HESI PN MED SURGE PROCTORED EXAM
VERSION 1
A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following
actions should the nurse take?
1) Provide a diet high in protein.
2) Provide ibuprofen for retroperitoneal discomfort.
3) Monitor intake and output hourly
4) Encourage the client to consume at least 2 L of fluid daily.
A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper
gastric pain. Which of the following statements should the nurse include in the teaching?
1) "A flexible tube is introduced through the nose during the procedure."
2) "During the procedure you are in a sitting position."
3) "You will remain NPO for 8 hours before the procedure."
4) "You will be awake while the procedure is performed."
A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a
generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when
documenting this finding in the medical record?
1) Aura phase
2) Presence of automatisms
3) Postictal phase
4) Presence of absence seizures
A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic
cholecystectomy. Which of the following statements should the nurse make?
1) "The pain results from lying in one position too long during surgery."
2) "The pain occurs as a residual pain from cholecystitis."
3) "The pain will dissipate if you ambulate frequently."
4) "The pain is caused from the nitrous dioxide injected into the abdomen."
A nurse is checking the suction control chamber of a client's chest tube and notes that there is no
bubbling in the suction control chamber. Which of the following actions should the nurse take?
1) Notify the provider.
Answer Rationale:
The nurse should check for kinks and take other measures before notifying the provider.
2) Verify that the suction regulator is on.
3) Continue to monitor the client because this is an expected finding.
4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it.
A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the
following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
3) Insert a urinary catheter.
4) Elevate the client’s head of bed.
5) Apply a cervical collar to the client.
A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured
mandible. The client’s jaw is wired shut to repair and stabilize the fracture. The nurse should recognize
which of the following is the priority action?
,1) Relieve the client's pain.
2) Check the client’s pressure points for redness.
3) Provide oral hygiene.
4) Prevent aspiration.
A nurse is collecting data from a client who has scleroderma. Which of the following findings should the
nurse expect?
1) A dry raised rash
2) Excessive salivation
3) Periorbital edema
4) Hardened skin
A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a
stroke. Which of the following actions should the nurse take?
1) Instruct the client to tilt her head back when she swallows.
2) Place food on the left side of the client's mouth.
3) Add thickener to fluids.
4) Serve food at room temperature.
A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and
chest. The nurse should recognize which of the following is the priority risk to the client?
1) Airway obstruction
2) Infection
3) Fluid imbalance
4) Contractures
A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to
start taking neostigmine. Which of the following instructions should the nurse include in the teaching?
1) Take the medication 45 minutes before eating.
2) Expect diaphoresis as a side effect of the neostigmine.
3) If a medication dose is missed, wait until the next scheduled dose to take the
medication.
4) Treat nasal rhinitis with an over-the-counter antihistamine.
A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the
prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has
not been any urinary output in the last hour. Which of the following actions should the nurse perform
first?
1) Notify the provider.
2) Administer a prescribed analgesic.
3) Offer oral fluids.
4) Determine the patency of the tubing.
A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the
procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse
make?
1) "You must be very worried about what the biopsy will show."
2) "You'll be asleep for the whole biopsy procedure and won't be aware of what’s
happening."
3) "Your provider scheduled this, so she will want to know you still have questions about
the procedure."
4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as
possible."
,A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke.
Which of the following interventions should the nurse include in the plan?
1) Control impulsive behavior.
2) Compensate for left visual field deficits.
3) Re-establish communication.
4) Improve left-side motor function.
A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the
client for which of the following manifestations?
1) Hypotension
2) Polyphagia
3) Hyperglycemia
4) Bradycardia
A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of
7/min. The arterial blood gas (ABG) values include:
pH 7.22
PaCO2 68 mm Hg
Base excess -2
PaO2 78 mm Hg
Oxygen saturation 80%
Bicarbonate 28 mEq/L
Which of the following interpretations of the ABG
values should the nurse make
, 1) Metabolic acidosis
2) Respiratory acidosis
3) Metabolic alkalosis
4) Respiratory alkalosis
A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse
should recognize that which of the following statements by the client indicates a need for further
teaching?
1) "I will avoid crossing my legs at the knees."
2) "I will use a thermometer to check the temperature of my bath water."
3) "I will not go barefoot."
4) "I will wear stockings with elastic tops."
A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The
client becomes agitated and combative when the nurse approaches him. Which of the following actions
should the nurse plan to take?
1) Turn the water on and ask the client to test the temperature.
2) Obtain assistance to place mitten restraints on the client.
3) Firmly tell the client that good hygiene is important.
4) Calmly ask the client if he would like to listen to some music.
A nurse is collecting data on a client’s wound. The nurse observes that the wound surface is covered
with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of
the following?
1) Decreased perfusion
2) Infection
3) Granulation tissue
4) An inflammatory response
A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of
the following food items brought by the family should the nurse prohibit from being given to the client?
1) Baked chicken
2) Bagels
3) A factory-sealed box of chocolates
4) Fresh fruit basket
A nurse is contributing to the plan of care for an older adult client who is postoperative following a right
hip arthroplasty. Which of the following interventions should the nurse include in the plan?
1) Perform the client's personal care activities for her.
2) Limit the client’s fluid intake.
3) Monitor the Homan’s sign.
4) Maintain abduction of the right hip.
A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions
should the nurse take first?
1) Establish IV access.
2) Feel for a carotid pulse.
3) Establish an open airway.
4) Auscultate for breath sounds.
A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer
certain he wants to have the procedure. Which of the following responses should the nurse make?
1) "Why have you changed your mind about the surgery?"
2) "Bypass surgery must be very frightening for you."
VERSION 1
A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following
actions should the nurse take?
1) Provide a diet high in protein.
2) Provide ibuprofen for retroperitoneal discomfort.
3) Monitor intake and output hourly
4) Encourage the client to consume at least 2 L of fluid daily.
A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper
gastric pain. Which of the following statements should the nurse include in the teaching?
1) "A flexible tube is introduced through the nose during the procedure."
2) "During the procedure you are in a sitting position."
3) "You will remain NPO for 8 hours before the procedure."
4) "You will be awake while the procedure is performed."
A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a
generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when
documenting this finding in the medical record?
1) Aura phase
2) Presence of automatisms
3) Postictal phase
4) Presence of absence seizures
A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic
cholecystectomy. Which of the following statements should the nurse make?
1) "The pain results from lying in one position too long during surgery."
2) "The pain occurs as a residual pain from cholecystitis."
3) "The pain will dissipate if you ambulate frequently."
4) "The pain is caused from the nitrous dioxide injected into the abdomen."
A nurse is checking the suction control chamber of a client's chest tube and notes that there is no
bubbling in the suction control chamber. Which of the following actions should the nurse take?
1) Notify the provider.
Answer Rationale:
The nurse should check for kinks and take other measures before notifying the provider.
2) Verify that the suction regulator is on.
3) Continue to monitor the client because this is an expected finding.
4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it.
A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the
following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
3) Insert a urinary catheter.
4) Elevate the client’s head of bed.
5) Apply a cervical collar to the client.
A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured
mandible. The client’s jaw is wired shut to repair and stabilize the fracture. The nurse should recognize
which of the following is the priority action?
,1) Relieve the client's pain.
2) Check the client’s pressure points for redness.
3) Provide oral hygiene.
4) Prevent aspiration.
A nurse is collecting data from a client who has scleroderma. Which of the following findings should the
nurse expect?
1) A dry raised rash
2) Excessive salivation
3) Periorbital edema
4) Hardened skin
A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a
stroke. Which of the following actions should the nurse take?
1) Instruct the client to tilt her head back when she swallows.
2) Place food on the left side of the client's mouth.
3) Add thickener to fluids.
4) Serve food at room temperature.
A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and
chest. The nurse should recognize which of the following is the priority risk to the client?
1) Airway obstruction
2) Infection
3) Fluid imbalance
4) Contractures
A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to
start taking neostigmine. Which of the following instructions should the nurse include in the teaching?
1) Take the medication 45 minutes before eating.
2) Expect diaphoresis as a side effect of the neostigmine.
3) If a medication dose is missed, wait until the next scheduled dose to take the
medication.
4) Treat nasal rhinitis with an over-the-counter antihistamine.
A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the
prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has
not been any urinary output in the last hour. Which of the following actions should the nurse perform
first?
1) Notify the provider.
2) Administer a prescribed analgesic.
3) Offer oral fluids.
4) Determine the patency of the tubing.
A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the
procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse
make?
1) "You must be very worried about what the biopsy will show."
2) "You'll be asleep for the whole biopsy procedure and won't be aware of what’s
happening."
3) "Your provider scheduled this, so she will want to know you still have questions about
the procedure."
4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as
possible."
,A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke.
Which of the following interventions should the nurse include in the plan?
1) Control impulsive behavior.
2) Compensate for left visual field deficits.
3) Re-establish communication.
4) Improve left-side motor function.
A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the
client for which of the following manifestations?
1) Hypotension
2) Polyphagia
3) Hyperglycemia
4) Bradycardia
A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of
7/min. The arterial blood gas (ABG) values include:
pH 7.22
PaCO2 68 mm Hg
Base excess -2
PaO2 78 mm Hg
Oxygen saturation 80%
Bicarbonate 28 mEq/L
Which of the following interpretations of the ABG
values should the nurse make
, 1) Metabolic acidosis
2) Respiratory acidosis
3) Metabolic alkalosis
4) Respiratory alkalosis
A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse
should recognize that which of the following statements by the client indicates a need for further
teaching?
1) "I will avoid crossing my legs at the knees."
2) "I will use a thermometer to check the temperature of my bath water."
3) "I will not go barefoot."
4) "I will wear stockings with elastic tops."
A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The
client becomes agitated and combative when the nurse approaches him. Which of the following actions
should the nurse plan to take?
1) Turn the water on and ask the client to test the temperature.
2) Obtain assistance to place mitten restraints on the client.
3) Firmly tell the client that good hygiene is important.
4) Calmly ask the client if he would like to listen to some music.
A nurse is collecting data on a client’s wound. The nurse observes that the wound surface is covered
with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of
the following?
1) Decreased perfusion
2) Infection
3) Granulation tissue
4) An inflammatory response
A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of
the following food items brought by the family should the nurse prohibit from being given to the client?
1) Baked chicken
2) Bagels
3) A factory-sealed box of chocolates
4) Fresh fruit basket
A nurse is contributing to the plan of care for an older adult client who is postoperative following a right
hip arthroplasty. Which of the following interventions should the nurse include in the plan?
1) Perform the client's personal care activities for her.
2) Limit the client’s fluid intake.
3) Monitor the Homan’s sign.
4) Maintain abduction of the right hip.
A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions
should the nurse take first?
1) Establish IV access.
2) Feel for a carotid pulse.
3) Establish an open airway.
4) Auscultate for breath sounds.
A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer
certain he wants to have the procedure. Which of the following responses should the nurse make?
1) "Why have you changed your mind about the surgery?"
2) "Bypass surgery must be very frightening for you."
