MINDPLUG SOLUTIONS, EMPOWERING MINDS, BUILDING FUTURES
HESI MEDICAL-SURGICAL NURSING COMPLETE
EXAM (2025/2025) PREP WITH VERIFIED QUESTIONS
& ANSWERS (A+ GRADED)
The earliest and most sensitive assessment finding that would indicate an alteration in
intracranial regulation would be:
A) change in level of consciousness.
B) unequal pupil size.
C) loss of primitive reflexes.
D) inability to focus visually.
A
A change in level of consciousness is the earliest and most sensitive indication of a change
in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which
assesses eye opening and verbal and motor response. The inability to focus may indicate a
change, but it is not one of the earliest indicators or a component of the GCS. Primitive
reflexes refers to those reflexes found in a normal infant that disappear with maturation.
These reflexes may reappear with frontal lobe dysfunction and may be tested for with a
suspected brain injury, so it would be the reappearance of primitive reflexes. A change in
pupil size or unequal pupils may indicate a change, but they are not one of the earliest
indicators or a component of the GCS.
Which client statement indicates a good understanding regarding antibiotic therapy for
recurrent urinary tract infections?
A) "Even if I feel completely well, I should take the medication until it is gone."
B) "When my urine no longer burns, I will no longer need to take the antibiotics."
EDUCATIONAL SUPPORT • ACADEMIC RESOURCES • PROFESSIONAL GUIDANCE
,MINDPLUG SOLUTIONS, EMPOWERING MINDS, BUILDING FUTURES
C) "If my urine becomes lighter and clearer, I can stop taking my medicine."
D) "If I have a fever higher than 100° F (37.8° C), I should take twice as much medicine."
A
Antibiotic therapy is most effective, especially for recurrent urinary tract infections, when
the client takes the prescribed medication for the entire course, not just when symptoms
are present. The other statements demonstrate that additional teaching is needed for the
client.
A client presents with a pressure ulcer on the ankle. Which is the first intervention that the
nurse implements?
A) Place the client in bed and instruct him or her to elevate the foot.
B) Prepare for and assist with obtaining a wound culture.
C) Assess the affected leg for pulses, skin color, and temperature.
D) Draw blood for albumin, prealbumin, and total protein.
C
A client with an ulcer on the foot should be assessed for interruption in arterial flow to the
area. This begins with assessment of pulses and color and temperature of the skin. The
nurse can also assess for pulses noninvasively with a Doppler if unable to palpate with his
or her fingers. Elevation of the foot would impair the ability of arterial blood to flow to the
area. Wound cultures are done after it has been determined drainage, odor, and other risks
for infection are present. Tests to determine nutritional status and risk assessment would
be completed after the initial assessment is done.
EDUCATIONAL SUPPORT • ACADEMIC RESOURCES • PROFESSIONAL GUIDANCE
,MINDPLUG SOLUTIONS, EMPOWERING MINDS, BUILDING FUTURES
During assessment of a client with a 15-year history of diabetes, the nurse notes that the
client has decreased tactile sensation in both feet. Which action does the nurse take first?
A) Notify the health care provider.
B) Document the finding in the client's chart.
C) Examine the client's feet for signs of injury.
D) Test sensory perception in the client's hands.
C
Diabetic neuropathy is common when the disease is of long duration. The client is at great
risk for injury in any area with decreased sensation because he or she is less able to feel
injurious events. Feet are common locations for neuropathy and injury, so the nurse should
inspect them for any signs of injury. After assessing, the nurse should document findings in
the client's chart. Testing sensory perception in the hands may or may not be needed. The
health care provider can be notified after assessment and documentation have been
completed.
Which nursing intervention best assists a bedridden client to keep skin intact?
A) Use a lift sheet to move the client in bed.
B) Turn the client every 2 to 4 hours.
C) Use a foam mattress pad.
D) Apply talcum powder to the perineal area.
A
Friction forces are generated when the client is dragged or pulled across bed linen; this
often leads to altered skin integrity. Using a lift sheet will prevent friction. Keeping the skin
clean and dry is an important intervention, but powders should not be used in the perineal
EDUCATIONAL SUPPORT • ACADEMIC RESOURCES • PROFESSIONAL GUIDANCE
, MINDPLUG SOLUTIONS, EMPOWERING MINDS, BUILDING FUTURES
area. To minimize vasoconstriction and possible pressure ulcer development from
dependency, the client should be turned at a minimum of every 2 hours. A foam mattress
will not significantly decrease pressure to an area.
A client presents with an acute exacerbation of multiple sclerosis. Which prescribed
medication does the nurse prepare to administer?
A) Interferon beta-1b (Betaseron)
B) Baclofen (Lioresal)
C) Methylprednisolone (Medrol)
D) Dantrolene sodium (Dantrium)
C
Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other
medications are not appropriate.
The nurse is assessing a client's understanding of his hypertension therapy. What client
statement indicates a need for further teaching?
A) "When my blood pressure is normal, I will no longer need to take medication."
B) "If my blood pressure stays under control, I will reduce my risk for a heart attack."
C) "If I lose weight, I might be able to reduce my blood pressure medication."
D) "When getting out of bed in the morning, I will sit for a few moments then stand."
A
EDUCATIONAL SUPPORT • ACADEMIC RESOURCES • PROFESSIONAL GUIDANCE
HESI MEDICAL-SURGICAL NURSING COMPLETE
EXAM (2025/2025) PREP WITH VERIFIED QUESTIONS
& ANSWERS (A+ GRADED)
The earliest and most sensitive assessment finding that would indicate an alteration in
intracranial regulation would be:
A) change in level of consciousness.
B) unequal pupil size.
C) loss of primitive reflexes.
D) inability to focus visually.
A
A change in level of consciousness is the earliest and most sensitive indication of a change
in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which
assesses eye opening and verbal and motor response. The inability to focus may indicate a
change, but it is not one of the earliest indicators or a component of the GCS. Primitive
reflexes refers to those reflexes found in a normal infant that disappear with maturation.
These reflexes may reappear with frontal lobe dysfunction and may be tested for with a
suspected brain injury, so it would be the reappearance of primitive reflexes. A change in
pupil size or unequal pupils may indicate a change, but they are not one of the earliest
indicators or a component of the GCS.
Which client statement indicates a good understanding regarding antibiotic therapy for
recurrent urinary tract infections?
A) "Even if I feel completely well, I should take the medication until it is gone."
B) "When my urine no longer burns, I will no longer need to take the antibiotics."
EDUCATIONAL SUPPORT • ACADEMIC RESOURCES • PROFESSIONAL GUIDANCE
,MINDPLUG SOLUTIONS, EMPOWERING MINDS, BUILDING FUTURES
C) "If my urine becomes lighter and clearer, I can stop taking my medicine."
D) "If I have a fever higher than 100° F (37.8° C), I should take twice as much medicine."
A
Antibiotic therapy is most effective, especially for recurrent urinary tract infections, when
the client takes the prescribed medication for the entire course, not just when symptoms
are present. The other statements demonstrate that additional teaching is needed for the
client.
A client presents with a pressure ulcer on the ankle. Which is the first intervention that the
nurse implements?
A) Place the client in bed and instruct him or her to elevate the foot.
B) Prepare for and assist with obtaining a wound culture.
C) Assess the affected leg for pulses, skin color, and temperature.
D) Draw blood for albumin, prealbumin, and total protein.
C
A client with an ulcer on the foot should be assessed for interruption in arterial flow to the
area. This begins with assessment of pulses and color and temperature of the skin. The
nurse can also assess for pulses noninvasively with a Doppler if unable to palpate with his
or her fingers. Elevation of the foot would impair the ability of arterial blood to flow to the
area. Wound cultures are done after it has been determined drainage, odor, and other risks
for infection are present. Tests to determine nutritional status and risk assessment would
be completed after the initial assessment is done.
EDUCATIONAL SUPPORT • ACADEMIC RESOURCES • PROFESSIONAL GUIDANCE
,MINDPLUG SOLUTIONS, EMPOWERING MINDS, BUILDING FUTURES
During assessment of a client with a 15-year history of diabetes, the nurse notes that the
client has decreased tactile sensation in both feet. Which action does the nurse take first?
A) Notify the health care provider.
B) Document the finding in the client's chart.
C) Examine the client's feet for signs of injury.
D) Test sensory perception in the client's hands.
C
Diabetic neuropathy is common when the disease is of long duration. The client is at great
risk for injury in any area with decreased sensation because he or she is less able to feel
injurious events. Feet are common locations for neuropathy and injury, so the nurse should
inspect them for any signs of injury. After assessing, the nurse should document findings in
the client's chart. Testing sensory perception in the hands may or may not be needed. The
health care provider can be notified after assessment and documentation have been
completed.
Which nursing intervention best assists a bedridden client to keep skin intact?
A) Use a lift sheet to move the client in bed.
B) Turn the client every 2 to 4 hours.
C) Use a foam mattress pad.
D) Apply talcum powder to the perineal area.
A
Friction forces are generated when the client is dragged or pulled across bed linen; this
often leads to altered skin integrity. Using a lift sheet will prevent friction. Keeping the skin
clean and dry is an important intervention, but powders should not be used in the perineal
EDUCATIONAL SUPPORT • ACADEMIC RESOURCES • PROFESSIONAL GUIDANCE
, MINDPLUG SOLUTIONS, EMPOWERING MINDS, BUILDING FUTURES
area. To minimize vasoconstriction and possible pressure ulcer development from
dependency, the client should be turned at a minimum of every 2 hours. A foam mattress
will not significantly decrease pressure to an area.
A client presents with an acute exacerbation of multiple sclerosis. Which prescribed
medication does the nurse prepare to administer?
A) Interferon beta-1b (Betaseron)
B) Baclofen (Lioresal)
C) Methylprednisolone (Medrol)
D) Dantrolene sodium (Dantrium)
C
Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other
medications are not appropriate.
The nurse is assessing a client's understanding of his hypertension therapy. What client
statement indicates a need for further teaching?
A) "When my blood pressure is normal, I will no longer need to take medication."
B) "If my blood pressure stays under control, I will reduce my risk for a heart attack."
C) "If I lose weight, I might be able to reduce my blood pressure medication."
D) "When getting out of bed in the morning, I will sit for a few moments then stand."
A
EDUCATIONAL SUPPORT • ACADEMIC RESOURCES • PROFESSIONAL GUIDANCE
