HESI 55 Questions – Med Surg [2026/2027] Updated Version
| Verified Questions & Detailed Rationales
The nurse is receiving report from surgery about a client with a penrose
drain who is to be admitted to the postoperative unit. Before choosing a
room for this client, which information is most important for the nurse to
obtain?
A) If suctioning will be needed for drainage of the wound.
B) If the family would prefer a private or semi-private room.
C) If the client also has a Hemovac® in place.
D) If the client's wound is infected. - VERIFIED ANSWER - D) If the client's
wound is infected.
Rationale: Penrose drains provide a sinus tract or opening and are often
used to provide drainage of an abscess. The fact that the client has a
penrose drain should alert the nurse to the possibility that the client is
infected. To avoid contamination of another postoperative client, it is most
important to place an infected client in a private room (D). A penrose
drain does not require (A). Although (B) is information that should be
considered, it does not have the priority of (D). (C) is used to drain fluid
from a dead space and is not important in choosing a room.
,A patient admitted for a head injusry develops dry skin and urine output of
600 mL/hr. Which of the following interventions should the nurse perform
first?
a) Assess the patient's urine specific gravity
b) Slow IV fluid infusion rate
c) Assess the patient's level of conciousness
d) Notify the physician - VERIFIED ANSWER - a) Assess the patient's urine
specific gravity
Ratoinale: A urine output of 400 mL/hr after sustaining a head injury may
be indictative of diabetes insipidus. The nurse should assess for low
specific gravity and elevated serum osmolarity.
-Diabetes insipidus is the failure to produce antidiuretic hormone due to
damage to the pituitary gland from increased ICP.
-Notifying the physician is appropriate after the nurse has gathered
additional data.
A patient is prescribed dexamethasone (Decadron) to reduce cerebral
edema after a motor vehicle accident. Which of the following assessment
findings should the nurse expect if this treatment is effective?
a) Increased response to stimuli
,b) decreased urine output
c) respiration rate of 12
d) Increased blood pressure - VERIFIED ANSWER - a) Increased response
to stimuli
rationale: Dexamethasone (Decadron) is a corticosteroid that reduces
inflammation in the brain. When effectivness is achieved, the patient's
neurological status should improve.
-Decadron has little effect on blood pressure, respiration rate, and urine
output.
The nurse is assessing a client who is bedfast and refuses to turn or
move from a supine position. How should the nurse assess the client for
possible dependent edema?
A) Compress the flank and upper buttocks.
B) Measure the client's abdominal girth.
C) Gently palpate the lower abdomen.
D) Apply light pressure over the shins. - VERIFIED ANSWER - A) Compress
the flank and upper buttocks.
, Rationale: Dependent edema collects in dependent areas, such as the
flank and upper buttocks (A) of the client who is persistently flat in bed.
(B) provides data about ascites (fluid collection in the abdomen), rather
than dependent edema, and (C) provides data about abdominal distention.
(D) provides data about the collection of dependent edema for a client
whose lower extremities are often in a dependent position, such as when
sitting in a chair.
A male client with chronic atrial fibrillation and a slow ventricular
response is scheduled for surgical placement of a permanent pacemaker.
The client asks the nurse how this devise will help him. How should the
nurse explain the action of a synchronous pacemaker?
A) Ventricular irritability is prevented by the constant rate setting of
pacemaker.
B) Ectopic stimulus in the atria is suppressed by the device usurping
depolarization.
C) An impulse is fired every second to maintain a heart rate of 60 beats
per minute.
D) An electrical stimulus is discharged when no ventricular response is
sensed. - VERIFIED ANSWER - D) An electrical stimulus is discharged when
no ventricular response is sensed.
| Verified Questions & Detailed Rationales
The nurse is receiving report from surgery about a client with a penrose
drain who is to be admitted to the postoperative unit. Before choosing a
room for this client, which information is most important for the nurse to
obtain?
A) If suctioning will be needed for drainage of the wound.
B) If the family would prefer a private or semi-private room.
C) If the client also has a Hemovac® in place.
D) If the client's wound is infected. - VERIFIED ANSWER - D) If the client's
wound is infected.
Rationale: Penrose drains provide a sinus tract or opening and are often
used to provide drainage of an abscess. The fact that the client has a
penrose drain should alert the nurse to the possibility that the client is
infected. To avoid contamination of another postoperative client, it is most
important to place an infected client in a private room (D). A penrose
drain does not require (A). Although (B) is information that should be
considered, it does not have the priority of (D). (C) is used to drain fluid
from a dead space and is not important in choosing a room.
,A patient admitted for a head injusry develops dry skin and urine output of
600 mL/hr. Which of the following interventions should the nurse perform
first?
a) Assess the patient's urine specific gravity
b) Slow IV fluid infusion rate
c) Assess the patient's level of conciousness
d) Notify the physician - VERIFIED ANSWER - a) Assess the patient's urine
specific gravity
Ratoinale: A urine output of 400 mL/hr after sustaining a head injury may
be indictative of diabetes insipidus. The nurse should assess for low
specific gravity and elevated serum osmolarity.
-Diabetes insipidus is the failure to produce antidiuretic hormone due to
damage to the pituitary gland from increased ICP.
-Notifying the physician is appropriate after the nurse has gathered
additional data.
A patient is prescribed dexamethasone (Decadron) to reduce cerebral
edema after a motor vehicle accident. Which of the following assessment
findings should the nurse expect if this treatment is effective?
a) Increased response to stimuli
,b) decreased urine output
c) respiration rate of 12
d) Increased blood pressure - VERIFIED ANSWER - a) Increased response
to stimuli
rationale: Dexamethasone (Decadron) is a corticosteroid that reduces
inflammation in the brain. When effectivness is achieved, the patient's
neurological status should improve.
-Decadron has little effect on blood pressure, respiration rate, and urine
output.
The nurse is assessing a client who is bedfast and refuses to turn or
move from a supine position. How should the nurse assess the client for
possible dependent edema?
A) Compress the flank and upper buttocks.
B) Measure the client's abdominal girth.
C) Gently palpate the lower abdomen.
D) Apply light pressure over the shins. - VERIFIED ANSWER - A) Compress
the flank and upper buttocks.
, Rationale: Dependent edema collects in dependent areas, such as the
flank and upper buttocks (A) of the client who is persistently flat in bed.
(B) provides data about ascites (fluid collection in the abdomen), rather
than dependent edema, and (C) provides data about abdominal distention.
(D) provides data about the collection of dependent edema for a client
whose lower extremities are often in a dependent position, such as when
sitting in a chair.
A male client with chronic atrial fibrillation and a slow ventricular
response is scheduled for surgical placement of a permanent pacemaker.
The client asks the nurse how this devise will help him. How should the
nurse explain the action of a synchronous pacemaker?
A) Ventricular irritability is prevented by the constant rate setting of
pacemaker.
B) Ectopic stimulus in the atria is suppressed by the device usurping
depolarization.
C) An impulse is fired every second to maintain a heart rate of 60 beats
per minute.
D) An electrical stimulus is discharged when no ventricular response is
sensed. - VERIFIED ANSWER - D) An electrical stimulus is discharged when
no ventricular response is sensed.
