HESI EXAM vc
Exam Solution vc
Hesi Review Med Surg 2026 A+ GRADE ASSURED COMPL
vc vc vc vc vc vc vc vc
ETE SOLUTIONS AND VERIFIED ANSWERS (236CD)
vc vc vc vc vc
QUESTION 1 vc
A client who has undergone abdominal surgery calls the nurse and reports that she just f
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
elt "something give way" in the abdominal incision. The nurse checks the incision and no
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
tes the presence of wound dehiscence. The nurse immediately:
vc vc vc vc vc vc vc vc
ANSWER
Covers the abdominal wound with a sterile dressing moistened with sterile saline solution. Rationale: T
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
hese actions will minimize protrusion of the underlying tissues. The nurse then covers the wound with
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
a sterile dressing moistened with sterile saline. The physician is notified, and the nurse documents the o
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ccurrence and the nursing actions that were implemented in response.
vc vc vc vc vc vc vc vc vc
QUESTION 2 vc
A client who just returned from the recovery room after a tonsillectomy and adenoidecto
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my is restless and her pulse rate is increased. As the nurse continues the assessment, the
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
client begins to vomit a copious amount of bright-
vc vc vc vc vc vc vc vc vc
red blood. The immediate nursing action is to:
vc vc vc vc vc vc vc
ANSWER
Notify the surgeon Rationale: Hemorrhage is a common complication after tonsillectomies.
vc vc vc vc vc vc vc vc vc vc
QUESTION 3 vc
A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and t
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achypnea. The nurse suspects that the client has a pulmonary embolism and immediatel
vc vc vc vc vc vc vc vc vc vc vc vc
y sets about:
vc vc
ANSWER
Administer oxygen via nasal cannula Rationale: Pulmonary embolism is a life-
vc vc vc vc vc vc vc vc vc vc
threatening emergency. Oxygen is immediately administered nasally to relieve hypoxemia, respiratory d
vc vc vc vc vc vc vc vc vc vc vc
istress, and central cyanosis, and the physician is notified.
vc vc vc vc vc vc vc vc
,QUESTION 4 vc
A nurse is assessing a client who has a closed chest tube drainage system. The nurse not
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
es constant bubbling in the water seal chamber. What actions should the nurse take? (Sel
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ect all that apply).
vc vc vc
ANSWER
Assessing the system for an external air leak Documenting assessment findings, actions taken, and client
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
response Rationale: : Constant bubbling in the water seal chamber of a closed chest tube drainage syste
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
m may indicate the presence of an air leak. The nurse would assess the chest tube system for the presen
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ce of an external air leak if constant bubbling were noted in this chamber. If an external air leak is not p
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
resent and the air leak is a new occurrence, the physician is notified immediately, because an air leak m
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ay be present in the pleural space. Leakage and trapping of air in the pleural space can result in a tensio
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
n pneumothorax.
vc
QUESTION 5 vc
A nurse is helping a client with a closed chest tube drainage system get out of bed and in
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
to a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodg
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ed from the insertion site. The immediate priority on the part of the nurse is:
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ANSWER
Covering the insertion site with a sterile occlusive dressing Rationale: : If a chest tube is dislodged from
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
the insertion site, the nurse immediately covers the site with sterile occlusive dressing.
vc vc vc vc vc vc vc vc vc vc vc vc
QUESTION 6 vc
A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloo
vc vc vc vc vc vc vc vc vc vc vc
dy secretions. The nurse would first:
vc vc vc vc vc
ANSWER
Check the degree of suction Rationale: The return of bloody secretions is an unexpected outcome of suct
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ioning. If it occurs, the nurse should first assess the client and then determine the degree of suction bein
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
g applied. The degree of suction pressure may need to be decreased.
vc vc vc vc vc vc vc vc vc vc vc
QUESTION 7 vc
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the cli
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ent begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
catheter from the client's trachea but is unable to do so. The nurse would first:
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ANSWER
Disconnect the suction source from the catheter Rationale: This is indicative of bronchospasm and bron
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
choconstriction.
, QUESTION 8 vc
A nurse assesses the closed chest tube drainage system of a client who underwent lobect
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omy 24 hours ago. The nurse notes that there has been no chest tube drainage for the pa
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
st hour. The nurse first:
vc vc vc vc
ANSWER
Checks for kinks Rationale: : If a chest tube is not draining, the nurse must first check for a kink or clot i
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
n the chest drainage system.
vc vc vc vc
QUESTION 9 vc
A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the cl
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ient's urine output for the past hour was 25 mL. On the basis of this finding, the nurse fir
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
st:
ANSWER
Checks the client's overall intake and output Rationale: Clients are at risk for becoming hypovolemic aft
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
er surgery, and often the first sign of hypovolemia is decreasing urine output. However, the nurse needs
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc v
additional data to make an accurate interpretation.
c vc vc vc vc vc vc
QUESTION 10 vc
A nurse is getting a client out of bed for the first time since surgery. The nurse raises the
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
head of the bed, and the client complains of dizziness. Which of the following actions sho
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
uld the nurse take first?
vc vc vc vc
ANSWER
Slowly lower the head of the bed Rationale: Dizziness or a feeling of faintness is not uncommon when a
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
client is positioned upright for the first time after surgery. If this occurs, the nurse lowers the head of th
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
e bed slowly until the dizziness is relieved.
vc vc vc vc vc vc vc
QUESTION 11 vc
A nurse is preparing for intershift report when a nurse's aide pulls an emergency call lig
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ht in a client's room. Upon answering the light, the nurse finds a client who returned fro
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
m surgery earlier in the day experiencing tachycardia and tachypnea. The client's blood
vc vc vc vc vc vc vc vc vc vc vc vc vc
pressure is 88/60 mm Hg. Which action should the nurse take first?
vc vc vc vc vc vc vc vc vc vc vc
ANSWER
Placing the client in a modified Trendelenburg position Rationale: The client is exhibiting signs of shock
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
and requires emergency intervention. The first action is to place the client in a modified Trendelenburg
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
position to increase blood return from the legs, which in turn increases venous return and subsequently
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc v
the blood pressure.
c vc vc
Exam Solution vc
Hesi Review Med Surg 2026 A+ GRADE ASSURED COMPL
vc vc vc vc vc vc vc vc
ETE SOLUTIONS AND VERIFIED ANSWERS (236CD)
vc vc vc vc vc
QUESTION 1 vc
A client who has undergone abdominal surgery calls the nurse and reports that she just f
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
elt "something give way" in the abdominal incision. The nurse checks the incision and no
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
tes the presence of wound dehiscence. The nurse immediately:
vc vc vc vc vc vc vc vc
ANSWER
Covers the abdominal wound with a sterile dressing moistened with sterile saline solution. Rationale: T
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
hese actions will minimize protrusion of the underlying tissues. The nurse then covers the wound with
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
a sterile dressing moistened with sterile saline. The physician is notified, and the nurse documents the o
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ccurrence and the nursing actions that were implemented in response.
vc vc vc vc vc vc vc vc vc
QUESTION 2 vc
A client who just returned from the recovery room after a tonsillectomy and adenoidecto
vc vc vc vc vc vc vc vc vc vc vc vc vc
my is restless and her pulse rate is increased. As the nurse continues the assessment, the
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
client begins to vomit a copious amount of bright-
vc vc vc vc vc vc vc vc vc
red blood. The immediate nursing action is to:
vc vc vc vc vc vc vc
ANSWER
Notify the surgeon Rationale: Hemorrhage is a common complication after tonsillectomies.
vc vc vc vc vc vc vc vc vc vc
QUESTION 3 vc
A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and t
vc vc vc vc vc vc vc vc vc vc vc vc vc
achypnea. The nurse suspects that the client has a pulmonary embolism and immediatel
vc vc vc vc vc vc vc vc vc vc vc vc
y sets about:
vc vc
ANSWER
Administer oxygen via nasal cannula Rationale: Pulmonary embolism is a life-
vc vc vc vc vc vc vc vc vc vc
threatening emergency. Oxygen is immediately administered nasally to relieve hypoxemia, respiratory d
vc vc vc vc vc vc vc vc vc vc vc
istress, and central cyanosis, and the physician is notified.
vc vc vc vc vc vc vc vc
,QUESTION 4 vc
A nurse is assessing a client who has a closed chest tube drainage system. The nurse not
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
es constant bubbling in the water seal chamber. What actions should the nurse take? (Sel
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ect all that apply).
vc vc vc
ANSWER
Assessing the system for an external air leak Documenting assessment findings, actions taken, and client
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
response Rationale: : Constant bubbling in the water seal chamber of a closed chest tube drainage syste
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
m may indicate the presence of an air leak. The nurse would assess the chest tube system for the presen
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ce of an external air leak if constant bubbling were noted in this chamber. If an external air leak is not p
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
resent and the air leak is a new occurrence, the physician is notified immediately, because an air leak m
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ay be present in the pleural space. Leakage and trapping of air in the pleural space can result in a tensio
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
n pneumothorax.
vc
QUESTION 5 vc
A nurse is helping a client with a closed chest tube drainage system get out of bed and in
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
to a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodg
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ed from the insertion site. The immediate priority on the part of the nurse is:
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ANSWER
Covering the insertion site with a sterile occlusive dressing Rationale: : If a chest tube is dislodged from
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
the insertion site, the nurse immediately covers the site with sterile occlusive dressing.
vc vc vc vc vc vc vc vc vc vc vc vc
QUESTION 6 vc
A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloo
vc vc vc vc vc vc vc vc vc vc vc
dy secretions. The nurse would first:
vc vc vc vc vc
ANSWER
Check the degree of suction Rationale: The return of bloody secretions is an unexpected outcome of suct
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ioning. If it occurs, the nurse should first assess the client and then determine the degree of suction bein
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
g applied. The degree of suction pressure may need to be decreased.
vc vc vc vc vc vc vc vc vc vc vc
QUESTION 7 vc
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the cli
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ent begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
catheter from the client's trachea but is unable to do so. The nurse would first:
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ANSWER
Disconnect the suction source from the catheter Rationale: This is indicative of bronchospasm and bron
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
choconstriction.
, QUESTION 8 vc
A nurse assesses the closed chest tube drainage system of a client who underwent lobect
vc vc vc vc vc vc vc vc vc vc vc vc vc vc
omy 24 hours ago. The nurse notes that there has been no chest tube drainage for the pa
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
st hour. The nurse first:
vc vc vc vc
ANSWER
Checks for kinks Rationale: : If a chest tube is not draining, the nurse must first check for a kink or clot i
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
n the chest drainage system.
vc vc vc vc
QUESTION 9 vc
A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the cl
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ient's urine output for the past hour was 25 mL. On the basis of this finding, the nurse fir
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
st:
ANSWER
Checks the client's overall intake and output Rationale: Clients are at risk for becoming hypovolemic aft
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
er surgery, and often the first sign of hypovolemia is decreasing urine output. However, the nurse needs
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc v
additional data to make an accurate interpretation.
c vc vc vc vc vc vc
QUESTION 10 vc
A nurse is getting a client out of bed for the first time since surgery. The nurse raises the
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
head of the bed, and the client complains of dizziness. Which of the following actions sho
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
uld the nurse take first?
vc vc vc vc
ANSWER
Slowly lower the head of the bed Rationale: Dizziness or a feeling of faintness is not uncommon when a
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
client is positioned upright for the first time after surgery. If this occurs, the nurse lowers the head of th
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
e bed slowly until the dizziness is relieved.
vc vc vc vc vc vc vc
QUESTION 11 vc
A nurse is preparing for intershift report when a nurse's aide pulls an emergency call lig
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
ht in a client's room. Upon answering the light, the nurse finds a client who returned fro
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
m surgery earlier in the day experiencing tachycardia and tachypnea. The client's blood
vc vc vc vc vc vc vc vc vc vc vc vc vc
pressure is 88/60 mm Hg. Which action should the nurse take first?
vc vc vc vc vc vc vc vc vc vc vc
ANSWER
Placing the client in a modified Trendelenburg position Rationale: The client is exhibiting signs of shock
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
and requires emergency intervention. The first action is to place the client in a modified Trendelenburg
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc
position to increase blood return from the legs, which in turn increases venous return and subsequently
vc vc vc vc vc vc vc vc vc vc vc vc vc vc vc v
the blood pressure.
c vc vc
