HESI MEDSURG 1 EXAM REVIEW
1. Nurse in ED caring for a client who is having an acute asthma attack. How can she tell the
client in in respiratory distress (Select all)
A. 95% O2
B. Wheezing
C. Retraction of sternal muscles
D. Pink mucous membranes
E. Premature ventricular complexes (PVCs)
2. Morning
3. Newly admitted patient w/diagnosis of ascites. What order would the nurse question?
(select all)
a. High sodium
b. Spironolactone
c. Paracentesis
d. Administration of salt-poor albumin
e. Assisted ambulation
4. A client is administered to the emergency department with several large kidney stones.
What is the nursing priority of this patient?
a. Administer a Foley catheter
b. Have the patient transferred to the ER to have the stones surgically removed
c. Administer hydrochlorothiazide
d. Administer acetaminophen
5. A student nurse is completing a pain assessment. The patient states that the pain is
located in his abdomen, and relieved by defecation. After reviewing his chart she noticed
the consistency of his stools also changed. What would the student suspect his diagnosis
to be?
a. Appendicitis
b. Irritable bowel syndrome
c. Irregular diet
d. Abdominal hernia
6. The nurse obtains a diet history from a pregnant 16 yr old girl. The girl tells the nurse her
typical daily diet includes cereal and milk for breakfast, pizza and soda for lunch, and a
cheeseburger, milkshake, fries and a salad for dinner. Which of the following is the MOST
accurate nursing diagnosis based on the data?
https://www.coursehero.com/file/54147092/Level-3-Medsurg-HESIpdf/
, a. Altered nutrition: more than body requirements related to high-fat diet
b. Knowledge deficit: nutrition in pregnancy
c. Altered nutrition: less that body requirements related to increased nutritional
demands of pregnancy
d. Risk for injury: fetal malnutrition related to poor maternal diet
7. A boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The
school nurse was called and found him alert and conscious, but in severe pain with a
possible fracture to the right femur. Which of the following is the FIRST action the nurse
should take
a. check the pedal pulse and blanching sign in both legs
b. immobilize the affected limb with a splint and ask him not to move
c. make a thorough assessment of the circumstances surrounding the accident
d. put him in semi-fowler’s position for comfort
8. A 65 year old patient with pneumonia is receiving gentamicin. It would be most important
for a nurse to monitor which of the following lab values in this patient
a. Hemoglobin and Hematocrit
b. BUN and creatinine: cleared by kidneys, gentamicin is nephrotoxic
c. Platelet count and clotting time
d. Sodium and potassium
9. To enhance the percutaneous absorption of nitroglycerin ointment, it would be MOST
important for the nurse to select a site that is
a. Muscular, non-hairy, near the heart. Nitro placement on anterior chest wall; want
to keep up with it, need it to attach and be seen. Non-hairy is the most important
so that it can be seen
10. The nurse care for a client diagnosed with a right-sided cerebrovascular accident (CVA)
with dysphagia. Which of the following actions by the nurse reflects appropriate care for
the client (SELECT ALL THAT APPLY).
a. The nurse assesses the client’s ability to swallow
b. the nurse offers the client scrambled eggs (make sure they are more whole)
c. the nurse positions the client at a 45 degree angle-should be 90 degrees
d. the nurse instructs the client to place food on the left side of the mouth-stroke
affects the left side of the mouth, can’t chew on this side
e. the nurse turns off the tv
11. You are teaching a patient with a sigmoid colostomy about colostomy care. Which
statement made by the patient shows the patient has an understanding?
a. I should clean my stoma with hydrogen peroxide
b. I will have watery stools now-ileostomy
c. I should make sure my stoma is dry
d. My stools will be formed-location
https://www.coursehero.com/file/54147092/Level-3-Medsurg-HESIpdf/
, 12. A 30 year old patient had a subtotal thyroidectomy in the morning. During the evening,
the nurse records his vital signs and has a temp of 105 F, tachycardia, and appears
restless. What is most likely the cause of these signs?
a. Hyperglycemia
b. Thyroid crisis
c. DKA
d. Tetany
13. A patient with B-folic deficiency should eat these foods for supplement
a. Nuts
b. Leafy greans
c. Meats, cheese, and eggs
d. Citrus juices
14. A client admitted to the hospital with a subarachnoid hemorrhage complains of a
headache, vomiting and nuchal rigidity. The nurse knows a lumbar puncture would be
contraindicated in the client in which of the following circumstances
a. ICP increased
b. Blood pressure decreases
c. Vomiting continues
d. dyspnea
15. A 35 year old patient with liver cirrhosis has developed ascites and now requires a
paracentesis. Before her procedure you instruct the patient the patient to:
a. Remain NPO for 4 hours
b. Clean their bowels with an enema
c. Empty their bladder-patient safety to prevent puncture, full bladder can displace
and become punctured
d. Take ordered pain medicine
16. A nurse was monitoring a patient who is 72 hours post-op from surgery. Which finding
requires intervention?
a. A pain rating of 2 on a scale of 1-10
b. Blood pressure of 130/90
c. Temperature of 100.8-cutoff temperature is 100.4
d. The patient is thirsty
17. A patient who is post-op from an abdominal surgery calls his nurse and asks her to come
immediately. Upon arrival, you see that some of his internal organs are protruding
through his incision. What is nursing intervention would you do FIRST?
a. notify the provider
b. press the call light to recruit more nurses to help
c. cover the wound with a normal saline dressing
d. take the patient’s blood pressure and observe for signs of hypovolemia
https://www.coursehero.com/file/54147092/Level-3-Medsurg-HESIpdf/
, 18. While performing a skin assessment the nurse notices small purple dots on the patient’s
tors. The patient says that they are not painful but have been there for some time. What
term should the nurse use when charting this finding?
a. cellulitis
b. petechia
c. stretch marks
d. shingles virus
19. A 36 year old patient has been diagnosed with scleroderma and has breathing difficulties,
including wheezing and dry cough. Which of the following skin changes would the nurse
also expect to see upon assessment of this patient?
a. A pinpoint rash across the neck and chest
b. Excess skin folds that break down easily
c. Moist pale skin that feel cool to the touch
d. Stiff, tight skin that is lighter or darker than surrounding skin
20. A nurse is helping a 47 year old female patient with getting up in the morning and
performing activities of daily living. The patient was diagnosed with myasthenia gravis 6
years ago. Which of the following would the nurse most likely expect the patient to find
difficult because of this diagnosis
a. Eating breakfast
b. Controlling bowel movements
c. Sitting in a chair
d. Listening to a radio program
21. A nurse is working with a patient who is being tested for diabetes. The physician has
ordered a hemoglobin A1C test and the nurse checks the results. The paitent asks, “What
is the hemoglobin A1C test?” Which response from the nurse is correct?
a. This test will tell us how much insulin is circulating in your bloodstream
b. This test checks how insulin responds to increased sugar in the hemoglobin of your
red blood cells
c. This test checks how much sugar is coating he hg in your RBCs; it can tell us your
blood sugar levels for the past two months
d. This test determines what your blood sugar is two hours after you have some
glucose, you will drink a sugary drink
22. The pads of the fingers. DO NOT PALPATE AN ABDOMINAL ANEURUSYM, LISTEN FOR
ABDOMINAL BRUIT….AUSCULTATE FIRST
MEDSURG 2 HESI RATIONALES
Cardiac
The normal level of serum potassium is between 3.5-5.0 mEq/L (3.5 and 5.0 mmol/L). Elevated potassium
levels greater than 6 mEq/L (mmol/L) can lead to muscle weakness and cardiac arrhythmias. The normal
levels of serum phosphorus are between 2.4-4.4 mg/dL (0.78 and 1.42 mmol/L). The normal levels of serum
calcium are usually between 8.6-10.2 mg/dL (2.15 and 2.55 mmol/L). The normal level of serum
https://www.coursehero.com/file/54147092/Level-3-Medsurg-HESIpdf/
1. Nurse in ED caring for a client who is having an acute asthma attack. How can she tell the
client in in respiratory distress (Select all)
A. 95% O2
B. Wheezing
C. Retraction of sternal muscles
D. Pink mucous membranes
E. Premature ventricular complexes (PVCs)
2. Morning
3. Newly admitted patient w/diagnosis of ascites. What order would the nurse question?
(select all)
a. High sodium
b. Spironolactone
c. Paracentesis
d. Administration of salt-poor albumin
e. Assisted ambulation
4. A client is administered to the emergency department with several large kidney stones.
What is the nursing priority of this patient?
a. Administer a Foley catheter
b. Have the patient transferred to the ER to have the stones surgically removed
c. Administer hydrochlorothiazide
d. Administer acetaminophen
5. A student nurse is completing a pain assessment. The patient states that the pain is
located in his abdomen, and relieved by defecation. After reviewing his chart she noticed
the consistency of his stools also changed. What would the student suspect his diagnosis
to be?
a. Appendicitis
b. Irritable bowel syndrome
c. Irregular diet
d. Abdominal hernia
6. The nurse obtains a diet history from a pregnant 16 yr old girl. The girl tells the nurse her
typical daily diet includes cereal and milk for breakfast, pizza and soda for lunch, and a
cheeseburger, milkshake, fries and a salad for dinner. Which of the following is the MOST
accurate nursing diagnosis based on the data?
https://www.coursehero.com/file/54147092/Level-3-Medsurg-HESIpdf/
, a. Altered nutrition: more than body requirements related to high-fat diet
b. Knowledge deficit: nutrition in pregnancy
c. Altered nutrition: less that body requirements related to increased nutritional
demands of pregnancy
d. Risk for injury: fetal malnutrition related to poor maternal diet
7. A boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The
school nurse was called and found him alert and conscious, but in severe pain with a
possible fracture to the right femur. Which of the following is the FIRST action the nurse
should take
a. check the pedal pulse and blanching sign in both legs
b. immobilize the affected limb with a splint and ask him not to move
c. make a thorough assessment of the circumstances surrounding the accident
d. put him in semi-fowler’s position for comfort
8. A 65 year old patient with pneumonia is receiving gentamicin. It would be most important
for a nurse to monitor which of the following lab values in this patient
a. Hemoglobin and Hematocrit
b. BUN and creatinine: cleared by kidneys, gentamicin is nephrotoxic
c. Platelet count and clotting time
d. Sodium and potassium
9. To enhance the percutaneous absorption of nitroglycerin ointment, it would be MOST
important for the nurse to select a site that is
a. Muscular, non-hairy, near the heart. Nitro placement on anterior chest wall; want
to keep up with it, need it to attach and be seen. Non-hairy is the most important
so that it can be seen
10. The nurse care for a client diagnosed with a right-sided cerebrovascular accident (CVA)
with dysphagia. Which of the following actions by the nurse reflects appropriate care for
the client (SELECT ALL THAT APPLY).
a. The nurse assesses the client’s ability to swallow
b. the nurse offers the client scrambled eggs (make sure they are more whole)
c. the nurse positions the client at a 45 degree angle-should be 90 degrees
d. the nurse instructs the client to place food on the left side of the mouth-stroke
affects the left side of the mouth, can’t chew on this side
e. the nurse turns off the tv
11. You are teaching a patient with a sigmoid colostomy about colostomy care. Which
statement made by the patient shows the patient has an understanding?
a. I should clean my stoma with hydrogen peroxide
b. I will have watery stools now-ileostomy
c. I should make sure my stoma is dry
d. My stools will be formed-location
https://www.coursehero.com/file/54147092/Level-3-Medsurg-HESIpdf/
, 12. A 30 year old patient had a subtotal thyroidectomy in the morning. During the evening,
the nurse records his vital signs and has a temp of 105 F, tachycardia, and appears
restless. What is most likely the cause of these signs?
a. Hyperglycemia
b. Thyroid crisis
c. DKA
d. Tetany
13. A patient with B-folic deficiency should eat these foods for supplement
a. Nuts
b. Leafy greans
c. Meats, cheese, and eggs
d. Citrus juices
14. A client admitted to the hospital with a subarachnoid hemorrhage complains of a
headache, vomiting and nuchal rigidity. The nurse knows a lumbar puncture would be
contraindicated in the client in which of the following circumstances
a. ICP increased
b. Blood pressure decreases
c. Vomiting continues
d. dyspnea
15. A 35 year old patient with liver cirrhosis has developed ascites and now requires a
paracentesis. Before her procedure you instruct the patient the patient to:
a. Remain NPO for 4 hours
b. Clean their bowels with an enema
c. Empty their bladder-patient safety to prevent puncture, full bladder can displace
and become punctured
d. Take ordered pain medicine
16. A nurse was monitoring a patient who is 72 hours post-op from surgery. Which finding
requires intervention?
a. A pain rating of 2 on a scale of 1-10
b. Blood pressure of 130/90
c. Temperature of 100.8-cutoff temperature is 100.4
d. The patient is thirsty
17. A patient who is post-op from an abdominal surgery calls his nurse and asks her to come
immediately. Upon arrival, you see that some of his internal organs are protruding
through his incision. What is nursing intervention would you do FIRST?
a. notify the provider
b. press the call light to recruit more nurses to help
c. cover the wound with a normal saline dressing
d. take the patient’s blood pressure and observe for signs of hypovolemia
https://www.coursehero.com/file/54147092/Level-3-Medsurg-HESIpdf/
, 18. While performing a skin assessment the nurse notices small purple dots on the patient’s
tors. The patient says that they are not painful but have been there for some time. What
term should the nurse use when charting this finding?
a. cellulitis
b. petechia
c. stretch marks
d. shingles virus
19. A 36 year old patient has been diagnosed with scleroderma and has breathing difficulties,
including wheezing and dry cough. Which of the following skin changes would the nurse
also expect to see upon assessment of this patient?
a. A pinpoint rash across the neck and chest
b. Excess skin folds that break down easily
c. Moist pale skin that feel cool to the touch
d. Stiff, tight skin that is lighter or darker than surrounding skin
20. A nurse is helping a 47 year old female patient with getting up in the morning and
performing activities of daily living. The patient was diagnosed with myasthenia gravis 6
years ago. Which of the following would the nurse most likely expect the patient to find
difficult because of this diagnosis
a. Eating breakfast
b. Controlling bowel movements
c. Sitting in a chair
d. Listening to a radio program
21. A nurse is working with a patient who is being tested for diabetes. The physician has
ordered a hemoglobin A1C test and the nurse checks the results. The paitent asks, “What
is the hemoglobin A1C test?” Which response from the nurse is correct?
a. This test will tell us how much insulin is circulating in your bloodstream
b. This test checks how insulin responds to increased sugar in the hemoglobin of your
red blood cells
c. This test checks how much sugar is coating he hg in your RBCs; it can tell us your
blood sugar levels for the past two months
d. This test determines what your blood sugar is two hours after you have some
glucose, you will drink a sugary drink
22. The pads of the fingers. DO NOT PALPATE AN ABDOMINAL ANEURUSYM, LISTEN FOR
ABDOMINAL BRUIT….AUSCULTATE FIRST
MEDSURG 2 HESI RATIONALES
Cardiac
The normal level of serum potassium is between 3.5-5.0 mEq/L (3.5 and 5.0 mmol/L). Elevated potassium
levels greater than 6 mEq/L (mmol/L) can lead to muscle weakness and cardiac arrhythmias. The normal
levels of serum phosphorus are between 2.4-4.4 mg/dL (0.78 and 1.42 mmol/L). The normal levels of serum
calcium are usually between 8.6-10.2 mg/dL (2.15 and 2.55 mmol/L). The normal level of serum
https://www.coursehero.com/file/54147092/Level-3-Medsurg-HESIpdf/
