MED SURGE HESI REAL EXAM 1 & 2 (2 VERSIONS) WITH ALL 300 QUESTIONS
AND CORRECT ANSWERS WITH RATIONALES/ MEDICAL SURGICAL HESI EXAM
TEST BANK
Question 1
Understanding classifications of pain helps nurses develop a plan of care. A 62-year-old male has
fallen while trimming tree branches sustaining tissue injury. He describes his condition as an
aching, throbbing back. This is characteristic of:
A) Mixed pain syndrome
B) Chronic pain
C) Neuropathic pain
D) Nociceptive pain
E) Psychogenic pain
Correct Answer: D) nociceptive pain.
Rationale: Nociceptive pain refers to the normal functioning of physiological systems that
leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe
this type of pain as aching, cramping, or throbbing. Neuropathic pain results from damage
to the nervous system and is described as burning or shooting. Chronic pain is unrelenting
and long-term (e.g., cancer). Mixed pain syndrome involves multiple poorly understood
mechanisms like fibromyalgia.
Question 2
The nurse is caring for a client with a high temperature (febrile). Which action should the nurse
perform FIRST to promote cooling?
A) Obtaining a fan from central supply for the client's room
B) Monitoring the client's temperature every 4 hours
C) Sponging the client with ice water while monitoring for shivering
D) Applying cool packs to the client's axillae and groin
E) Administering an extra dose of prescribed antibiotics
Correct Answer: D) Apply cool packs to the client's axillae and groin
Rationale: Applying cool packs to areas with high blood flow (axillae and groin) is an
effective non-pharmacological way to reduce core temperature. The use of fans is
discouraged in clinical settings because they can disperse pathogens throughout the room.
Sponging with ice water can cause shivering, which actually increases metabolic heat
production and core temperature.
Question 3
A patient has been newly diagnosed with hypertension. The nurse assesses the need to develop a
collaborative plan of care. Which is the most important initial goal for the nurse during the
planning phase of patient teaching?
A) The patient will demonstrate coping skills needed to manage hypertension.
B) The patient will verbalize the side effects of all treatment options.
, 2
C) The patient will select the type of learning materials they prefer.
D) The patient will verbalize an understanding of following the regimen.
E) The patient will record their blood pressure daily for one week.
Correct Answer: C) The patient will select the type of learning materials they prefer.
Rationale: According to adult learning theory, adults learn best when information is
tailored to their specific learning styles and needs. Before teaching can be effective, the
nurse must assess how the patient learns best (visual, auditory, or kinesthetic). This
facilitates better engagement and adherence to the prescribed medical regimen.
Question 4
When reviewing the purposes of a family assessment, the nurse educator would identify a need
for further teaching if the student responded that family assessment is used to gain an
understanding of the family’s:
A) Development
B) Function
C) Structure
D) Political views
E) Communication patterns
Correct Answer: D) political views.
Rationale: A family assessment is designed to understand the family’s structure,
development, and function to provide holistic and quality healthcare. While social factors
are important, the personal political views of family members are not a primary objective
or required component of a clinical nursing family assessment.
Question 5
The client was given 15 mg of morphine IM for postsurgical pain. One hour later, the nurse finds
the client sleeping with a respiratory rate of 10 breaths/min. What is the nurse's priority action?
A) Administering oxygen at 2L via nasal cannula
B) Documenting the findings and continuing to monitor closely
C) Arousing the client by calling his or her name
D) Administering naloxone (Narcan) 0.4mg IV push
E) Calling a Rapid Response Team
Correct Answer: C) Arousing the client by calling his or her name
Rationale: Minimal respiratory depression is common with opioid use. If the client is easily
arousable and their respiratory rate increases spontaneously upon awakening, no further
intervention (like Narcan) is necessary. Narcan should be reserved for clients who are
unresponsive and show significant respiratory compromise, as it will also immediately
reverse all pain control.
Question 6
The physician orders Digoxin (Lanoxin) 0.375 mg PO every day. On hand, the nurse has 0.25
, 3
mg/5 mL. How many mL should the nurse administer?
A) 8 mL
B) 7.5 mL
C) 7 mL
D) 5.5 mL
E) 10 mL
Correct Answer: B) 7.5 mL
Rationale: Using the formula (Desired / Have) x Volume: (0.375 mg / 0.25 mg) = 1.5. Then,
1.5 x 5 mL = 7.5 mL. Accuracy in medication calculation is vital for cardiac glycosides like
Digoxin due to their narrow therapeutic index.
Question 7
The nurse is admitting an older adult with decompensated congestive heart failure. The
assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question
which of the following orders?
A) KCl 20 mEq PO two times per day
B) Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
C) Oxygen via face mask at 8 L/min
D) Furosemide (Lasix) 20 mg PO now
E) Daily weights and I&O
Correct Answer: B) Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
Rationale: A patient with decompensated heart failure is already in a state of extracellular
fluid volume (ECV) excess. Administering normal saline (0.9% NaCl) will further expand
the intravascular volume and increase the workload on the failing heart, worsening the
pulmonary edema. Lasix is appropriate to remove fluid, and KCl is needed to replace losses
from the diuretic.
Question 8
Which of the following is the priority nursing intervention for a patient suspected of being
hypothermic?
A) Hydrating with intravenous (IV) warm fluids.
B) Removing the patient’s wet clothes.
C) Assessing the patient’s vital signs and core temperature.
D) Providing a warm, dry blanket.
E) Performing a focused neurological assessment.
Correct Answer: B) remove wet clothes.
Rationale: Heat loss is five times greater when clothing is wet. The most immediate and
effective action to stop further heat loss is removing the wet garments. While blankets and
IV fluids are part of the warming process, they are ineffective if the patient remains in cold,
wet clothing.
, 4
Question 9
The nurse is admitting a patient to the emergency department on a record-breaking hot summer
day. Which finding would most likely cause the nurse to suspect hyperthermia?
A) Slow capillary refill and pale extremities
B) Red, sweaty skin that is hot to the touch
C) Low pulse rate and bradypnea
D) Decreased respirations and cool skin
E) Sunken eyes and poor skin turgor
Correct Answer: B) red, sweaty skin.
Rationale: In hyperthermia, the body attempts to dissipate heat through vasodilation,
causing the skin to appear flushed (red) and feel warm/hot. Sweating is the body's primary
cooling mechanism. Conversely, slow capillary refill and cool skin are associated with
hypothermia.
Question 10
Why does the nurse always include a pain level assessment immediately following the
measurement of routine vital signs?
A) To follow McCaffery's national guidelines on pain management.
B) To ensure that pain assessment occurs on a regular, systematic basis.
C) To determine if the patient needs more frequent vital sign measurement.
D) To determine if pain is the primary driver of an elevated heart rate.
E) To satisfy hospital billing requirements.
Correct Answer: B) To ensure that pain assessment occurs on a regular basis
Rationale: By establishing pain as the "fifth vital sign," healthcare facilities ensure that
pain is assessed at every routine check. This systematic approach promotes better pain
management outcomes and ensures that pain is not overlooked during the nursing
assessment.
Question 11
The nurse observes "skin tenting" on the back of an 80-year-old client’s hand. Which action
should the nurse take next to accurately assess for dehydration?
A) Examine the patient’s dependent body areas for edema.
B) Notify the physician of the positive tenting result.
C) Document the finding as a sign of severe dehydration.
D) Assess skin turgor on the client's forehead or chest.
E) Offer the patient 8 ounces of water immediately.
Correct Answer: D) Assess turgor on the client's forehead.
Rationale: Skin turgor cannot be accurately assessed on an older adult’s hands because of
the age-related loss of subcutaneous tissue and skin elasticity (normal aging). To determine
AND CORRECT ANSWERS WITH RATIONALES/ MEDICAL SURGICAL HESI EXAM
TEST BANK
Question 1
Understanding classifications of pain helps nurses develop a plan of care. A 62-year-old male has
fallen while trimming tree branches sustaining tissue injury. He describes his condition as an
aching, throbbing back. This is characteristic of:
A) Mixed pain syndrome
B) Chronic pain
C) Neuropathic pain
D) Nociceptive pain
E) Psychogenic pain
Correct Answer: D) nociceptive pain.
Rationale: Nociceptive pain refers to the normal functioning of physiological systems that
leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe
this type of pain as aching, cramping, or throbbing. Neuropathic pain results from damage
to the nervous system and is described as burning or shooting. Chronic pain is unrelenting
and long-term (e.g., cancer). Mixed pain syndrome involves multiple poorly understood
mechanisms like fibromyalgia.
Question 2
The nurse is caring for a client with a high temperature (febrile). Which action should the nurse
perform FIRST to promote cooling?
A) Obtaining a fan from central supply for the client's room
B) Monitoring the client's temperature every 4 hours
C) Sponging the client with ice water while monitoring for shivering
D) Applying cool packs to the client's axillae and groin
E) Administering an extra dose of prescribed antibiotics
Correct Answer: D) Apply cool packs to the client's axillae and groin
Rationale: Applying cool packs to areas with high blood flow (axillae and groin) is an
effective non-pharmacological way to reduce core temperature. The use of fans is
discouraged in clinical settings because they can disperse pathogens throughout the room.
Sponging with ice water can cause shivering, which actually increases metabolic heat
production and core temperature.
Question 3
A patient has been newly diagnosed with hypertension. The nurse assesses the need to develop a
collaborative plan of care. Which is the most important initial goal for the nurse during the
planning phase of patient teaching?
A) The patient will demonstrate coping skills needed to manage hypertension.
B) The patient will verbalize the side effects of all treatment options.
, 2
C) The patient will select the type of learning materials they prefer.
D) The patient will verbalize an understanding of following the regimen.
E) The patient will record their blood pressure daily for one week.
Correct Answer: C) The patient will select the type of learning materials they prefer.
Rationale: According to adult learning theory, adults learn best when information is
tailored to their specific learning styles and needs. Before teaching can be effective, the
nurse must assess how the patient learns best (visual, auditory, or kinesthetic). This
facilitates better engagement and adherence to the prescribed medical regimen.
Question 4
When reviewing the purposes of a family assessment, the nurse educator would identify a need
for further teaching if the student responded that family assessment is used to gain an
understanding of the family’s:
A) Development
B) Function
C) Structure
D) Political views
E) Communication patterns
Correct Answer: D) political views.
Rationale: A family assessment is designed to understand the family’s structure,
development, and function to provide holistic and quality healthcare. While social factors
are important, the personal political views of family members are not a primary objective
or required component of a clinical nursing family assessment.
Question 5
The client was given 15 mg of morphine IM for postsurgical pain. One hour later, the nurse finds
the client sleeping with a respiratory rate of 10 breaths/min. What is the nurse's priority action?
A) Administering oxygen at 2L via nasal cannula
B) Documenting the findings and continuing to monitor closely
C) Arousing the client by calling his or her name
D) Administering naloxone (Narcan) 0.4mg IV push
E) Calling a Rapid Response Team
Correct Answer: C) Arousing the client by calling his or her name
Rationale: Minimal respiratory depression is common with opioid use. If the client is easily
arousable and their respiratory rate increases spontaneously upon awakening, no further
intervention (like Narcan) is necessary. Narcan should be reserved for clients who are
unresponsive and show significant respiratory compromise, as it will also immediately
reverse all pain control.
Question 6
The physician orders Digoxin (Lanoxin) 0.375 mg PO every day. On hand, the nurse has 0.25
, 3
mg/5 mL. How many mL should the nurse administer?
A) 8 mL
B) 7.5 mL
C) 7 mL
D) 5.5 mL
E) 10 mL
Correct Answer: B) 7.5 mL
Rationale: Using the formula (Desired / Have) x Volume: (0.375 mg / 0.25 mg) = 1.5. Then,
1.5 x 5 mL = 7.5 mL. Accuracy in medication calculation is vital for cardiac glycosides like
Digoxin due to their narrow therapeutic index.
Question 7
The nurse is admitting an older adult with decompensated congestive heart failure. The
assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question
which of the following orders?
A) KCl 20 mEq PO two times per day
B) Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
C) Oxygen via face mask at 8 L/min
D) Furosemide (Lasix) 20 mg PO now
E) Daily weights and I&O
Correct Answer: B) Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
Rationale: A patient with decompensated heart failure is already in a state of extracellular
fluid volume (ECV) excess. Administering normal saline (0.9% NaCl) will further expand
the intravascular volume and increase the workload on the failing heart, worsening the
pulmonary edema. Lasix is appropriate to remove fluid, and KCl is needed to replace losses
from the diuretic.
Question 8
Which of the following is the priority nursing intervention for a patient suspected of being
hypothermic?
A) Hydrating with intravenous (IV) warm fluids.
B) Removing the patient’s wet clothes.
C) Assessing the patient’s vital signs and core temperature.
D) Providing a warm, dry blanket.
E) Performing a focused neurological assessment.
Correct Answer: B) remove wet clothes.
Rationale: Heat loss is five times greater when clothing is wet. The most immediate and
effective action to stop further heat loss is removing the wet garments. While blankets and
IV fluids are part of the warming process, they are ineffective if the patient remains in cold,
wet clothing.
, 4
Question 9
The nurse is admitting a patient to the emergency department on a record-breaking hot summer
day. Which finding would most likely cause the nurse to suspect hyperthermia?
A) Slow capillary refill and pale extremities
B) Red, sweaty skin that is hot to the touch
C) Low pulse rate and bradypnea
D) Decreased respirations and cool skin
E) Sunken eyes and poor skin turgor
Correct Answer: B) red, sweaty skin.
Rationale: In hyperthermia, the body attempts to dissipate heat through vasodilation,
causing the skin to appear flushed (red) and feel warm/hot. Sweating is the body's primary
cooling mechanism. Conversely, slow capillary refill and cool skin are associated with
hypothermia.
Question 10
Why does the nurse always include a pain level assessment immediately following the
measurement of routine vital signs?
A) To follow McCaffery's national guidelines on pain management.
B) To ensure that pain assessment occurs on a regular, systematic basis.
C) To determine if the patient needs more frequent vital sign measurement.
D) To determine if pain is the primary driver of an elevated heart rate.
E) To satisfy hospital billing requirements.
Correct Answer: B) To ensure that pain assessment occurs on a regular basis
Rationale: By establishing pain as the "fifth vital sign," healthcare facilities ensure that
pain is assessed at every routine check. This systematic approach promotes better pain
management outcomes and ensures that pain is not overlooked during the nursing
assessment.
Question 11
The nurse observes "skin tenting" on the back of an 80-year-old client’s hand. Which action
should the nurse take next to accurately assess for dehydration?
A) Examine the patient’s dependent body areas for edema.
B) Notify the physician of the positive tenting result.
C) Document the finding as a sign of severe dehydration.
D) Assess skin turgor on the client's forehead or chest.
E) Offer the patient 8 ounces of water immediately.
Correct Answer: D) Assess turgor on the client's forehead.
Rationale: Skin turgor cannot be accurately assessed on an older adult’s hands because of
the age-related loss of subcutaneous tissue and skin elasticity (normal aging). To determine
