MED SURG HESI V2 - 2025/2026 Correct and Verified Answers Graded A
- The nurse is providing preoperative education for a Jewish client scheduled to
- While caring for a client with Amyotrophic lateral sclerosis (ALS) a nurse performs a
receive a xenograft to promote burn healing. Which information should the provider give this client? A. Grafting increase the risk for bacterial infections B. The xenograft is taken from a non-human source. C. Grafts are later removed by a debriding procedure D.As the burns heals, the graft permanently Correct Answer: B. The xenograft is taken from a non-human source.
neurological assessment every 4 hours. Which assessment finding warrants immediate intervention by the nurse? A. Inappropriate laughter B. Increasing anxiety C.
Weakened cough effort D. Asymmetrical weakness Correct Answer: D. Asymmetrical
weakness
- A client with Cholelithiasis has a gallstone lodged in the common bile duct and is
unable to eat or drink without becoming nauseous and vomiting. Which finding should the nurse report to the healthcare provider? A. Belching B. Amber urine C. Yellow sclera
D. Flatulence Correct Answer: C. Yellow sclera
- The nurse is caring for a client with a lower left lobe pulmonary abscess. What
position should the nurse instruct the client to maintain? A. Left lateral B. Supine, knees
flexed. C. Dorsal recumbent D. Knee-chest Correct Answer: A. Left lateral
- A cardiac catheterization of a client with heart disease indicates the following
- A client with a history of asthma and bronchitis arrives at the clinic with shortness
blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and 95% proximal right coronary artery (RCA) the client later asks the nurse "What does all of that mean for me?" What information should the nurse provide? B. Three main arteries have major blockages, with only 1-5% of the blood flow getting through to the heart muscles Correct Answer: B. Three main arteries have major blockages, with only 1-5% of the blood flow getting through to the heart muscles
of breath, productive cough with thickening mucous and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self care? A. Increase the daily intake of oral fluids to liquify secretions B. Avoid crowded enclosed areas to reduce pathogens exposure
- Call the clinic if undesirable side effects or medications Correct Answer: A. Increase
- An older adult woman with a long history of COPD is admitted with progressive
the daily intake of oral fluids to liquify secretions
shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth. Which intervention should the nurse implement? A. Administer a prescribed sedative B. Encourage client to drink water C. Apply a high flow Venturi mask D. Assist her
to an upright position Correct Answer: D. Assist her to an upright position
- A male client with heart failure calls the clinic and reports that he cannot put his
shoes on because they are too tight. Which additional information should the nurse obtain? A. What time did he take his medication? B. Has his weight changed in the last several days? C. Is he still able to tighten his belt buckle? D. How many hours did he sleep
last night?Correct Answer: B. Has his weight changed in the last several days?
- After hospitalization for SIADH, a client develops pontine myelinolysis. Which
intervention should the nurse implement first? A. Reorient client to room B. Place a patch on one eye C. Evaluate clients ability to swallow D. Perform range of motion
exercises Correct Answer: A. Reorient client to room
- What information should the nurse include in the teaching plan of a client
diagnosed with GERD? A. Sleep without pillows B. Adjust food intake to three full meals per day with no snacks C. Minimize symptoms by wearing loose comfortable clothing D.
Avoid participation in any aerobic exercise program Correct Answer: C. Minimize
symptoms by wearing loose comfortable clothing
- A male client who had colon surgery 3 days ago is anxious and requesting
assistance to reposition. While the nurse is turning him, the wound dehiscences and ulcerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next? A. Bring additional sterile dressing supplies to the room. B. Prepare the client to return to the OR C. Obtain a sample of the drainage to send to the lab D. Auscultate the abdomen for bowel sounds Correct
Answer: A. Bring additional sterile dressing supplies to the room.
- A client with carcinoma of the lung is complaining of weakness and has a serum
- A female client enters the clinic and insists on being seen. She is weak, nervous
sodium level of 117 mEq/L. Which nursing problem should the nurse include in the clients plan of care? A. Altered urinary elimination B. Impaired gas exchange C. Fluid volume excess D. Decreased cardiac output Correct Answer: C. Fluid volume excess
and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the MD suspects hyperthyroidism and admits her for testing.
Which action should the nurse do? A. Begin preparing the client for thyroidectomy procedure B. Space the clients care to provide periods of rest C. Assess the client for hyperactive bowel sounds D. Provide warm blanket to prevent heat loss Correct Answer:
- Assess the client for hyperactive bowel sounds
- The nurse is teaching a client with glomerulonephritis about self care. Which
dietary recommendations should the nurse encourage the client to follow? A. Increase intake of high-fiber foods, such as bran cereal. B. Restrict protein intake by limiting meals and other high-protein foods C. Limit oral fluid intake of 500 ml/day D. Increase intake of
potassium rich foods such as bananas and cantaloupe Correct Answer: B. Restrict
protein intake by limiting meals and other high-protein foods
- An overweight young adult male who was recently diagnosed with type 2 DM is
admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery.Which actions should the nurse implement? Select all that apply. A. Check his fingerstick glucose B. Assess his skin temperature and moisture C. Measure his pulse and BP D. Document anxiety on the surgical checklist E. Administer a PRN dose of regular
insulin Correct Answer: A, B, C (Check his fingerstick glucose, Assess his skin
temperature and moisture, Measure his pulse and BP)
- A client with Cushing Syndrome is recovering from an elective laparoscopic
- Irregular apical pulse B. Purple marks on skin of the abdomen C. Quarter sized blood
- An adult woman with primary Raynaud phenomenon develops pallor and then
- Continue to monitor the fingers until color returns to normal
- A male client with muscular dystrophy fell in his home and is admitted with a right
procedure. Which assessment finding warrants immediate intervention by the nurse?
spot on the dressing D. Pitting ankle edema Correct Answer: A. Irregular apical pulse
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? A. Apply a cool compress to the affected fingers for 20 minutes B. Secure a pulse oximeter to monitor the client's oxygen saturation C. Report the finding to the healthcare provider as soon as possible D. Continue to monitor the fingers until color returns to normal Correct Answer:
hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are T: 101 degrees, HR: 128, RR: 28, B/P: 122/82. Which intervention is most important for the nurse to implement first? A.Obtain oxygen saturation level. B. Encourage incentive spirometry C. Assess lower extremity circulation D. Administer oral PRN antipyretic Correct Answer: D. Administer oral PRN antipyretic
- The nurse is completing the preoperative assessment of a client who is scheduled
- A client who has a history of hyperthyroidism was initially admitted with lethargy
for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the HCP prior to proceeding with the scheduled procedure? A. Light yellow coloring of the clients skin and eyes. B. The clients blood pressure reading 184/88mm C. The client vomits 20 mL of clear yellowish fluid D. The IV insertion site is red, swollen, and leaking IV fluid Correct Answer: B. The clients blood pressure reading 184/88mm
and confusion. Which additional finding warrants the most immediate action by the nurse? A. Facial puffiness and periorbital edema B. Hematocrit of 30% C. Cold and dry skin
D. Further decline in LOC Correct Answer: D. Further decline in LOC
- Following surgical repair of the bladder, a female client is being discharged from
- Which client has the highest risk for developing skin cancer? A. A 16 year old dark
- When caring for a client with nephrotic syndrome, which assessment is most
the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client? A. Avoid coiling the tubing and keep it free of kinks B. Cleanse the perineal area with soap and water twice daily C. Keep the drainage bag lower than the level of the bladder D. Drink 1,000 ml of fluids daily to irrigate catheter Correct Answer: C. Keep the drainage bag lower than the level of the bladder
skinned female who tans in tanning bed once a week. B. A 65 year old fair skinned male who is a construction worker C. A 25 year old dark skinned male who mother had skin cancer. D. A 70 year old fair skinned female who works as a secretary Correct Answer: B. A 65 year old fair skinned male who is a construction worker
important for the nurse to obtain? A. Daily weight B. Vital signs C. Level of consciousness
D. Bowel sounds Correct Answer: A. Daily weight
- 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 prep for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement?Select all that apply. B. Verify pedal pulses using a Doppler C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure D. Evaluate the splint to the left leg Correct Answer: B, C, D (Verify pedal pulses using a Doppler; Monitor left leg for pain, pallor, paresthesia, paralysis, pressure; Evaluate the splint to the left leg)
