Medical-Surgical HESI Correct and Verified Answers Graded A

• | P a g e

Medical-Surgical HESI Correct and Verified Answers Graded A

• What is the correct location for placement of the hands for manual chest

compressions during cardiopulmonary resuscitation (CPR) on the adult client?

• Just above the xiphoid process, on the upper third of the sternum
• Below the xiphoid process, midway between the sternum and the umbilicus
• Just above the xiphoid process, on the lower third of the sternum
• Below the xiphoid process, midway between the sternum and the first rib

Correct Answer: C. Just above the xiphoid process, on the lower third of the sternum

• A hospitalized client is receiving nasogastric tube feedings via a small-bore tube

and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first?

• Auscultate the client's breath sounds.
• Turn off the continuous feeding pump.
• Check placement of the nasogastric tube.
• Measure the amount of residual feeding.

Correct Answer: B. Turn off the continuous feeding pump.

• The nurse observes ventricular fibrillation on telemetry and, on entering the client's

bathroom, finds the client unconscious on the floor. Which intervention should the nurse implement first?

• Administer an antidysrhythmic medication.
• Start cardiopulmonary resuscitation.
• Defibrillate the client at 200 J.
• Assess the client's pulse oximetry.

• | P a g e

Correct Answer: B. Start cardiopulmonary resuscitation.

• A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid

ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment?

• Administer lidocaine,75 mg intravenous push.
• Perform synchronized cardioversion.
• Defibrillate the client as soon as possible.
• Administer atropine, 0.4 mg intravenous push.

Correct Answer: B. Perform synchronized cardioversion.

• The nurse is reviewing routine medications taken by a client with chronic angle

closure glaucoma. Which medication prescription should the nurse question?

• Antianginal with a therapeutic effect of vasodilation
• Anticholinergic with a side effect of pupillary dilation
• Antihistamine with a side effect of sedation
• Corticosteroid with a side effect of hyperglycemia

Correct Answer: B. Anticholinergic with a side effect of pupillary dilation

• A client is admitted to the hospital with a diagnosis of severe acute diverticulitis.

Which nursing intervention has the highest priority?

• Place the client on NPO status.
• Assess the client's temperature.
• Obtain a stool specimen.
• Administer IV fluids.

Correct Answer: A. Place the client on NPO status.

• A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated

at a community hemodialysis facility. Before his scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate?

• Hypophosphatemia
• Hypocalcemia

• | P a g e

• Hyponatremia
• Hypokalemia

Correct Answer: B. Hypocalcemia

• The nurse notes that a client who is scheduled for surgery the next morning has an

elevated blood urea nitrogen (BUN) level. Which condition is most likely to have contributed to this finding?

• Myocardial infarction 2 months ago
• Anorexia and vomiting for the past 2 days
• Recently diagnosed type 2 diabetes mellitus
• Skeletal traction for a right hip fracture

Correct Answer: B. Anorexia and vomiting for the past 2 days

• During the shift report, the charge nurse informs a nurse that she has been assigned

to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings as she prepares to leave, making it known that she is very unhappy about being floated to the other unit. What is the best immediate action for the charge nurse to take?

• Continue with the shift report and talk to the nurse about the incident at a later time.
• Ask the nurse to call the house supervisor to see if she must be reassigned.
• Stop the shift report and remind the nurse that all staff are floated equally.
• Inform the nurse that her behavior is disruptive to the rest of the staff.

Correct Answer: A. Continue with the shift report and talk to the nurse about the incident at a later time.

• A male client has just undergone a laryngectomy and has a cuffed tracheostomy

tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?

• Immediately after feeding
• Just prior to tube feeding
• Continuous inflation is required
• Inflation is not required

• | P a g e

Correct Answer: B. Just prior to tube feeding

• A client is ready for discharge following the creation of an ileostomy. Which

instruction should the nurse include in discharge teaching?

• Replace the stoma appliance every day.
• Use warm tap water to irrigate the ileostomy.
• Change the bag when the seal is broken.
• Measure and record the ileostomy output.

Correct Answer: C. Change the bag when the seal is broken.

• A female client with a nasogastric tube attached to low suction states that she is

nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. Which action should the nurse take first?

• Irrigate the nasogastric tube with sterile normal saline.
• Reposition the client on her side.
• Advance the nasogastric tube 5 cm.
• Administer an intravenous antiemetic as prescribed.

Correct Answer: B. Reposition the client on her side.

• Which condition should the nurse anticipate as a potential problem in a female

client with a neurogenic bladder?

• Stress incontinence
• Infection
• Painless gross hematuria
• Peritonitis

Correct Answer: B. Infection

• The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12

hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take?

• Document this expected decrease in drainage.
• Clamp the chest tube while assessing for air leaks.