★ ★
HESI / Elsevier
GRUS DEM
H Health Education Systems, Inc.
EXCELLENCE IN NURSING ASSESSMENT · SINCE 1948
EST. 1948
HESI Med Surg
M E D I C A L-S U R G I C A L N U R S I N G · CO M P R E H E N S I V E A SS E SS M E N T
INSTITUTION HESI / Elsevier Nursing Assessments COURSE CODE HESI Med Surg
PROGRAM Registered Nurse (ADN / BSN) ACADEMIC YEAR
EXAM TITLE HESI Med Surg Comprehensive TOTAL QUESTIONS 60 Questions
COURSE TITLE Medical-Surgical Nursing I FORMAT Multiple Choice / Select All That Apply /
Ordered Response
EXAMINATION INSTRUCTIONS
▸ Select the single best answer unless "Select all that apply" is specified.
▸ For ordered response questions, arrange actions in the correct sequence.
▸ Clinical scenarios include relevant assessment findings and nursing actions.
▸ Correct answers and detailed rationales are provided for board review.
SECTION I — CLINICAL SCENARIOS & NURSING ACTIONS Questions 1 – 60
1. A 75-year-old male presents to the emergency department with poorly controlled diabetes. He has been
experiencing polyuria, nausea, vomiting, confusion, and unstable blood sugars. What are the potential conditions
and actions to take?
POTENTIAL CONDITION Diabetic complications, pressure injury.
ACTIONS TO TAKE Offload coccyx and other bony prominences, cleanse and dress wounds.
PARAMETERS TO MONITOR Wound status and documentation of skin prevention measures.
RATIONALE Poorly controlled diabetes with polyuria, nausea, vomiting, and confusion suggests diabetic ketoacidosis
(DKA) or hyperosmolar hyperglycemic state (HHS). Concurrent pressure injury prevention is critical due to
immobility and poor tissue perfusion. Offloading bony prominences prevents pressure ulcers, and wound
care addresses existing skin breakdown.
2. A client is a 47-year-old female with a history of type 2 diabetes mellitus. She is in the hospital recovering from
pneumonia. During a sleep assessment, the client informs the nurse that she will never get eight hours of sleep
because she wakes up several times at night to urinate. What are the potential conditions and actions to take?
POTENTIAL CONDITION Nocturia.
ACTIONS TO TAKE Implement fall precautions, review home medication.
PARAMETERS TO MONITOR Diabetes, UTI.
RATIONALE Nocturia (frequent nighttime urination) is common in diabetes due to hyperglycemia-induced osmotic
diuresis. It increases fall risk when the client gets up frequently at night. Fall precautions are essential.
Reviewing home medications may identify diuretics or other contributors. Diabetes control and UTI screening
should be monitored as underlying causes.
, 3. A client was involved in a multicar collision six days ago and sustained a liver laceration, right rib fracture, and right
femur fracture. The liver laceration was repaired. What are the recommended exercises and parameters to
monitor?
EXERCISE Isometric.
ACTIONS TO TAKE Support the extremity during the exercise routine, have the client contract the muscle group for 10
seconds then release.
PARAMETERS TO MONITOR Number of muscle group contractions, relaxation repetitions, pain level.
RATIONALE Isometric exercises strengthen muscles without joint movement, which is appropriate for a client with
fractures who cannot perform active ROM. Supporting the extremity prevents displacement. The 10-second
contraction protocol builds strength safely. Monitoring contraction count, relaxation repetitions, and pain
level ensures the exercise is therapeutic without causing harm.
4. The nurse is assisting a client who has a history of obstructive sleep apnea with care. Which action should the nurse
implement before leaving the client?
CORRECT ANSWER Apply the client's positive airway pressure device.
RATIONALE For a client with obstructive sleep apnea, the positive airway pressure (CPAP/BiPAP) device maintains airway
patency during sleep. Ensuring it is applied before leaving the client prevents apnea episodes, oxygen
desaturation, and cardiovascular strain during sleep.
5. A client who had an emergency gallbladder surgery yesterday is preparing for discharge. When teaching wound
care, which method should the nurse use to evaluate the client's understanding of self-care at home?
CORRECT ANSWER Have the client demonstrate the prescribed wound care.
RATIONALE Return demonstration is the gold standard for evaluating psychomotor skill learning and understanding.
Watching the client perform wound care provides direct evidence of competency. This is especially important
when a language barrier or health literacy concern exists.
6. The client is a 65-year-old woman who had an anteroposterior spinal fusion two days ago. She tolerated the
procedure well and has progressively increased her walking distance. Which action should the nurse take?
CORRECT ANSWER Consult with the surgeon, lead the client to guided imagery, assess for sources of pain.
RATIONALE Post-spinal fusion, pain management is critical for mobilization. Consulting the surgeon addresses any
surgical concerns. Guided imagery provides non-pharmacological pain relief. Assessing pain sources ensures
appropriate treatment. These actions support continued recovery and mobility progression.
7. The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult
using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the
thermometer. Which action should the nurse implement?
CORRECT ANSWER Provide positive reinforcement to confirm that the procedure is being performed correctly.
RATIONALE For an adult, pulling the auricle up and back straightens the ear canal, allowing proper tympanic
thermometer insertion. This technique is correct. The nurse should reinforce this correct behavior with
positive feedback. For children under 3, the auricle is pulled down and back.
HESI / Elsevier
GRUS DEM
H Health Education Systems, Inc.
EXCELLENCE IN NURSING ASSESSMENT · SINCE 1948
EST. 1948
HESI Med Surg
M E D I C A L-S U R G I C A L N U R S I N G · CO M P R E H E N S I V E A SS E SS M E N T
INSTITUTION HESI / Elsevier Nursing Assessments COURSE CODE HESI Med Surg
PROGRAM Registered Nurse (ADN / BSN) ACADEMIC YEAR
EXAM TITLE HESI Med Surg Comprehensive TOTAL QUESTIONS 60 Questions
COURSE TITLE Medical-Surgical Nursing I FORMAT Multiple Choice / Select All That Apply /
Ordered Response
EXAMINATION INSTRUCTIONS
▸ Select the single best answer unless "Select all that apply" is specified.
▸ For ordered response questions, arrange actions in the correct sequence.
▸ Clinical scenarios include relevant assessment findings and nursing actions.
▸ Correct answers and detailed rationales are provided for board review.
SECTION I — CLINICAL SCENARIOS & NURSING ACTIONS Questions 1 – 60
1. A 75-year-old male presents to the emergency department with poorly controlled diabetes. He has been
experiencing polyuria, nausea, vomiting, confusion, and unstable blood sugars. What are the potential conditions
and actions to take?
POTENTIAL CONDITION Diabetic complications, pressure injury.
ACTIONS TO TAKE Offload coccyx and other bony prominences, cleanse and dress wounds.
PARAMETERS TO MONITOR Wound status and documentation of skin prevention measures.
RATIONALE Poorly controlled diabetes with polyuria, nausea, vomiting, and confusion suggests diabetic ketoacidosis
(DKA) or hyperosmolar hyperglycemic state (HHS). Concurrent pressure injury prevention is critical due to
immobility and poor tissue perfusion. Offloading bony prominences prevents pressure ulcers, and wound
care addresses existing skin breakdown.
2. A client is a 47-year-old female with a history of type 2 diabetes mellitus. She is in the hospital recovering from
pneumonia. During a sleep assessment, the client informs the nurse that she will never get eight hours of sleep
because she wakes up several times at night to urinate. What are the potential conditions and actions to take?
POTENTIAL CONDITION Nocturia.
ACTIONS TO TAKE Implement fall precautions, review home medication.
PARAMETERS TO MONITOR Diabetes, UTI.
RATIONALE Nocturia (frequent nighttime urination) is common in diabetes due to hyperglycemia-induced osmotic
diuresis. It increases fall risk when the client gets up frequently at night. Fall precautions are essential.
Reviewing home medications may identify diuretics or other contributors. Diabetes control and UTI screening
should be monitored as underlying causes.
, 3. A client was involved in a multicar collision six days ago and sustained a liver laceration, right rib fracture, and right
femur fracture. The liver laceration was repaired. What are the recommended exercises and parameters to
monitor?
EXERCISE Isometric.
ACTIONS TO TAKE Support the extremity during the exercise routine, have the client contract the muscle group for 10
seconds then release.
PARAMETERS TO MONITOR Number of muscle group contractions, relaxation repetitions, pain level.
RATIONALE Isometric exercises strengthen muscles without joint movement, which is appropriate for a client with
fractures who cannot perform active ROM. Supporting the extremity prevents displacement. The 10-second
contraction protocol builds strength safely. Monitoring contraction count, relaxation repetitions, and pain
level ensures the exercise is therapeutic without causing harm.
4. The nurse is assisting a client who has a history of obstructive sleep apnea with care. Which action should the nurse
implement before leaving the client?
CORRECT ANSWER Apply the client's positive airway pressure device.
RATIONALE For a client with obstructive sleep apnea, the positive airway pressure (CPAP/BiPAP) device maintains airway
patency during sleep. Ensuring it is applied before leaving the client prevents apnea episodes, oxygen
desaturation, and cardiovascular strain during sleep.
5. A client who had an emergency gallbladder surgery yesterday is preparing for discharge. When teaching wound
care, which method should the nurse use to evaluate the client's understanding of self-care at home?
CORRECT ANSWER Have the client demonstrate the prescribed wound care.
RATIONALE Return demonstration is the gold standard for evaluating psychomotor skill learning and understanding.
Watching the client perform wound care provides direct evidence of competency. This is especially important
when a language barrier or health literacy concern exists.
6. The client is a 65-year-old woman who had an anteroposterior spinal fusion two days ago. She tolerated the
procedure well and has progressively increased her walking distance. Which action should the nurse take?
CORRECT ANSWER Consult with the surgeon, lead the client to guided imagery, assess for sources of pain.
RATIONALE Post-spinal fusion, pain management is critical for mobilization. Consulting the surgeon addresses any
surgical concerns. Guided imagery provides non-pharmacological pain relief. Assessing pain sources ensures
appropriate treatment. These actions support continued recovery and mobility progression.
7. The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult
using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the
thermometer. Which action should the nurse implement?
CORRECT ANSWER Provide positive reinforcement to confirm that the procedure is being performed correctly.
RATIONALE For an adult, pulling the auricle up and back straightens the ear canal, allowing proper tympanic
thermometer insertion. This technique is correct. The nurse should reinforce this correct behavior with
positive feedback. For children under 3, the auricle is pulled down and back.
