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HESI NUR 209 MEDICAL SURGICAL NURSING II
ACTUAL EXAM PREP 2026 ALL QUESTIONS
AND CORRECT DETAILED ANSWERS WITH
RATIONALES ALREADY A GRADED WITH
EXPERT FEEDBACK |NEW AND REVISED
1. A client with heart failure is receiving furosemide 40 mg IV push. Which
assessment finding requires the nurse to hold the next dose and notify the
healthcare provider?
A. Weight loss of 1 kg in 24 hours
B. Serum potassium level of 3.4 mEq/L
C. Blood pressure of 100/60 mm Hg
D. New onset of tinnitus
D. New onset of tinnitus
*Rationale: Tinnitus is a sign of ototoxicity, a known adverse effect of high-dose
or rapid IV furosemide. This requires immediate provider notification. Mild
hypokalemia (3.4) and BP 100/60 may be expected with diuresis. Weight loss
indicates therapeutic effect.*
2. A client with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 86% on room air. The nurse initiates oxygen at 2 L/min via nasal
cannula. Which follow-up assessment is most important?
A. Level of consciousness
B. Respiratory rate and depth
C. Presence of cyanosis
D. Pain level
B. Respiratory rate and depth
Rationale: COPD patients may have chronic hypercapnia and rely on a hypoxic
drive. High oxygen can suppress respiratory drive, leading to hypoventilation
and worsened CO2 retention. Monitoring respiratory rate and depth is essential
to detect this complication.
3. A client is admitted with diabetic ketoacidosis (DKA). The nurse notes a fruity
odor on the client’s breath. What is the underlying cause of this finding?
A. Accumulation of ammonia from protein breakdown
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B. Production of acetone from fat metabolism
C. Incomplete breakdown of dietary carbohydrates
D. Bacterial overgrowth in the oral cavity
B. Production of acetone from fat metabolism
Rationale: In DKA, lack of insulin leads to lipolysis and ketone body production
(acetoacetate, beta-hydroxybutyrate, and acetone). Acetone is exhaled, causing a
sweet, fruity breath odor.
4. A nurse is caring for a client with a chest tube following a left lower lobectomy.
Which finding requires immediate intervention?
A. Continuous bubbling in the water seal chamber
B. Tidaling (fluctuation) in the water seal chamber
C. 100 mL of serosanguinous drainage over 2 hours
D. Subcutaneous emphysema at the insertion site
A. Continuous bubbling in the water seal chamber
Rationale: Continuous bubbling indicates an air leak, which can prevent lung
re-expansion and lead to tension pneumothorax. Tidaling is normal. 100 mL
over 2 hours is acceptable post-op. Subcutaneous emphysema requires
monitoring but is not immediately life-threatening.
5. A client with end-stage renal disease (ESRD) has a serum potassium of 6.9
mEq/L. Which electrocardiogram (ECG) change would the nurse expect to see?
A. Flattened T waves
B. Prominent U waves
C. Tall, peaked T waves
D. Prolonged QT interval
C. Tall, peaked T waves
*Rationale: Hyperkalemia (K+ >5.5) causes tall, peaked (tented) T waves,
widened QRS, and prolonged PR interval. Hypokalemia causes flat T waves and
U waves.*
6. A client with a history of atrial fibrillation is taking warfarin. The international
normalized ratio (INR) is 4.8, and the client has epistaxis. Which action should the
nurse take first?
A. Administer vitamin K 10 mg orally
B. Hold the next dose of warfarin and apply direct pressure to the nose
C. Transfuse fresh frozen plasma
D. Increase the warfarin dose
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B. Hold the next dose of warfarin and apply direct pressure to the nose
Rationale: The priority is to control active bleeding (direct pressure). Then hold
warfarin and notify the provider. Vitamin K or fresh frozen plasma may be
needed if bleeding is severe, but direct pressure is immediate. Increasing
warfarin would worsen bleeding.
7. A client with a new diagnosis of type 1 diabetes asks the nurse about insulin
storage. Which statement indicates correct understanding?
A. “I will store my unopened insulin vials in the freezer.”
B. “I will keep the insulin vial I am using in the refrigerator until it is empty.”
C. “I can leave my insulin out at room temperature for up to 28 days.”
D. “Once opened, insulin must be used within 7 days.”
C. “I can leave my insulin out at room temperature for up to 28 days.”
Rationale: Opened insulin vials can be stored at room temperature (59°F-86°F)
for up to 28 days, which reduces injection pain and improves convenience.
Unopened vials should be refrigerated, not frozen. Freezing destroys insulin.
8. A client with chronic heart failure has a weight gain of 5 lb (2.3 kg) in 2 days.
Which action should the nurse take first?
A. Restrict oral fluids to 1000 mL/day
B. Administer furosemide as ordered
C. Assess for jugular venous distention and pedal edema
D. Notify the healthcare provider
C. Assess for jugular venous distention and pedal edema
Rationale: Weight gain indicates fluid retention. The nurse should first assess
for other signs of worsening heart failure (JVD, edema, crackles). After
assessment, notify the provider and administer diuretics as ordered. Restricting
fluids without an order is premature.
9. A client receiving a blood transfusion develops chills, fever, and hypotension.
After stopping the transfusion, which action is next?
A. Obtain a urine sample for hemoglobin
B. Send the blood bag and tubing to the lab
C. Infuse normal saline through a new IV line
D. Administer diphenhydramine
C. Infuse normal saline through a new IV line
Rationale: After stopping the transfusion, the nurse must maintain IV access
with normal saline (never dextrose) to treat hypotension and support the patient.
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Then notify the provider, send blood bag to lab, and obtain urine sample.
Normal saline is the priority.
10. A client with cirrhosis has ascites and is receiving spironolactone. Which
laboratory value requires immediate notification of the provider?
A. Serum sodium 130 mEq/L
B. Serum potassium 5.9 mEq/L
C. Serum creatinine 1.2 mg/dL
D. Serum albumin 3.0 g/dL
B. Serum potassium 5.9 mEq/L
Rationale: Spironolactone is a potassium-sparing diuretic. Hyperkalemia (>5.5)
can cause life-threatening dysrhythmias. Hyponatremia (130) is expected with
ascites; creatinine 1.2 and albumin 3.0 are not immediately critical.
11. A client with a traumatic brain injury has an intracranial pressure (ICP) of 24
mm Hg. The nurse should position the client with the head of the bed at:
A. 0 degrees (flat)
B. 15 degrees
C. 30 degrees
D. 45 degrees
C. 30 degrees
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage
from the brain, reducing ICP. Flat position increases ICP. Higher elevations
(>30°) may compromise cerebral perfusion pressure.
12. A client with a new colostomy asks about foods that could cause blockage.
Which food should the nurse recommend avoiding?
A. Applesauce
B. Mashed potatoes
C. Popcorn
D. Yogurt
C. Popcorn
Rationale: High-fiber, poorly digestible foods (popcorn, nuts, seeds, corn) can
cause stoma obstruction. Low-fiber, well-cooked or pureed foods are safer,
especially in the early postoperative period.
13. A client with myasthenia gravis is receiving pyridostigmine. The client
develops excessive salivation, diarrhea, and muscle fasciculations. The nurse
recognizes these as signs of:
HESI NUR 209 MEDICAL SURGICAL NURSING II
ACTUAL EXAM PREP 2026 ALL QUESTIONS
AND CORRECT DETAILED ANSWERS WITH
RATIONALES ALREADY A GRADED WITH
EXPERT FEEDBACK |NEW AND REVISED
1. A client with heart failure is receiving furosemide 40 mg IV push. Which
assessment finding requires the nurse to hold the next dose and notify the
healthcare provider?
A. Weight loss of 1 kg in 24 hours
B. Serum potassium level of 3.4 mEq/L
C. Blood pressure of 100/60 mm Hg
D. New onset of tinnitus
D. New onset of tinnitus
*Rationale: Tinnitus is a sign of ototoxicity, a known adverse effect of high-dose
or rapid IV furosemide. This requires immediate provider notification. Mild
hypokalemia (3.4) and BP 100/60 may be expected with diuresis. Weight loss
indicates therapeutic effect.*
2. A client with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 86% on room air. The nurse initiates oxygen at 2 L/min via nasal
cannula. Which follow-up assessment is most important?
A. Level of consciousness
B. Respiratory rate and depth
C. Presence of cyanosis
D. Pain level
B. Respiratory rate and depth
Rationale: COPD patients may have chronic hypercapnia and rely on a hypoxic
drive. High oxygen can suppress respiratory drive, leading to hypoventilation
and worsened CO2 retention. Monitoring respiratory rate and depth is essential
to detect this complication.
3. A client is admitted with diabetic ketoacidosis (DKA). The nurse notes a fruity
odor on the client’s breath. What is the underlying cause of this finding?
A. Accumulation of ammonia from protein breakdown
,2|Page
B. Production of acetone from fat metabolism
C. Incomplete breakdown of dietary carbohydrates
D. Bacterial overgrowth in the oral cavity
B. Production of acetone from fat metabolism
Rationale: In DKA, lack of insulin leads to lipolysis and ketone body production
(acetoacetate, beta-hydroxybutyrate, and acetone). Acetone is exhaled, causing a
sweet, fruity breath odor.
4. A nurse is caring for a client with a chest tube following a left lower lobectomy.
Which finding requires immediate intervention?
A. Continuous bubbling in the water seal chamber
B. Tidaling (fluctuation) in the water seal chamber
C. 100 mL of serosanguinous drainage over 2 hours
D. Subcutaneous emphysema at the insertion site
A. Continuous bubbling in the water seal chamber
Rationale: Continuous bubbling indicates an air leak, which can prevent lung
re-expansion and lead to tension pneumothorax. Tidaling is normal. 100 mL
over 2 hours is acceptable post-op. Subcutaneous emphysema requires
monitoring but is not immediately life-threatening.
5. A client with end-stage renal disease (ESRD) has a serum potassium of 6.9
mEq/L. Which electrocardiogram (ECG) change would the nurse expect to see?
A. Flattened T waves
B. Prominent U waves
C. Tall, peaked T waves
D. Prolonged QT interval
C. Tall, peaked T waves
*Rationale: Hyperkalemia (K+ >5.5) causes tall, peaked (tented) T waves,
widened QRS, and prolonged PR interval. Hypokalemia causes flat T waves and
U waves.*
6. A client with a history of atrial fibrillation is taking warfarin. The international
normalized ratio (INR) is 4.8, and the client has epistaxis. Which action should the
nurse take first?
A. Administer vitamin K 10 mg orally
B. Hold the next dose of warfarin and apply direct pressure to the nose
C. Transfuse fresh frozen plasma
D. Increase the warfarin dose
,3|Page
B. Hold the next dose of warfarin and apply direct pressure to the nose
Rationale: The priority is to control active bleeding (direct pressure). Then hold
warfarin and notify the provider. Vitamin K or fresh frozen plasma may be
needed if bleeding is severe, but direct pressure is immediate. Increasing
warfarin would worsen bleeding.
7. A client with a new diagnosis of type 1 diabetes asks the nurse about insulin
storage. Which statement indicates correct understanding?
A. “I will store my unopened insulin vials in the freezer.”
B. “I will keep the insulin vial I am using in the refrigerator until it is empty.”
C. “I can leave my insulin out at room temperature for up to 28 days.”
D. “Once opened, insulin must be used within 7 days.”
C. “I can leave my insulin out at room temperature for up to 28 days.”
Rationale: Opened insulin vials can be stored at room temperature (59°F-86°F)
for up to 28 days, which reduces injection pain and improves convenience.
Unopened vials should be refrigerated, not frozen. Freezing destroys insulin.
8. A client with chronic heart failure has a weight gain of 5 lb (2.3 kg) in 2 days.
Which action should the nurse take first?
A. Restrict oral fluids to 1000 mL/day
B. Administer furosemide as ordered
C. Assess for jugular venous distention and pedal edema
D. Notify the healthcare provider
C. Assess for jugular venous distention and pedal edema
Rationale: Weight gain indicates fluid retention. The nurse should first assess
for other signs of worsening heart failure (JVD, edema, crackles). After
assessment, notify the provider and administer diuretics as ordered. Restricting
fluids without an order is premature.
9. A client receiving a blood transfusion develops chills, fever, and hypotension.
After stopping the transfusion, which action is next?
A. Obtain a urine sample for hemoglobin
B. Send the blood bag and tubing to the lab
C. Infuse normal saline through a new IV line
D. Administer diphenhydramine
C. Infuse normal saline through a new IV line
Rationale: After stopping the transfusion, the nurse must maintain IV access
with normal saline (never dextrose) to treat hypotension and support the patient.
, 4|Page
Then notify the provider, send blood bag to lab, and obtain urine sample.
Normal saline is the priority.
10. A client with cirrhosis has ascites and is receiving spironolactone. Which
laboratory value requires immediate notification of the provider?
A. Serum sodium 130 mEq/L
B. Serum potassium 5.9 mEq/L
C. Serum creatinine 1.2 mg/dL
D. Serum albumin 3.0 g/dL
B. Serum potassium 5.9 mEq/L
Rationale: Spironolactone is a potassium-sparing diuretic. Hyperkalemia (>5.5)
can cause life-threatening dysrhythmias. Hyponatremia (130) is expected with
ascites; creatinine 1.2 and albumin 3.0 are not immediately critical.
11. A client with a traumatic brain injury has an intracranial pressure (ICP) of 24
mm Hg. The nurse should position the client with the head of the bed at:
A. 0 degrees (flat)
B. 15 degrees
C. 30 degrees
D. 45 degrees
C. 30 degrees
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage
from the brain, reducing ICP. Flat position increases ICP. Higher elevations
(>30°) may compromise cerebral perfusion pressure.
12. A client with a new colostomy asks about foods that could cause blockage.
Which food should the nurse recommend avoiding?
A. Applesauce
B. Mashed potatoes
C. Popcorn
D. Yogurt
C. Popcorn
Rationale: High-fiber, poorly digestible foods (popcorn, nuts, seeds, corn) can
cause stoma obstruction. Low-fiber, well-cooked or pureed foods are safer,
especially in the early postoperative period.
13. A client with myasthenia gravis is receiving pyridostigmine. The client
develops excessive salivation, diarrhea, and muscle fasciculations. The nurse
recognizes these as signs of:
