2026/2027 HESI MED-SURG RN CUSTOM EXAM |
Medical-Surgical Nursing II Review Questions with Verified
Answers & Rationales | Pass Guaranteed - A+ Graded
Time Allowed: 120 minutes
Total Questions: 50
Passing Score: 80% (40/50)
[IMAGE: Wound staging diagram showing pressure injury depths would appear here]
Q1: A nurse is assessing a pressure injury on a patient's sacrum. The wound presents
with full-thickness skin loss; subcutaneous fat is visible but bone, tendon, and muscle
are not exposed. How should the nurse stage this wound?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury. [CORRECT]
D. Stage 4 pressure injury
Correct Answer: C
,Rationale: A Stage 3 pressure injury involves full-thickness skin loss with visible adipose
(subcutaneous fat) tissue. Granulation tissue may be present, and rolled wound edges
(epibole) are common. Stage 2 (B) presents as partial-thickness with exposed dermis,
pink/red moist wound bed, and no subcutaneous fat visible. Stage 4 (D) involves
exposed bone, tendon, or muscle. Stage 1 (A) presents as intact skin with
non-blanchable erythema. Accurate staging is critical for treatment selection and
reimbursement (Medicare does not cover Stage 1 or unstagable wounds in some
settings).
[IMAGE: EKG strip showing atrial fibrillation with rapid ventricular response would
appear here]
Q2: A patient with a history of heart failure presents with shortness of breath and an
irregularly irregular heart rate of 132 bpm. The nurse reviews the cardiac monitor. Which
medication should the nurse anticipate administering first?
A. Metoprolol
B. Digoxin
C. Amiodarone. [CORRECT]
D. Adenosine
Correct Answer: C
,Rationale: The EKG shows rapid atrial fibrillation (irregularly irregular rhythm, no P
waves, fibrillatory waves). In a hemodynamically unstable patient with acute heart
failure exacerbation, amiodarone is preferred for rate control and possible
cardioversion. It has less negative inotropy than beta-blockers (A) and faster onset than
digoxin (B). Adenosine (D) is contraindicated—it's for narrow-complex supraventricular
tachycardias with regular rhythm, not atrial fibrillation. Metoprolol may be used in stable
patients but can worsen acute decompensated HF.
Q3: A nurse is caring for a patient 2 hours post-hip arthroplasty. The patient's blood
pressure is 98/52 mmHg, heart rate 118 bpm, respiratory rate 24/min, and oxygen
saturation 89% on room air. The patient reports sudden shortness of breath and
pleuritic chest pain. Which action should the nurse take first?
A. Notify the healthcare provider
B. Apply oxygen at 100% via non-rebreather mask. [CORRECT]
C. Elevate the head of the bed
D. Prepare for STAT chest x-ray
Correct Answer: B
Rationale: The presentation (sudden SOB, chest pain, tachypnea, hypoxemia,
tachycardia, hypotension in postoperative orthopedic patient) is classic for pulmonary
embolism. Following the ABC priority framework, airway and breathing take precedence.
, Immediate high-flow oxygen improves oxygenation and reduces pulmonary
vasoconstriction. While elevating HOB (C) and preparing for diagnostics (D) are
appropriate, oxygenation is the life-saving priority. Notification (A) should occur
simultaneously with or immediately after initial stabilization.
Q4: A patient with cirrhosis presents with confusion, asterixis (flapping tremor), and
elevated ammonia levels. Which dietary order should the nurse question?
A. Low sodium diet
B. High protein diet. [CORRECT]
C. Low fat diet
D. High carbohydrate diet
Correct Answer: B
Rationale: In acute hepatic encephalopathy, excessive protein intake can worsen
ammonia accumulation and neurological symptoms. Standard management involves
temporary protein restriction (0.5-1.0 g/kg/day) during acute episodes, with gradual
reintroduction as mental status improves. Lactulose and rifaximin are primary
treatments. Low sodium (A) is appropriate for ascites management. Low fat (C) and
high carbohydrate (D) are generally acceptable in liver disease. The nurse should
question high protein orders during acute encephalopathy.
Medical-Surgical Nursing II Review Questions with Verified
Answers & Rationales | Pass Guaranteed - A+ Graded
Time Allowed: 120 minutes
Total Questions: 50
Passing Score: 80% (40/50)
[IMAGE: Wound staging diagram showing pressure injury depths would appear here]
Q1: A nurse is assessing a pressure injury on a patient's sacrum. The wound presents
with full-thickness skin loss; subcutaneous fat is visible but bone, tendon, and muscle
are not exposed. How should the nurse stage this wound?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury. [CORRECT]
D. Stage 4 pressure injury
Correct Answer: C
,Rationale: A Stage 3 pressure injury involves full-thickness skin loss with visible adipose
(subcutaneous fat) tissue. Granulation tissue may be present, and rolled wound edges
(epibole) are common. Stage 2 (B) presents as partial-thickness with exposed dermis,
pink/red moist wound bed, and no subcutaneous fat visible. Stage 4 (D) involves
exposed bone, tendon, or muscle. Stage 1 (A) presents as intact skin with
non-blanchable erythema. Accurate staging is critical for treatment selection and
reimbursement (Medicare does not cover Stage 1 or unstagable wounds in some
settings).
[IMAGE: EKG strip showing atrial fibrillation with rapid ventricular response would
appear here]
Q2: A patient with a history of heart failure presents with shortness of breath and an
irregularly irregular heart rate of 132 bpm. The nurse reviews the cardiac monitor. Which
medication should the nurse anticipate administering first?
A. Metoprolol
B. Digoxin
C. Amiodarone. [CORRECT]
D. Adenosine
Correct Answer: C
,Rationale: The EKG shows rapid atrial fibrillation (irregularly irregular rhythm, no P
waves, fibrillatory waves). In a hemodynamically unstable patient with acute heart
failure exacerbation, amiodarone is preferred for rate control and possible
cardioversion. It has less negative inotropy than beta-blockers (A) and faster onset than
digoxin (B). Adenosine (D) is contraindicated—it's for narrow-complex supraventricular
tachycardias with regular rhythm, not atrial fibrillation. Metoprolol may be used in stable
patients but can worsen acute decompensated HF.
Q3: A nurse is caring for a patient 2 hours post-hip arthroplasty. The patient's blood
pressure is 98/52 mmHg, heart rate 118 bpm, respiratory rate 24/min, and oxygen
saturation 89% on room air. The patient reports sudden shortness of breath and
pleuritic chest pain. Which action should the nurse take first?
A. Notify the healthcare provider
B. Apply oxygen at 100% via non-rebreather mask. [CORRECT]
C. Elevate the head of the bed
D. Prepare for STAT chest x-ray
Correct Answer: B
Rationale: The presentation (sudden SOB, chest pain, tachypnea, hypoxemia,
tachycardia, hypotension in postoperative orthopedic patient) is classic for pulmonary
embolism. Following the ABC priority framework, airway and breathing take precedence.
, Immediate high-flow oxygen improves oxygenation and reduces pulmonary
vasoconstriction. While elevating HOB (C) and preparing for diagnostics (D) are
appropriate, oxygenation is the life-saving priority. Notification (A) should occur
simultaneously with or immediately after initial stabilization.
Q4: A patient with cirrhosis presents with confusion, asterixis (flapping tremor), and
elevated ammonia levels. Which dietary order should the nurse question?
A. Low sodium diet
B. High protein diet. [CORRECT]
C. Low fat diet
D. High carbohydrate diet
Correct Answer: B
Rationale: In acute hepatic encephalopathy, excessive protein intake can worsen
ammonia accumulation and neurological symptoms. Standard management involves
temporary protein restriction (0.5-1.0 g/kg/day) during acute episodes, with gradual
reintroduction as mental status improves. Lactulose and rifaximin are primary
treatments. Low sodium (A) is appropriate for ascites management. Low fat (C) and
high carbohydrate (D) are generally acceptable in liver disease. The nurse should
question high protein orders during acute encephalopathy.
