MED SURG 2 HESI TEST BANK REAL EXAM 250+ QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES |A+ GRADE ASSURED/NEWEST UPDATE!!!
Question 1
A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which
assessment finding warrants immediate intervention by the nurse?
A) Purple marks (striae) on the skin of the abdomen
B) Irregular apical pulse
C) Quarter-size blood spot on the surgical dressing
D) 2+ Pitting ankle edema
E) Muscle weakness in the lower extremities
Correct Answer: B) Irregular apical pulse
Rationale: Cushing’s syndrome involves an excess of cortisol, which often leads to
significant electrolyte imbalances, most notably hypokalemia (low potassium). Potassium is
critical for cardiac conduction; therefore, an irregular apical pulse may indicate a life-
threatening dysrhythmia. While purple striae, edema, and weakness are common
symptoms of Cushing’s, they are not immediately life-threatening compared to cardiac
instability.
Question 2
A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of
breath and difficult to arouse. During the assessment, the nurse discovers four analgesic patches
on the client's body. Which intervention should the nurse implement first?
A) Remove all of the morphine patches
B) Administer a narcotic antagonist (Naloxone)
C) Apply oxygen per face mask at 40%
D) Measure the client's blood pressure and heart rate
E) Notify the palliative care physician immediately
Correct Answer: B) Administer a narcotic antagonist
Rationale: The client is exhibiting signs of opioid overdose (respiratory depression and
altered consciousness) due to the accumulation of multiple morphine patches. Following the
ABC (Airway, Breathing, Circulation) priority framework, the nurse must immediately
reverse the opioid effect with a narcotic antagonist like Naloxone to restore respiratory
drive. Removing the patches (Option A) is necessary but will not immediately reverse the
morphine already in the bloodstream.
Question 3
A client receives prescriptions for a multidrug regimen for the treatment of tuberculosis (TB).
Which information should the nurse prioritize during teaching?
A) Adherence to the regimen is imperative
B) Medications should be taken with a high-protein snack
C) Serum liver panels must be collected every month
D) Enhanced sun protection measures will be needed during therapy
E) Vision checks are required every six months
, 2
Correct Answer: A) Adherence to the regimen is imperative
Rationale: The most critical aspect of TB treatment is strict adherence to the long-term
multidrug regimen (often 6-9 months). Non-compliance is the primary cause of multi-drug
resistant TB (MDR-TB) and treatment failure. While liver toxicity (Option C) and
photosensitivity (Option D) are important side effects, they are secondary to the public
health and individual risk of therapeutic failure due to skipped doses.
Question 4
A client admitted after a motor vehicle collision has an open femur fracture and is bleeding
moderately. The nurse discovers the client receives 5,000 units of heparin sodium
subcutaneously daily. What is the priority nursing action?
A) Notify the healthcare provider of the client's medication history
B) Observe the heparin injection sites for signs of bruising
C) Have the client sign the surgical and transfusion permits
D) Ensure the potential for bleeding is explained to the client
E) Document the medication history in the electronic health record
Correct Answer: A) Notify the healthcare provider of the client's medication history
Rationale: The client is bleeding from an open fracture and is scheduled for surgery.
Heparin is an anticoagulant that increases the risk of hemorrhage. The surgeon and
anesthesiologist must be notified immediately to determine if the surgery should be delayed
or if a reversal agent (Protamine Sulfate) is required. Bruising (Option B) is expected with
heparin but is not the priority in an emergency surgical scenario.
Question 5
A client with orthopnea expresses concern about the ability to "get enough air" during a
scheduled thoracentesis. On which information should the nurse's response be based?
A) A thoracentesis is a brief process that involves minimal discomfort
B) Orthopnea is frequently caused by a client's uncontrolled anxiety
C) The procedure is performed with the client in an upright position
D) Extra pillows can be used if needed to elevate the client's head
E) Local anesthesia will be used to numb the area before the needle is inserted
Correct Answer: C) The procedure is performed with the client in an upright position
Rationale: Orthopnea is the inability to breathe comfortably while lying flat. The nurse can
reassure the client because a thoracentesis is typically performed while the client is sitting
upright and leaning forward over a bedside table. This position actually facilitates easier
breathing (lung expansion) compared to lying down, addressing the client’s specific
concern.
Question 6
What information should the nurse include in the teaching plan of a client diagnosed with
gastroesophageal reflux disease (GERD)?
, 3
A) Sleep without pillows at night to maintain neck alignment
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 programs
E) Drink a glass of milk before bedtime to coat the stomach
Correct Answer: C) Minimize symptoms by wearing loose, comfortable clothing
Rationale: Tight clothing, especially around the waist, increases intra-abdominal pressure,
which can force gastric contents upward through the lower esophageal sphincter (LES).
Clients should also be taught to sleep with the head of the bed elevated (not flat, as in
Option A) and to eat small, frequent meals rather than large, full meals (Option B).
Question 7
The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral
neuropathy. Which information should the nurse provide?
A) Family members can help with regular foot exams
B) Heating pads are useful if kept on the lowest setting
C) Aching feet may be soaked in lukewarm water for one hour
D) Shoes should be worn outside, but it is fine to be barefoot inside
E) Apply lotion between the toes daily to prevent cracking
Correct Answer: A) Family members can help with regular foot exams
Rationale: Peripheral neuropathy reduces sensation in the feet, making it difficult for the
client to feel injuries, blisters, or infections. Daily foot inspection is vital. If the client has
limited mobility or poor vision, a family member should assist. Heating pads (Option B)
and soaking (Option C) are dangerous due to the risk of burns and skin breakdown, and
being barefoot (Option D) is never recommended for diabetics.
Question 8
A client in the operating room received succinylcholine and is now experiencing muscle rigidity
and an extremely high temperature. What action should the nurse implement?
A) Hold a prescription for dantrolene until the fever is reduced
B) Prepare ice packs for placement in the client's axillary area
C) Call the PACU nurse to prepare for prolonged ventilator support
D) Determine if prescribed antibiotics were administered preoperatively
E) Increase the room temperature to prevent shivering
Correct Answer: B) Prepare ice packs for placement in the client's axillary area
Rationale: The client is exhibiting symptoms of Malignant Hyperthermia (MH), a life-
threatening reaction to volatile anesthetics or succinylcholine. Priority actions include
administering Dantrolene (the reversal agent, so Option A is wrong) and active cooling.
Placing ice packs in the axilla, groin, and neck helps reduce the core temperature rapidly.
MH is a medical emergency.
, 4
Question 9
The nurse is developing a plan of care for a client newly diagnosed with cardiovascular disease
who reports blurred vision. Which outcome should the nurse include?
A) The nurse will encourage the client to walk thirty minutes every day
B) The client's family will state signs and symptoms about the disease
C) The client's daily blood pressure will be less than 140/80 this month
D) The client's blood pressure readings will be less than 160/90
E) The client will report an improvement in visual acuity by next week
Correct Answer: C) The client's daily blood pressure will be less than 140/80 this month
Rationale: An effective outcome must be specific, measurable, attainable, realistic, and
timed (SMART). Option C provides a specific numeric goal (<140/80) and a timeframe
(this month). Blurred vision in cardiovascular disease often suggests hypertensive
retinopathy; therefore, controlling blood pressure is the priority intervention.
Question 10
The family suspects that acquired immune deficiency syndrome (AIDS) dementia is occurring in
their son who is HIV positive. Which symptom confirms their suspicions?
A) He has begun to sleep 18 out of 24 hours
B) A change has recently occurred in his handwriting
C) He refuses to see any of his friends or return phone calls
D) He exhibits angry outbursts when the subject of dying is approached
E) He has developed a persistent dry cough and night sweats
Correct Answer: B) A change has recently occurred in his handwriting
Rationale: AIDS Dementia Complex (HIV-associated encephalopathy) often manifests
initially as subtle motor impairments, such as loss of fine motor coordination, which would
be visible in a change in handwriting. While withdrawal (Option C) and outbursts (Option
D) can be psychological reactions to the disease, a physical change in handwriting is a
classic neurological indicator of dementia.
Question 11
A hospitalized client with peripheral arterial disease (PAD) is instructed regarding leg and foot
care. Which statement by the client indicates that learning has occurred?
A) "Whenever I am sitting in a chair I will keep my legs up to reduce swelling"
B) "I can use a mirror to check the bottoms of my feet for any signs of breakdown"
C) "I will try to keep moving if leg pain occurs to help promote good circulation"
D) "I will use my swimming pool early in the day while the water is still very cool"
E) "I will use a firm-bristle brush to scrub my feet and stimulate blood flow"
Correct Answer: B) "I can use a mirror to check the bottoms of my feet for any signs of
breakdown"
Rationale: PAD causes decreased blood flow to the extremities, leading to high risks of non-
ANSWERS WITH RATIONALES |A+ GRADE ASSURED/NEWEST UPDATE!!!
Question 1
A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which
assessment finding warrants immediate intervention by the nurse?
A) Purple marks (striae) on the skin of the abdomen
B) Irregular apical pulse
C) Quarter-size blood spot on the surgical dressing
D) 2+ Pitting ankle edema
E) Muscle weakness in the lower extremities
Correct Answer: B) Irregular apical pulse
Rationale: Cushing’s syndrome involves an excess of cortisol, which often leads to
significant electrolyte imbalances, most notably hypokalemia (low potassium). Potassium is
critical for cardiac conduction; therefore, an irregular apical pulse may indicate a life-
threatening dysrhythmia. While purple striae, edema, and weakness are common
symptoms of Cushing’s, they are not immediately life-threatening compared to cardiac
instability.
Question 2
A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of
breath and difficult to arouse. During the assessment, the nurse discovers four analgesic patches
on the client's body. Which intervention should the nurse implement first?
A) Remove all of the morphine patches
B) Administer a narcotic antagonist (Naloxone)
C) Apply oxygen per face mask at 40%
D) Measure the client's blood pressure and heart rate
E) Notify the palliative care physician immediately
Correct Answer: B) Administer a narcotic antagonist
Rationale: The client is exhibiting signs of opioid overdose (respiratory depression and
altered consciousness) due to the accumulation of multiple morphine patches. Following the
ABC (Airway, Breathing, Circulation) priority framework, the nurse must immediately
reverse the opioid effect with a narcotic antagonist like Naloxone to restore respiratory
drive. Removing the patches (Option A) is necessary but will not immediately reverse the
morphine already in the bloodstream.
Question 3
A client receives prescriptions for a multidrug regimen for the treatment of tuberculosis (TB).
Which information should the nurse prioritize during teaching?
A) Adherence to the regimen is imperative
B) Medications should be taken with a high-protein snack
C) Serum liver panels must be collected every month
D) Enhanced sun protection measures will be needed during therapy
E) Vision checks are required every six months
, 2
Correct Answer: A) Adherence to the regimen is imperative
Rationale: The most critical aspect of TB treatment is strict adherence to the long-term
multidrug regimen (often 6-9 months). Non-compliance is the primary cause of multi-drug
resistant TB (MDR-TB) and treatment failure. While liver toxicity (Option C) and
photosensitivity (Option D) are important side effects, they are secondary to the public
health and individual risk of therapeutic failure due to skipped doses.
Question 4
A client admitted after a motor vehicle collision has an open femur fracture and is bleeding
moderately. The nurse discovers the client receives 5,000 units of heparin sodium
subcutaneously daily. What is the priority nursing action?
A) Notify the healthcare provider of the client's medication history
B) Observe the heparin injection sites for signs of bruising
C) Have the client sign the surgical and transfusion permits
D) Ensure the potential for bleeding is explained to the client
E) Document the medication history in the electronic health record
Correct Answer: A) Notify the healthcare provider of the client's medication history
Rationale: The client is bleeding from an open fracture and is scheduled for surgery.
Heparin is an anticoagulant that increases the risk of hemorrhage. The surgeon and
anesthesiologist must be notified immediately to determine if the surgery should be delayed
or if a reversal agent (Protamine Sulfate) is required. Bruising (Option B) is expected with
heparin but is not the priority in an emergency surgical scenario.
Question 5
A client with orthopnea expresses concern about the ability to "get enough air" during a
scheduled thoracentesis. On which information should the nurse's response be based?
A) A thoracentesis is a brief process that involves minimal discomfort
B) Orthopnea is frequently caused by a client's uncontrolled anxiety
C) The procedure is performed with the client in an upright position
D) Extra pillows can be used if needed to elevate the client's head
E) Local anesthesia will be used to numb the area before the needle is inserted
Correct Answer: C) The procedure is performed with the client in an upright position
Rationale: Orthopnea is the inability to breathe comfortably while lying flat. The nurse can
reassure the client because a thoracentesis is typically performed while the client is sitting
upright and leaning forward over a bedside table. This position actually facilitates easier
breathing (lung expansion) compared to lying down, addressing the client’s specific
concern.
Question 6
What information should the nurse include in the teaching plan of a client diagnosed with
gastroesophageal reflux disease (GERD)?
, 3
A) Sleep without pillows at night to maintain neck alignment
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 programs
E) Drink a glass of milk before bedtime to coat the stomach
Correct Answer: C) Minimize symptoms by wearing loose, comfortable clothing
Rationale: Tight clothing, especially around the waist, increases intra-abdominal pressure,
which can force gastric contents upward through the lower esophageal sphincter (LES).
Clients should also be taught to sleep with the head of the bed elevated (not flat, as in
Option A) and to eat small, frequent meals rather than large, full meals (Option B).
Question 7
The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral
neuropathy. Which information should the nurse provide?
A) Family members can help with regular foot exams
B) Heating pads are useful if kept on the lowest setting
C) Aching feet may be soaked in lukewarm water for one hour
D) Shoes should be worn outside, but it is fine to be barefoot inside
E) Apply lotion between the toes daily to prevent cracking
Correct Answer: A) Family members can help with regular foot exams
Rationale: Peripheral neuropathy reduces sensation in the feet, making it difficult for the
client to feel injuries, blisters, or infections. Daily foot inspection is vital. If the client has
limited mobility or poor vision, a family member should assist. Heating pads (Option B)
and soaking (Option C) are dangerous due to the risk of burns and skin breakdown, and
being barefoot (Option D) is never recommended for diabetics.
Question 8
A client in the operating room received succinylcholine and is now experiencing muscle rigidity
and an extremely high temperature. What action should the nurse implement?
A) Hold a prescription for dantrolene until the fever is reduced
B) Prepare ice packs for placement in the client's axillary area
C) Call the PACU nurse to prepare for prolonged ventilator support
D) Determine if prescribed antibiotics were administered preoperatively
E) Increase the room temperature to prevent shivering
Correct Answer: B) Prepare ice packs for placement in the client's axillary area
Rationale: The client is exhibiting symptoms of Malignant Hyperthermia (MH), a life-
threatening reaction to volatile anesthetics or succinylcholine. Priority actions include
administering Dantrolene (the reversal agent, so Option A is wrong) and active cooling.
Placing ice packs in the axilla, groin, and neck helps reduce the core temperature rapidly.
MH is a medical emergency.
, 4
Question 9
The nurse is developing a plan of care for a client newly diagnosed with cardiovascular disease
who reports blurred vision. Which outcome should the nurse include?
A) The nurse will encourage the client to walk thirty minutes every day
B) The client's family will state signs and symptoms about the disease
C) The client's daily blood pressure will be less than 140/80 this month
D) The client's blood pressure readings will be less than 160/90
E) The client will report an improvement in visual acuity by next week
Correct Answer: C) The client's daily blood pressure will be less than 140/80 this month
Rationale: An effective outcome must be specific, measurable, attainable, realistic, and
timed (SMART). Option C provides a specific numeric goal (<140/80) and a timeframe
(this month). Blurred vision in cardiovascular disease often suggests hypertensive
retinopathy; therefore, controlling blood pressure is the priority intervention.
Question 10
The family suspects that acquired immune deficiency syndrome (AIDS) dementia is occurring in
their son who is HIV positive. Which symptom confirms their suspicions?
A) He has begun to sleep 18 out of 24 hours
B) A change has recently occurred in his handwriting
C) He refuses to see any of his friends or return phone calls
D) He exhibits angry outbursts when the subject of dying is approached
E) He has developed a persistent dry cough and night sweats
Correct Answer: B) A change has recently occurred in his handwriting
Rationale: AIDS Dementia Complex (HIV-associated encephalopathy) often manifests
initially as subtle motor impairments, such as loss of fine motor coordination, which would
be visible in a change in handwriting. While withdrawal (Option C) and outbursts (Option
D) can be psychological reactions to the disease, a physical change in handwriting is a
classic neurological indicator of dementia.
Question 11
A hospitalized client with peripheral arterial disease (PAD) is instructed regarding leg and foot
care. Which statement by the client indicates that learning has occurred?
A) "Whenever I am sitting in a chair I will keep my legs up to reduce swelling"
B) "I can use a mirror to check the bottoms of my feet for any signs of breakdown"
C) "I will try to keep moving if leg pain occurs to help promote good circulation"
D) "I will use my swimming pool early in the day while the water is still very cool"
E) "I will use a firm-bristle brush to scrub my feet and stimulate blood flow"
Correct Answer: B) "I can use a mirror to check the bottoms of my feet for any signs of
breakdown"
Rationale: PAD causes decreased blood flow to the extremities, leading to high risks of non-
