MED-SURG HESI 2023-2024 ACTUAL EXAM QUESTIONS
AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |AGRADE
A female client with a nasogastric tube attached to low suction states that she is
nauseated. The nurse assesses that there has been no drainage through the
nasogastric tube in the last 2 hours. Which action should the nurse take first? ✔✔
Reposition the client on her side. The priority is to determined if the tube is
functioningcorrectly, which would relieve the client's nausea. The least invasive
intervention is to reposition the client (B), should be attempted first, followed by (A
& C) if these are unsuccessful then (D).
When assigning clients on a medical-surgical floor to a RN and a LPN, it is best for
thecharge nurse to assign which client to the LPN?
• A child with bacterial meningitis with recent seizures.
• An older adult client with pneumonia and viral
meningitis.
• C. A female client in isolation wiht meningococcal
meningitis.
D. A male client 1 day post-op after drainage of a brain abscess. ✔✔ B. Is the
moststable. A, C, D have an increased risk for elevated ICP.
Which description of symptoms is characteristic of a client diagnosed with trigeminal
neuralgia (tic douloureux)?
• Tinnitus, vertigo, and hearing difficulties.
• Sudden, stabbing, severe pain over the lip and
chin.
• C. Unilateral facial weakness and paralysis.
D. Difficulty in talking, chewing, and swallowing. ✔✔ B. Trigeminal neuralgia is
characterized by paroxysms of pain, similar to an electric shock, in the area
innervated by one or more branches of the trigeminal nerve.
A. Characteristic of Meniere's C. Characteristic of Bell palsey
D. Characteristic of disorders of the hypoglossal (12th cranial nerve)
Which abnormal lab finding indicates that a client with diabetes needs further
evaluationfor diabetic nephropathy?
• Hypokalemia
• Microalbuminauria
,• C. Elevated serum lipids
D. Ketonuria ✔✔ B. Microalbuminuria is the earliest sign of nephropathy and
indicatesthe need for follow-up evaluation. Hyperkalemia (A) is associated with end
stage renaldisease caused by diabetic nephropathy. (C) may be elevated in end
stage renal disease. (D) may signal the onset of DKA.
An older male client comes to the geriatric screening clinic complaining of pain in his
leftcalf. The nurse notices a reddened area on the calf of his right leg that is warm to
touch and the nurse suspects that the client may have thrombophlebitis. Which
addition assessment is most important for the nurse to perform?
• Measure calf circumference.
• Auscultate the client's breath
sounds.
• C. Observe for ecchymosis and
petechiae.
D. Obtain the client's blood pressure. ✔✔ B. Since the client may have a
pulmonaryembolus secondary to the thrombophlebitis.
A. Would support the nurses assessment.
C. Least helpful since bruising is not associated with
thrombophlebitis.D. Less important then auscultation.
The nurse know that a client taking diuretics must be assessed for the development of
hypokalemia, and that hypokalemia will create changes in the client's normal ECG
tracing. Which ECG change would be an expected finding in the client with
hypokalemia?
• Tall, spiked T waves
• A prolonged QT
interval
• C. A widening QRS
complex
D. Presence of a U wave ✔✔ D. A U wave is a positive deflection following the T
waveand is often present with hypokalemia. A, B, C indicate hyperkalemia.
An older client is admitted with a diagnosis of bacterial pneumonia. The nurse's
assessment of the client will most likely reveal which S/SX?
A. Leukocytosis and
febrile.
B. Polycythemia and
crackles.
C. Pharyngitis and sputum production.
D. Confusion and tachycardia. ✔✔ D. The onset of pneumonia is the older may be
signaled by general deterioration, confusion, increased heart rate or increased
respiratory rate.
,(A, B, C) are often absent in the older with bacterial pneumonia.
The nurse observes ventricular fibrillation on telemetry and upon entering the
clients bathroom finds the client unconscious on the floor. What intervention should
the nurseimplement first?
A. Administer an antidysrhythmic
medication.
B. Start cardiopulmonary resuscitation.
C. Defibrillate the client at 200 joules.
D. Assess the client's pulse oximetry. ✔✔ B. Ventricular fibrillation is a life-threatening
dysrhythmia and CPR should be started immediately. A & C are appropriate but B is
thepriority. D does not address the seriousness of the situation.
An older female client with dementia is transferred from a long term care unit to an
acute care unit. The client's children express concern that their mother's confusion
isworsening. How should the nurse respond?
A. "It is to be expected that older people will experience progressive
confusion."
B. "Confusion in an older person often follows relocation to new surroundings."
C. "The dementia is progressing rapidly, but we will do everything we can to keep
your mother safe."
D. "The acute care staff is not as experienced as the long-term care staff at dealing
withdementia." ✔✔ B. Relocation often results in confusion among older clients and
is stressful to clients of all ages. (A) is an inaccurate stereotype. (C) is most likely
false there are many factors that cause increased temporary confusion. (D) may be
true but does not offer the family a sense of security about the care.
The nurse plans to help an 18-year-old developmentally disabled female client
ambulate on the first postoperative day. When the nurse tells her it is time to get out of
bed, the client becomes angry and yells at the nurse. "Get out of here! I'll get up
when I'm ready." Which response should the nurse provide?
A. "Your healthcare provider has prescribed ambulation on the first postoperative
day."
B. "You must ambulate to avoid serious complications that are much more painful."
C. "I know how you feel; you're angry about having to do this, but it is required."
D. "I'll be back in 30 minutes to help you get out of bed and walk around the room."
✔✔D. Returning in 30 minutes provides a cooling off period, is firm, direct,
nonthreatening, and avoids argument with the client. B is threatening. C. assumes
what the client is feeling. A. avoids the nurse's responsibility to ambulate the client.
, The nurse is performing hourly neurological check for a client with a head injury.
Whichnew assessment finding warrants the most 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 to the events leading up to the injury.
D. Onset of nausea, headache, and vertigo. ✔✔ A. Any changes in pupil size and
reactivity is an indication of increasing ICP and should be reported immediately. (B) is
normal for being awakened. (C & D) are common manifestations of head injury and
lessof an immediacy than (A).
A male client with arterial peripheral vascular disease (PVD) complains of pain in
his feet. Which instruction should the nurse give to the UPA to quickly relieve the
client'spain?
A. Help the client to dangle his
legs.
B. Apply compression stockings.
C. Assist with passive leg exercises.
D. Ambulate three times daily. ✔✔ A. A client who has arterial PVD may benefit
from a dependent position which can be achieved by dangling by improving blood
flow and relieving pain. (B) is indicated for venous insufficiency and (C) is indicated
for bed rest.(D) is indicated to facilitate collateral circulation and may improve long
term complaintsof pain.
A 58-year-old client, who has no health problems, asks the nurse about taking the
pneumococcal vaccine (Pneumovax). Which statement give by the nurse would
offerthe client accurate information about this vaccine?
A. "The vaccine is given annually before the flue season to those over 50 years of
age."
B. "The immunization is administered once to older adults or persons with a history of
chronic illness."
C. "The vaccine is for all ages and is given primarily to those person traveling
overseasto infected areas."
D. "The vaccine will prevent the occurrence of pneumococcal pneumonia for up to
5 years." ✔✔ B. It is usually recommended that persons over 65 years of age and
thosewith a history of chronic illness should receive the vaccine once in a lifetime.
(A) the influenza vaccine is given annually. (C) travel is not the main rationale for
the vaccine.(D) The vaccine is usually given once in a lifetime.
AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |AGRADE
A female client with a nasogastric tube attached to low suction states that she is
nauseated. The nurse assesses that there has been no drainage through the
nasogastric tube in the last 2 hours. Which action should the nurse take first? ✔✔
Reposition the client on her side. The priority is to determined if the tube is
functioningcorrectly, which would relieve the client's nausea. The least invasive
intervention is to reposition the client (B), should be attempted first, followed by (A
& C) if these are unsuccessful then (D).
When assigning clients on a medical-surgical floor to a RN and a LPN, it is best for
thecharge nurse to assign which client to the LPN?
• A child with bacterial meningitis with recent seizures.
• An older adult client with pneumonia and viral
meningitis.
• C. A female client in isolation wiht meningococcal
meningitis.
D. A male client 1 day post-op after drainage of a brain abscess. ✔✔ B. Is the
moststable. A, C, D have an increased risk for elevated ICP.
Which description of symptoms is characteristic of a client diagnosed with trigeminal
neuralgia (tic douloureux)?
• Tinnitus, vertigo, and hearing difficulties.
• Sudden, stabbing, severe pain over the lip and
chin.
• C. Unilateral facial weakness and paralysis.
D. Difficulty in talking, chewing, and swallowing. ✔✔ B. Trigeminal neuralgia is
characterized by paroxysms of pain, similar to an electric shock, in the area
innervated by one or more branches of the trigeminal nerve.
A. Characteristic of Meniere's C. Characteristic of Bell palsey
D. Characteristic of disorders of the hypoglossal (12th cranial nerve)
Which abnormal lab finding indicates that a client with diabetes needs further
evaluationfor diabetic nephropathy?
• Hypokalemia
• Microalbuminauria
,• C. Elevated serum lipids
D. Ketonuria ✔✔ B. Microalbuminuria is the earliest sign of nephropathy and
indicatesthe need for follow-up evaluation. Hyperkalemia (A) is associated with end
stage renaldisease caused by diabetic nephropathy. (C) may be elevated in end
stage renal disease. (D) may signal the onset of DKA.
An older male client comes to the geriatric screening clinic complaining of pain in his
leftcalf. The nurse notices a reddened area on the calf of his right leg that is warm to
touch and the nurse suspects that the client may have thrombophlebitis. Which
addition assessment is most important for the nurse to perform?
• Measure calf circumference.
• Auscultate the client's breath
sounds.
• C. Observe for ecchymosis and
petechiae.
D. Obtain the client's blood pressure. ✔✔ B. Since the client may have a
pulmonaryembolus secondary to the thrombophlebitis.
A. Would support the nurses assessment.
C. Least helpful since bruising is not associated with
thrombophlebitis.D. Less important then auscultation.
The nurse know that a client taking diuretics must be assessed for the development of
hypokalemia, and that hypokalemia will create changes in the client's normal ECG
tracing. Which ECG change would be an expected finding in the client with
hypokalemia?
• Tall, spiked T waves
• A prolonged QT
interval
• C. A widening QRS
complex
D. Presence of a U wave ✔✔ D. A U wave is a positive deflection following the T
waveand is often present with hypokalemia. A, B, C indicate hyperkalemia.
An older client is admitted with a diagnosis of bacterial pneumonia. The nurse's
assessment of the client will most likely reveal which S/SX?
A. Leukocytosis and
febrile.
B. Polycythemia and
crackles.
C. Pharyngitis and sputum production.
D. Confusion and tachycardia. ✔✔ D. The onset of pneumonia is the older may be
signaled by general deterioration, confusion, increased heart rate or increased
respiratory rate.
,(A, B, C) are often absent in the older with bacterial pneumonia.
The nurse observes ventricular fibrillation on telemetry and upon entering the
clients bathroom finds the client unconscious on the floor. What intervention should
the nurseimplement first?
A. Administer an antidysrhythmic
medication.
B. Start cardiopulmonary resuscitation.
C. Defibrillate the client at 200 joules.
D. Assess the client's pulse oximetry. ✔✔ B. Ventricular fibrillation is a life-threatening
dysrhythmia and CPR should be started immediately. A & C are appropriate but B is
thepriority. D does not address the seriousness of the situation.
An older female client with dementia is transferred from a long term care unit to an
acute care unit. The client's children express concern that their mother's confusion
isworsening. How should the nurse respond?
A. "It is to be expected that older people will experience progressive
confusion."
B. "Confusion in an older person often follows relocation to new surroundings."
C. "The dementia is progressing rapidly, but we will do everything we can to keep
your mother safe."
D. "The acute care staff is not as experienced as the long-term care staff at dealing
withdementia." ✔✔ B. Relocation often results in confusion among older clients and
is stressful to clients of all ages. (A) is an inaccurate stereotype. (C) is most likely
false there are many factors that cause increased temporary confusion. (D) may be
true but does not offer the family a sense of security about the care.
The nurse plans to help an 18-year-old developmentally disabled female client
ambulate on the first postoperative day. When the nurse tells her it is time to get out of
bed, the client becomes angry and yells at the nurse. "Get out of here! I'll get up
when I'm ready." Which response should the nurse provide?
A. "Your healthcare provider has prescribed ambulation on the first postoperative
day."
B. "You must ambulate to avoid serious complications that are much more painful."
C. "I know how you feel; you're angry about having to do this, but it is required."
D. "I'll be back in 30 minutes to help you get out of bed and walk around the room."
✔✔D. Returning in 30 minutes provides a cooling off period, is firm, direct,
nonthreatening, and avoids argument with the client. B is threatening. C. assumes
what the client is feeling. A. avoids the nurse's responsibility to ambulate the client.
, The nurse is performing hourly neurological check for a client with a head injury.
Whichnew assessment finding warrants the most 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 to the events leading up to the injury.
D. Onset of nausea, headache, and vertigo. ✔✔ A. Any changes in pupil size and
reactivity is an indication of increasing ICP and should be reported immediately. (B) is
normal for being awakened. (C & D) are common manifestations of head injury and
lessof an immediacy than (A).
A male client with arterial peripheral vascular disease (PVD) complains of pain in
his feet. Which instruction should the nurse give to the UPA to quickly relieve the
client'spain?
A. Help the client to dangle his
legs.
B. Apply compression stockings.
C. Assist with passive leg exercises.
D. Ambulate three times daily. ✔✔ A. A client who has arterial PVD may benefit
from a dependent position which can be achieved by dangling by improving blood
flow and relieving pain. (B) is indicated for venous insufficiency and (C) is indicated
for bed rest.(D) is indicated to facilitate collateral circulation and may improve long
term complaintsof pain.
A 58-year-old client, who has no health problems, asks the nurse about taking the
pneumococcal vaccine (Pneumovax). Which statement give by the nurse would
offerthe client accurate information about this vaccine?
A. "The vaccine is given annually before the flue season to those over 50 years of
age."
B. "The immunization is administered once to older adults or persons with a history of
chronic illness."
C. "The vaccine is for all ages and is given primarily to those person traveling
overseasto infected areas."
D. "The vaccine will prevent the occurrence of pneumococcal pneumonia for up to
5 years." ✔✔ B. It is usually recommended that persons over 65 years of age and
thosewith a history of chronic illness should receive the vaccine once in a lifetime.
(A) the influenza vaccine is given annually. (C) travel is not the main rationale for
the vaccine.(D) The vaccine is usually given once in a lifetime.
