a client diagnosed with peripheral arterial disease. Which
genitourinary system complication should the nurse include in the teaching?
A: Altered sexual response.
B: Sterility.
C: Urinary incontinence.
D: Decreased pelvic muscle tone.
Correct Answer: A: Altered sexual response.
- Which assessment finding is of greatest concern to the nurse who is caring for a client
with stomatitis?
A: Cough brought on by swallowing.
B: Sore throat caused by speaking.
C: Painful and dry oral cavity.
D: Unintended weight loss.
Correct Answer: A: Cough brought on by swallowing.
- Which dietary assessment finding is most important for the nurse to address when
caring for a client with diabetic nephropathy?
A: Drinks a six pack of beer every day.
B: Enjoys a hamburger once a month.
C: Eats fortified breakfast cereal daily.
D: Consumes beans and rice every day.
Correct Answer: A: Drinks a six pack of beer every day.
- Which client should be further assessed for an ectopic pregnancy?
A: A 24-year-old with shoulder and lower abdominal quadrant pain.
B: A 33-year-old with intermittent lower abdominal cramping.
C: A 20-year-old with fever and right lower abdominal colic.
D: A 40-year-old with jaundice and right lower abdominal pain.
Correct Answer: A: A 24-year-old with shoulder and lower abdominal quadrant pain.
- A client with history of atrial fibrillation is admitted to the telemetry unit with sudden
onset of shortness of breath. The nurse observes a new irregular heart rhythm and should perform which assessment at this time?
A: Check for a pulse deficit.
B: Palpate the apical impulse.
C: Inspect jugular vein pulse.
D: Examine for a carotid bruit.
Correct Answer: A: Check for a pulse deficit.
- A male client comes into the clinic with a history of penile discharge with painful,
burning urination. Which action should the nurse implement?
A: Collect a culture of the penile discharge.
B: Palpate the inguinal lymph nodes gently.
C: Observe for scrotal swelling and redness.
D: Express the discharge to determine color.
Correct Answer: A: Collect a culture of the penile discharge.
- Which assessment is most important for the nurse to perform on a client who is
hospitalized for Guillain-Barre syndrome that is rapidly progressing?
A: Respiratory effort.
B: Unsteady gait.
C: Intensity of pain.
D: Ability to eat.
Correct Answer: A: Respiratory Effort
- While caring for a client who has esophageal varices, which nursing intervention is
most important for the registered nurse (RN) to implement?
A: Monitor infusing IV fluids and any replacement blood products.
B: Prepare for esophagogastroduodenoscopy (EGD).
C: Maintain the client on strict bedrest.
D: Insert a nasogastric tube (NGT) for intermittent suction.
Correct Answer: A: Monitor infusing IV fluids and any replacement blood products.
- The registered nurse (RN) is caring for a client who developed oliguria and was
diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the RN that the client is stabilizing?
A: Urine output of 40 mL/hour.
B: Apical pulse 100 and blood pressure 76/42.
C: Urine specific gravity 1.001.
D: Tented skin on dorsal surface of hands.
Correct Answer: A: Urine output of 40 mL/hour.
- After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned
the care of the client. Which nursing intervention is most important for the RN to implement?
A: Position client on left side with pillow placed under the costal margin.
B: Assist the client with voiding immediately after the procedure.
C: Evaluate vital signs q10 to 20 minutes for 2 hours after procedure.
D: Ambulate client 3 times in first hour with pillow held at abdomen.
Correct Answer: C: Evaluate vital signs q10 to 20 minutes for 2 hours after procedure.
- The registered nurse (RN) is caring for a client with aplastic anemia who is hospitalized
for weight loss and generalized weakness. Laboratory values show a white blood count (WBC) of 2,500/mm 3 and a platelet count of 160,000/mm 3. Which intervention is the primary focus in the client's plan of care for the RN to implement?
A: Assist with frequent ambulation.
B: Encourage visitors to visit.
C: Maintain strict protective precautions.
D: Avoid peripheral injections.
Correct Answer: C: Maintain strict protective precautions.
