MED-SURGE HESI RN QUESTIONS AND ANSWERS WITH RATIONALE
The nurse is counseling a healthy 30-year-old female client regarding osteoporosis
prevention. Which activity would be most beneficial in achieving the client's goal of
osteoporosis prevention?
A. Cross-country skiing
B. Scuba diving
C. Horseback riding
D. Kayaking - Correct answer Rationale: A
Weight-bearing exercise is an important measure to reduce the risk of osteoporosis. Of
the activities listed, cross-country skiing (A) includes the most weight-bearing, whereas
(B, C, and D) involve less.
The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours
after chest tube insertion for hemothorax. What is the best initial action for the nurse to
take?
A. Document this expected decrease in drainage.
B. Clamp the chest tube while assessing for air leaks.
C. Milk the tube to remove any excessive blood clot buildup.
D. Assess for kinks or dependent loops in the tubing. - Correct answer Rationale: D
The least invasive nursing action should be performed first to determine why the
drainage has diminished (D). (A) is completed after assessing for any problems causing
the decrease in drainage. (B) is no longer considered standard protocol because the
increase in pressure may be harmful to the client. (C) is an appropriate nursing action
after the tube has been assessed for kinks or dependent loops.
A practical nurse (PN) tells the charge nurse in a long-term facility that she does not
want to be assigned to one particular resident. She reports that the male client keeps
insisting that she is his daughter and begs her to stay in his room. What is the best
managerial decision?
A. Notify the family that the resident will have to be discharged if his behavior does not
improve.
B. Notify administration of the PN's insubordination and need for counseling about her
statements.
C. Ask the PN what she has done to encourage the resident to believe that she is his
daughter.
D. Reassign the PN until the resident can be assessed more completely for reality
orientation. - Correct answer Rationale: D
Temporary reassignment (D) is the best option until the resident can be examined and
his medications reviewed. He may have worsening cerebral dysfunction from an
infection or electrolyte imbalance. (A) is not the best option because the family cannot
control the resident's actions. The administration may need to know about the situation,
,but not as a case of insubordination (B). Implying that the PN is somehow creating the
situation is inappropriate until a further evaluation has been conducted (C).
The nurse assesses a postoperative client whose skin is cool, pale, and moist. The
client is very restless and has scant urine output. Oxygen is being administered at 2
L/min, and a saline lock is in place. Which intervention should the nurse implement first?
A. Measure the urine specific gravity.
B. Obtain IV fluids for infusion per protocol.
C. Prepare for insertion of a central venous catheter.
D. Auscultate the client's breath sounds. - Correct answer Rationale: B
The client is at risk for hypovolemic shock because of the postoperative status and is
exhibiting early signs of shock. A priority intervention is the initiation of IV fluids (B) to
restore tissue perfusion. (A, C, and D) are all important interventions, but are of less
priority than (B).
The nurse is performing hourly neurologic checks for a client with a head injury. Which
new assessment finding warrants immediate intervention by the nurse?
A. A unilateral pupil that is dilated and nonreactive to light
B. Client cries out when awakened by a verbal stimulus
C. Client demonstrates a loss of memory of the events leading up to the injury
D. Onset of nausea, headache, and vertigo - Correct answer Rationale: A
Any change in pupil size and reactivity is an indication of increasing intracranial
pressure and should be reported to the health care provider immediately (A). (B) is a
normal response to being awakened. (C and D) are common manifestations of head
injury and are of less immediacy than (A).
A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at
a community hemodialysis facility. Before his scheduled dialysis treatment, which
electrolyte imbalance should the nurse anticipate?
A. Hypophosphatemia
B. Hypocalcemia
C. Hyponatremia
D. Hypokalemia - Correct answer Rationale: B*
Hypocalcemia (B) develops in CKD because of chronic hyperphosphatemia, not (A).
Increased phosphate levels cause the peripheral deposition of calcium and resistance
to vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would
expect to find the client hypernatremic and hyperkalemic, not with (C or D).
A client with alcohol-related liver disease is admitted to the unit. Which prescription
should the nurse call the health care provider about for reverification for this client?
A. Vitamin K1 (AquaMEPHYTON), 5 mg IM daily
B. High-calorie, low-sodium diet
C. Fluid restriction to 1500 mL/day
D. Pentobarbital (Nembutal sodium) at bedtime for rest - Correct answer Rationale: D*
,Sedatives such as Nembutal (D) are contraindicated for clients with liver damage and
can have dangerous consequences. (A) is often prescribed because the normal clotting
mechanism is damaged. (B) is needed to help restore energy to the debilitated client.
Sodium is often restricted because of edema. Fluids are restricted (C) to decrease
ascites, which often accompanies cirrhosis, particularly in the later stages of the
disease.
What is the most important nursing priority for a client who has been admitted for a
possible kidney stone?
A. Reducing dairy products in the diet
B. Straining all urine
C. Measuring intake and output
D. Increasing fluid intake - Correct answer Rationale: B*
Straining all urine (B) is the most important nursing action to take in this case.
Encouraging fluid intake (D) is important for any client who may have a kidney stone,
but is even more important to strain all urine. Straining urine will enable the nurse to
determine when the kidney stone has been passed and may prevent the need for
surgery. (C) is not the highest priority action. (A) is usually not recommended until the
stone is obtained and the content of the stone is determined. Even then, dietary
restrictions are controversial
The nurse initiates neurologic checks for a client who is at risk for neurologic
compromise. Which manifestation typically provides the first indication of altered
neurologic function?
A. Change in level of consciousness
B. Increasing muscular weakness
C. Changes in pupil size bilaterally
D. Progressive nuchal rigidity - Correct answer Rationale: A
A decrease or change in the level of consciousness (A) is usually the first indication of
neurologic deterioration. (B and C) may also occur but are much less likely to be the
first sign of neurologic compromise. (D) is often a sign of meningitis.
A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid
ventricular response. Based on this finding, the nurse anticipates assisting the physician
with which treatment?
A. Administer lidocaine,75 mg intravenous push.
B. Perform synchronized cardioversion.
C. Defibrillate the client as soon as possible.
D. Administer atropine, 0.4 mg intravenous push - Correct answer Rationale: B
With uncontrolled atrial fibrillation, the treatment of choice is synchronized cardioversion
(B) to convert the cardiac rhythm back to normal sinus rhythm. (A) is a medication used
for ventricular dysrhythmias. (C) is not for a client with atrial fibrillation; it is reserved for
clients with life-threatening dysrhythmias, such as ventricular fibrillation and unstable
ventricular tachycardia. (D) is the drug of choice in symptomatic sinus bradycardia, not
atrial fibrillation.
, The nurse receives the client's next scheduled bag of TPN labeled with the additive
NPH insulin. Which action should the nurse implement?
A. Hang the solution at the current rate.
B. Refrigerate the solution until needed.
C. Prepare the solution with new tubing.
D. Return the solution to the pharmacy. - Correct answer Rationale: D
Only regular insulin is administered by the IV route, so the TPN solution containing NPH
insulin should be returned to the pharmacy (D). (A, B, and C) are not indicated because
the solution should not be administered.
In assessing a client diagnosed with primary aldosteronism, the nurse expects the
laboratory test results to indicate a decreased serum level of which substance?
A. Sodium
B. Phosphate
C. Potassium
D. Glucose - Correct answer Rationale: C*
Clients with primary aldosteronism exhibit a profound decline in serum levels of
potassium (C); hypokalemia; hypertension is the most prominent and universal sign.
The serum sodium level is normal or elevated, depending on the amount of water
resorbed with the sodium (A). (B) is influenced by parathyroid hormone (PTH). (D) is not
affected by primary aldosteronism.
A 77-year-old female client is admitted to the hospital with confusion and anorexia of
several days' duration. She has symptoms of nausea and vomiting and is currently
complaining of a headache. The client's pulse rate is 43 beats/min. The nurse is most
concerned about the client's history related to which medication?
A. Warfarin (Coumadin)
B. Ibuprofen (Motrin)
C. Nitroglycerin (Nitrostat)
D. Digoxin (Lanoxin) - Correct answer Rationale: D*
Older persons are particularly susceptible to the buildup of cardiac glycosides, such as
digoxin (Lanoxin) or digitoxin (medications derived from digitalis) (D), to a toxic level in
their systems. Toxicity can cause anorexia, nausea, vomiting, diarrhea, headache, and
fatigue. (A, B, and C) are unlikely to result in the symptoms described.
The nurse witnesses a baseball player receive a blunt trauma to the back of the head
with a softball. What assessment data should the nurse collect immediately?
A. Reactivity of deep tendon reflexes, comparing upper with lower extremities
B. Vital sign readings, excluding blood pressure if needed equipment is unavailable
C. Memory of events that occurred before and after the blow to the head
D. Ability to open the eyes spontaneously before any tactile stimuli are given - Correct
answer Rationale: D
The level of consciousness (LOC) should be established immediately when a head
injury has occurred. Spontaneous eye opening (D) is a simple measure of alertness that
indicates that arousal mechanisms are intact. (A) is not the best indicator of LOC.
Although (B) is important, vital signs are not the best indicators of LOC and can be
The nurse is counseling a healthy 30-year-old female client regarding osteoporosis
prevention. Which activity would be most beneficial in achieving the client's goal of
osteoporosis prevention?
A. Cross-country skiing
B. Scuba diving
C. Horseback riding
D. Kayaking - Correct answer Rationale: A
Weight-bearing exercise is an important measure to reduce the risk of osteoporosis. Of
the activities listed, cross-country skiing (A) includes the most weight-bearing, whereas
(B, C, and D) involve less.
The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours
after chest tube insertion for hemothorax. What is the best initial action for the nurse to
take?
A. Document this expected decrease in drainage.
B. Clamp the chest tube while assessing for air leaks.
C. Milk the tube to remove any excessive blood clot buildup.
D. Assess for kinks or dependent loops in the tubing. - Correct answer Rationale: D
The least invasive nursing action should be performed first to determine why the
drainage has diminished (D). (A) is completed after assessing for any problems causing
the decrease in drainage. (B) is no longer considered standard protocol because the
increase in pressure may be harmful to the client. (C) is an appropriate nursing action
after the tube has been assessed for kinks or dependent loops.
A practical nurse (PN) tells the charge nurse in a long-term facility that she does not
want to be assigned to one particular resident. She reports that the male client keeps
insisting that she is his daughter and begs her to stay in his room. What is the best
managerial decision?
A. Notify the family that the resident will have to be discharged if his behavior does not
improve.
B. Notify administration of the PN's insubordination and need for counseling about her
statements.
C. Ask the PN what she has done to encourage the resident to believe that she is his
daughter.
D. Reassign the PN until the resident can be assessed more completely for reality
orientation. - Correct answer Rationale: D
Temporary reassignment (D) is the best option until the resident can be examined and
his medications reviewed. He may have worsening cerebral dysfunction from an
infection or electrolyte imbalance. (A) is not the best option because the family cannot
control the resident's actions. The administration may need to know about the situation,
,but not as a case of insubordination (B). Implying that the PN is somehow creating the
situation is inappropriate until a further evaluation has been conducted (C).
The nurse assesses a postoperative client whose skin is cool, pale, and moist. The
client is very restless and has scant urine output. Oxygen is being administered at 2
L/min, and a saline lock is in place. Which intervention should the nurse implement first?
A. Measure the urine specific gravity.
B. Obtain IV fluids for infusion per protocol.
C. Prepare for insertion of a central venous catheter.
D. Auscultate the client's breath sounds. - Correct answer Rationale: B
The client is at risk for hypovolemic shock because of the postoperative status and is
exhibiting early signs of shock. A priority intervention is the initiation of IV fluids (B) to
restore tissue perfusion. (A, C, and D) are all important interventions, but are of less
priority than (B).
The nurse is performing hourly neurologic checks for a client with a head injury. Which
new assessment finding warrants immediate intervention by the nurse?
A. A unilateral pupil that is dilated and nonreactive to light
B. Client cries out when awakened by a verbal stimulus
C. Client demonstrates a loss of memory of the events leading up to the injury
D. Onset of nausea, headache, and vertigo - Correct answer Rationale: A
Any change in pupil size and reactivity is an indication of increasing intracranial
pressure and should be reported to the health care provider immediately (A). (B) is a
normal response to being awakened. (C and D) are common manifestations of head
injury and are of less immediacy than (A).
A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at
a community hemodialysis facility. Before his scheduled dialysis treatment, which
electrolyte imbalance should the nurse anticipate?
A. Hypophosphatemia
B. Hypocalcemia
C. Hyponatremia
D. Hypokalemia - Correct answer Rationale: B*
Hypocalcemia (B) develops in CKD because of chronic hyperphosphatemia, not (A).
Increased phosphate levels cause the peripheral deposition of calcium and resistance
to vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would
expect to find the client hypernatremic and hyperkalemic, not with (C or D).
A client with alcohol-related liver disease is admitted to the unit. Which prescription
should the nurse call the health care provider about for reverification for this client?
A. Vitamin K1 (AquaMEPHYTON), 5 mg IM daily
B. High-calorie, low-sodium diet
C. Fluid restriction to 1500 mL/day
D. Pentobarbital (Nembutal sodium) at bedtime for rest - Correct answer Rationale: D*
,Sedatives such as Nembutal (D) are contraindicated for clients with liver damage and
can have dangerous consequences. (A) is often prescribed because the normal clotting
mechanism is damaged. (B) is needed to help restore energy to the debilitated client.
Sodium is often restricted because of edema. Fluids are restricted (C) to decrease
ascites, which often accompanies cirrhosis, particularly in the later stages of the
disease.
What is the most important nursing priority for a client who has been admitted for a
possible kidney stone?
A. Reducing dairy products in the diet
B. Straining all urine
C. Measuring intake and output
D. Increasing fluid intake - Correct answer Rationale: B*
Straining all urine (B) is the most important nursing action to take in this case.
Encouraging fluid intake (D) is important for any client who may have a kidney stone,
but is even more important to strain all urine. Straining urine will enable the nurse to
determine when the kidney stone has been passed and may prevent the need for
surgery. (C) is not the highest priority action. (A) is usually not recommended until the
stone is obtained and the content of the stone is determined. Even then, dietary
restrictions are controversial
The nurse initiates neurologic checks for a client who is at risk for neurologic
compromise. Which manifestation typically provides the first indication of altered
neurologic function?
A. Change in level of consciousness
B. Increasing muscular weakness
C. Changes in pupil size bilaterally
D. Progressive nuchal rigidity - Correct answer Rationale: A
A decrease or change in the level of consciousness (A) is usually the first indication of
neurologic deterioration. (B and C) may also occur but are much less likely to be the
first sign of neurologic compromise. (D) is often a sign of meningitis.
A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid
ventricular response. Based on this finding, the nurse anticipates assisting the physician
with which treatment?
A. Administer lidocaine,75 mg intravenous push.
B. Perform synchronized cardioversion.
C. Defibrillate the client as soon as possible.
D. Administer atropine, 0.4 mg intravenous push - Correct answer Rationale: B
With uncontrolled atrial fibrillation, the treatment of choice is synchronized cardioversion
(B) to convert the cardiac rhythm back to normal sinus rhythm. (A) is a medication used
for ventricular dysrhythmias. (C) is not for a client with atrial fibrillation; it is reserved for
clients with life-threatening dysrhythmias, such as ventricular fibrillation and unstable
ventricular tachycardia. (D) is the drug of choice in symptomatic sinus bradycardia, not
atrial fibrillation.
, The nurse receives the client's next scheduled bag of TPN labeled with the additive
NPH insulin. Which action should the nurse implement?
A. Hang the solution at the current rate.
B. Refrigerate the solution until needed.
C. Prepare the solution with new tubing.
D. Return the solution to the pharmacy. - Correct answer Rationale: D
Only regular insulin is administered by the IV route, so the TPN solution containing NPH
insulin should be returned to the pharmacy (D). (A, B, and C) are not indicated because
the solution should not be administered.
In assessing a client diagnosed with primary aldosteronism, the nurse expects the
laboratory test results to indicate a decreased serum level of which substance?
A. Sodium
B. Phosphate
C. Potassium
D. Glucose - Correct answer Rationale: C*
Clients with primary aldosteronism exhibit a profound decline in serum levels of
potassium (C); hypokalemia; hypertension is the most prominent and universal sign.
The serum sodium level is normal or elevated, depending on the amount of water
resorbed with the sodium (A). (B) is influenced by parathyroid hormone (PTH). (D) is not
affected by primary aldosteronism.
A 77-year-old female client is admitted to the hospital with confusion and anorexia of
several days' duration. She has symptoms of nausea and vomiting and is currently
complaining of a headache. The client's pulse rate is 43 beats/min. The nurse is most
concerned about the client's history related to which medication?
A. Warfarin (Coumadin)
B. Ibuprofen (Motrin)
C. Nitroglycerin (Nitrostat)
D. Digoxin (Lanoxin) - Correct answer Rationale: D*
Older persons are particularly susceptible to the buildup of cardiac glycosides, such as
digoxin (Lanoxin) or digitoxin (medications derived from digitalis) (D), to a toxic level in
their systems. Toxicity can cause anorexia, nausea, vomiting, diarrhea, headache, and
fatigue. (A, B, and C) are unlikely to result in the symptoms described.
The nurse witnesses a baseball player receive a blunt trauma to the back of the head
with a softball. What assessment data should the nurse collect immediately?
A. Reactivity of deep tendon reflexes, comparing upper with lower extremities
B. Vital sign readings, excluding blood pressure if needed equipment is unavailable
C. Memory of events that occurred before and after the blow to the head
D. Ability to open the eyes spontaneously before any tactile stimuli are given - Correct
answer Rationale: D
The level of consciousness (LOC) should be established immediately when a head
injury has occurred. Spontaneous eye opening (D) is a simple measure of alertness that
indicates that arousal mechanisms are intact. (A) is not the best indicator of LOC.
Although (B) is important, vital signs are not the best indicators of LOC and can be
