MED SURG HESI V2 ADVANCED SET EXAM 2026/2027 QUESTIONS AND CORRECT ANSWERS 100% PASS

MED SURG HESI V2 ADVANCED SET EXAM 2026/2027 QUESTIONS AND CORRECT ANSWERS 100% PASS 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 Ans-Minimize symptoms by wearing loose comfortable clothing 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 Ans-Reorient client to room 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 Ans-Has his weight changed in the last several days? An older adult woman with a long history of COPD is admitted with progressive 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 Ans-Assist her to an upright position HESI RN HESI RN A client with a history of asthma and bronchitis arrives at the clinic with shortness 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 C. Call the clinic if undesirable side effects or medications - Correct Ans-Increase the daily intake of oral fluids to liquify secretions A cardiac catherization of a client with heart disease indicates the following 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 Ans-Three main arteries have major blockages, with only 1-5% of the blood flow getting through to the heart muscles 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 Ans-Left lateral 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 Ans-Yellow sclera While caring for a client with Amyotrophic lateral sclerosis (ALS) a nurse performs a 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 Ans-Asymmetrical weakness The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft to promote burn healing. Which information should the provider 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 HESI RN HESI RN D. As the burns heals, the graft permanently - Correct Ans-The xenograft is taken from a non-human source 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. ausculate the abdomen for bowel sounds - Correct Ans-Bring additional sterile dressing supplies to the room A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117/meq. 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 Ans-Fluid volume excess A female client enters the clinic and insists on being seen. She is weak, nervous and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the MD suspects hyperthyroidisms 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 Ans-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 Ans-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 HESI RN HESI RN E. Administer a PRN dose of regular insulin - Correct Ans-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 procedure. which assessment finding warrants immediate intervention by the nurse? A. Irregular apical pulse B. Purple marks on skin of the abdomen C. Quarter sized blood spot on the dressing D. Pitting ankle edema - Correct Ans-Irregular apical pulse An adult woman with primary Raynaud phenomenon develops pallor and then 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 Ans-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 hip fracture. His right foot is cool, with palpable pedal pulses. lung are coarse with diminished bibasilar breath sounds. Vital signs are T: 101 degrees, HR: 128, RR: 28, B/P: 122/82. Which interventions is most important for the nurse to implement first? A. Obtain oxygen saturation level. B. Encourage incentivize spirometry C. Assess lower extremity circulation D. Administer oral PRN antipyretic - Correct Ans-Administer oral PRN antipyretic The nurse is completing the preoperative assessment of a client who is scheduled 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 Ans-The clients blood pressure reading 184/88 A client who has a history of hyperthyroidism was initially admitted with lethargy 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 Ans-Further decline in LOC HESI RN HESI RN Following surgical repair of the bladder, a female client is being discharged from 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 if 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 Ans-Keep the drainage back lower than the level of the bladder Which client has the highest risk for developing skin cancer? A. A 16 year old dark 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 Ans-A 65 year old fair skinned male who is a construction worker When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain? A. Daily weight B. Vital signs C. Level of consciousness D. Bowel sounds - Correct Ans-Daily weight A female client 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 pulse are diminished in the left foot. Which interventions should the nurse implement? (SATA) 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 Ans-Verify pedal pulses using a Doppler, monitor left leg for pain, pallor, paresthesia, paralysis, pressure, evaluate the splint to the left leg A male client with heroes zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. what is the etiology of this problem? A. pain B. Nocturia C. Dyspnea D. Frequent cough - Correct Ans-Pain When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing diagnoises of "visual sensory/perceptual alterations." This diagnosis is based on which etiology? A. limited eye movement B. Decreased peripheral vision HESI RN HESI RN C. Blurred distance, vision D. Photosensitivity - Correct Ans-Decreased peripheral vision A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self-management? A. Allow additional time to complete physical activities to reduce oxygen demand B. Practice inhaling through the nose and exhaling slowly through pursed lips C. Use a humidifier to increase air quality between 30-50% D. Strengthen abdominal muscles by alternating leg raises during exhalation - Correct Ans-Practice inhaling through the nose and exhaling slowly through pursed lips A client with cancer is receiving chemotherapy with a known vesicant. the clients IV has been in place for 72hrs. The nurse determines that a new IV site cannot be obtained and leaves present IV in place. What is greatest clinical risk? A. impaired skin integrity B. fluid volume excess C. Acute pain and anxiety D. Peripheral neuron vascular dysfunction - Correct Ans-Impaired skin integrity A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the post-anesthesia unit. Before selecting which medication to administer, which action should the nurse implement? A. Document client report of pain in EMR B. Determine which prescription will have quickest onset action C. Compare the clients pain scale rating w/prescribed dosing D. Ask the client to choose which medication is needed for pain - Correct Ans-Compare the clients pain scale rating w/prescribed dosing While assisting a female client to the toilet, the client begins to have a seizure and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which interventions should the nurse implement first? A. Document details of the seizure activity B. Observe for lacerations to the tongue C. Observe for prolonged periods of apnea D. Evaluate the evidence of incontinence - Correct Ans-Document details of the seizure activity A male client with diabetes mellitus transferred from the hospital to a rehabilitation facility following treatment for a stroke resulting in right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. which action should the nurse implement? A. Provide a warming pad to feet B. Medicate the client with a prescribed sedative C. Use a bed cradle to hold the covers off feet HESI RN HESI RN D. Place warm blanket next to the clients feed - Correct Ans-Place warm blanket next to clients feet During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? A. An old friend with eczema came for a visit B. Recently received an influenza immunization C. A grandson and his new dog recently visited D. Corticosteroid cream was applied to eczema - Correct Ans-A grandson and his new dog recently visited While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. What is the etiology of this problem? A. Irritation of nerve endings B. Diminished blood flow C. ischemic tissue changes D. Compression of a nerve - Correct Ans-Compression of a nerve The nurse assesses a client being treated for Herpes Zoster (Shingles) which assessment should the nurse include when evaluating the effectiveness of treatment (SATA) A. Skin integrity B. Functional ability C. Heart sounds D. Pain scale E. Bowel sounds - Correct Ans-Skin integrity, Functional ability, Pain scale A male client tells the nurse that he is experiencing burning on urination, and assessment reveals that he had sexual inter course four days w/a women he casually met. Which action should the nurse implement? A. Observe the perineal area for a chancroid-like lesion B. Obtain a specimen of urethral drainage for culture C. Assess for perineal itching, erythema, and excoriation D. Identify all sexual partners in the last four days - Correct Ans-Obtain a specimen of urethral drainage for culture A client with Addison's disease taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum lab value? A. Osmolarity B. glucose C. Albumin D. Platelets - Correct Ans-glucose HESI RN HESI RN A client with AIDS has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse? A. Elevated temperature B. Generalized weakness C. Diminished lung sounds D. Pain when swallowing - Correct Ans-Pain when swallowing An older male client tells the nurse he is losing sleep because he has to get up several times at night to go bathroom, that he has trouble starting his urinary stream and he doesn't feel like his bladder is empty. Which interventions? A. collect a urine specimen for culture analysis B. Review the clients fluid intake prior to bedtime C. Palpate the bladder above the symphysis pubis D. obtain a fingerstick glucose level - Correct Ans-Palpate the bladder above the symphysis pubis Fluids are restricted to 1500 ml/day for a male client with AKI. He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. What intervention should the nurse implement? A. Remove all sources of liquids from the clients room B. Allow family to give the client a measured amount of ice chips C. Restrict family visiting until the clients condition is stable D. Provide the client with oral swabs to moisten his mouth. - Correct Ans-Provide the client with oral swabs to moisten his mouth. During a paracentesis, 2L of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed and 50mL of straw colored fluid drains within 1st hr. What action to take? A. Palpate for abdominal distention B. Send fluid to the lab for analysis C. Continue to monitor the fluid output D. Clamp drainage tube for 5 mins - Correct Ans-Continue to monitor the fluid output While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the clients finger that are reddened. The client reports the nodes are painful. Which action should nurse take? A. Review the clients dietary intake of high protein foods B. Notify the HCP of the finding immediately C. Discuss approaches to chronic pain control with the client D. Assess the clients radial pulses and capillary refill time - Correct Ans-Discuss approaches to chronic pain control with the client A client who took a camping vacation 2 weeks ago in a country with tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. which finding is most important for the nurse to report to the HCP. HESI RN HESI RN A. Weakness and fatigue B. Intestinal cramping C. Weight loss D. Jaundiced sclera - Correct Ans-Jaundiced sclera Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI) a client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia. Which findings should the nurse document in the EMR as therapeutic response to the lidocaine? A. Stabilization of BP ranges B. Cessation of chest pain C. Reduce heart rate D. Decreased frequency of episodes of VT - Correct Ans-Decreased frequency of episodes of VT After a CT scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement? A. Call respiratory therapy to give a breathing treatment. B. Send another nurse for emergency tracheostomy set C. Prepare a dose of epinephrine D. Review the clients complete list of allergies - Correct Ans-Prepare a dose of epinephrine The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding A. Unchallenged rigidity B. Carotid bruit C. Jugular vein distention D. Palpable cervical lymph node - Correct Ans-Carotid bruit The nurse is obtaining a clients fingerstick glucose level. After gently milking the clients finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take? A. Collect the blood sample B. Assess radial pulse volume C. Apply pressure to the site D. Select another finger - Correct Ans-Collect the blood sample A client being admitted to a surgical unit is being evaluated for an intestinal obstruction. The HCP prescribes a NG tube to be inserted and placed to intermittent low wall suction. which intervention should the nurse implement to facilitate proper tube placement. A. Soak NG tube in warm water B. Insert tube with clients head tilted back HESI RN HESI RN C. Apply suction while inserting tube D. Elevate head of bed to 60 to 90 degrees - Correct Ans-Elevate head of bed to 60 to 90 degrees A young female client with 7 children is having frequent morning headaches, dizziness, and blurred vision. Her b/p is 168/104. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV med, which intervention is important? A. Measure urine output hourly to assess for renal perfusion B. Request a prescription for pain medication C. Use an automated BP machine to monitor for hypotension D. Provide privacy - Correct Ans-Use an automated BP machine to monitor for hypotension The wife of a client with Parkinson's disease expresses concern because her husband has lost so much weight. Which teaching is best for the nurse to provide? A. Invite friends over regularly to share meal times B. Encourage the client to drink clear liquids between meals C. Coach the client to make an intentional effort to swallow D. Talk to the HCP about prescribing an appetite stimulant. - Correct Ans-Invite friends over regularly to share meal times. A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes. Which assessment should implement first? A. Evaluate distal capillary refill for relayed perfusion B. Check the extremities for bruising and petechiae C. Examine the pertibial regions for pitting edema D. Palpate the abdomen for tenderness/rigid - Correct Ans-Palpate the abdomen for tenderness/rigid A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions? A. Report when hematuria becomes pink tinged B. Use incentive spirometer C. Restrict physical activities D. Monitor urinary stream for decrease in output - Correct Ans-Monitor urinary stream for decrease in output