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HESI - MEDICAL SURGICAL NURSING TEST-EXAM TEST BANK
FOR MEDICAL SURGICAL NURSING 11TH EDITION IGNATAVICIUS
2024/2025 ACTUAL EXAM COMPLETE QUESTIONS AND
CORRECT DETAILED ANSWERS
Interrelated concepts to the professional nursing role a nurse manager would consider when
addressing concerns about the quality of patient education include:
A) adherence.
B) developmental level.
C) motivation.
D) technology. - ANSWER-D
The interrelated concepts to the professional role of a nurse include health promotion,
leadership, technology/informatics, quality, collaboration, and communication. Adherence,
culture, developmental level, family dynamics, and motivation are considered interrelated
concepts to patient attributes and preference.
During orientation to an emergency department, the nurse educator would be concerned if the
new nurse listed which of the following as a risk factor for impaired thermoregulation?
A) Temperature extremes
B) Occupational exposure
C) Impaired cognition
D) Physical agility - ANSWER-D
Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use
this information to plan additional teaching to include medical conditions and gait disturbance
as risk factors for hypothermia, because their bodies have a reduced ability to generate heat.
Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor.
Temperature extremes are risk factors for impaired thermoregulation.
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An older adult client is in physical restraints. Which intervention by the nurse is the priority?
A) Assess the client hourly while keeping the restraints in place.
B) Assess the client once each shift, releasing the restraints for feeding.
C) Assess the client twice each shift while keeping the restraints in place.
D) Assess the client every 30 to 60 minutes, releasing restraints every 2 hours. - ANSWER-D
The application of restraints can have serious consequences. Thus, the nurse should check the
client every 30 to 60 minutes, releasing the restraints every 2 hours for positioning and toileting.
The other answers would not be appropriate because the client would not be assessed
frequently enough, and circulation to the limbs could be compromised. Assessing every hour
and releasing the restraints every 2 hours is in compliance with federal policy for monitoring
clients in restraints.
The nurse is assessing a client with a long-term history of arthritic pain. Assessment reveals a
heart rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which intervention will the
nurse carry out first?
A) Administer blood pressure medication.
B) Administer a drug to lower the heart rate.
C) Continue to assess for possible causes of elevated vital signs.
D) Assess whether the client needs anti-arthritis medication. - ANSWER-C
Arthritis is categorized as chronic pain. With chronic pain, the body adapts by blocking the
sympathetic nervous system; this normally causes tachycardia and increased blood pressure.
Therefore, this client's high blood pressure and heart rate are not caused by chronic pain and
may be a result of a more acute type of pain. Therefore, the best intervention is for the nurse to
establish whether the client is having pain other than arthritic pain, and then to decide which
intervention should be carried out.
The nurse is assigned to care for the following four clients who have the potential for having
pain. Which client is most likely not to be treated adequately for this problem?
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A) Middle-aged woman with a fractured arm
B) Client with expressive aphasia
C) Younger adult with metastatic cancer
D) Client who has undergone an appendectomy - ANSWER-B
Populations at highest risk for inadequate pain treatment include older adults, minorities, and
those with a history of substance abuse. Nonverbal clients are very difficult to assess for pain
because self-report is not possible, and the nurse needs to rely on client behaviors or surrogate
reporting.
Before surgery, the nurse observes the client listening to music on the radio. Based on this
observation, the nurse may try which nonpharmacologic intervention for pain relief in the
postoperative setting?
A) Cutaneous skin stimulation
B) Imagery
C) Radiofrequency ablation
D) Hypnosis - ANSWER-B
Imagery is a form of distraction in which the client is encouraged to visualize about some
pleasant or desirable feeling, sensation, or event. Behaviors that are helpful in assessing a
client's capacity for imagery include being able to listen to music or other auditory stimuli.
The nurse is assessing a group of clients. Which clients are at greater risk for hypothermia or
frostbite? (select all that apply)
a. an older woman with hypertension
b. a young man with a body mass index of 42
c. a young many who has just consumed six martinis
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d. an older man who smokes a pack of cigarettes a day
e. a young woman who is anorexic
f. a young woman who is diabetic - ANSWER-C, D, E, F
clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk for
hypothermia. Clients who smoke, consume alcohol, or have impaired peripheral circulation have
a higher incidence of frostbite.
The nurse is caring for four clients. Which client assessment is the most indicative of having
pain?
A) Client stating that he is "anxious"
B) Heart rate of 105 beats/min and restlessness
C) Blood pressure 150/70 mm Hg and sleeping
D) Postoperative client with a neck incision - ANSWER-B
At times clients are unable to verbalize that they are in pain but there are indicators that the
client may have acute pain such as increased heart rate, increased blood pressure, increased
respirations, sweating, restlessness, and overall distress. All the other distractors could indicate
clients who have the potential for being in pain, but restlessness with tachycardia is the most
indicative.
When describing patient education approaches, the nurse educator would explain that informal
teaching is an approach that
a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs - ANSWER-C.
Informal teaching is individualized one on one teaching which represents the majority of patient
education done by nurses that occurs when an intervention is explained or a question is
HESI - MEDICAL SURGICAL NURSING TEST-EXAM TEST BANK
FOR MEDICAL SURGICAL NURSING 11TH EDITION IGNATAVICIUS
2024/2025 ACTUAL EXAM COMPLETE QUESTIONS AND
CORRECT DETAILED ANSWERS
Interrelated concepts to the professional nursing role a nurse manager would consider when
addressing concerns about the quality of patient education include:
A) adherence.
B) developmental level.
C) motivation.
D) technology. - ANSWER-D
The interrelated concepts to the professional role of a nurse include health promotion,
leadership, technology/informatics, quality, collaboration, and communication. Adherence,
culture, developmental level, family dynamics, and motivation are considered interrelated
concepts to patient attributes and preference.
During orientation to an emergency department, the nurse educator would be concerned if the
new nurse listed which of the following as a risk factor for impaired thermoregulation?
A) Temperature extremes
B) Occupational exposure
C) Impaired cognition
D) Physical agility - ANSWER-D
Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use
this information to plan additional teaching to include medical conditions and gait disturbance
as risk factors for hypothermia, because their bodies have a reduced ability to generate heat.
Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor.
Temperature extremes are risk factors for impaired thermoregulation.
,2|Page
An older adult client is in physical restraints. Which intervention by the nurse is the priority?
A) Assess the client hourly while keeping the restraints in place.
B) Assess the client once each shift, releasing the restraints for feeding.
C) Assess the client twice each shift while keeping the restraints in place.
D) Assess the client every 30 to 60 minutes, releasing restraints every 2 hours. - ANSWER-D
The application of restraints can have serious consequences. Thus, the nurse should check the
client every 30 to 60 minutes, releasing the restraints every 2 hours for positioning and toileting.
The other answers would not be appropriate because the client would not be assessed
frequently enough, and circulation to the limbs could be compromised. Assessing every hour
and releasing the restraints every 2 hours is in compliance with federal policy for monitoring
clients in restraints.
The nurse is assessing a client with a long-term history of arthritic pain. Assessment reveals a
heart rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which intervention will the
nurse carry out first?
A) Administer blood pressure medication.
B) Administer a drug to lower the heart rate.
C) Continue to assess for possible causes of elevated vital signs.
D) Assess whether the client needs anti-arthritis medication. - ANSWER-C
Arthritis is categorized as chronic pain. With chronic pain, the body adapts by blocking the
sympathetic nervous system; this normally causes tachycardia and increased blood pressure.
Therefore, this client's high blood pressure and heart rate are not caused by chronic pain and
may be a result of a more acute type of pain. Therefore, the best intervention is for the nurse to
establish whether the client is having pain other than arthritic pain, and then to decide which
intervention should be carried out.
The nurse is assigned to care for the following four clients who have the potential for having
pain. Which client is most likely not to be treated adequately for this problem?
,3|Page
A) Middle-aged woman with a fractured arm
B) Client with expressive aphasia
C) Younger adult with metastatic cancer
D) Client who has undergone an appendectomy - ANSWER-B
Populations at highest risk for inadequate pain treatment include older adults, minorities, and
those with a history of substance abuse. Nonverbal clients are very difficult to assess for pain
because self-report is not possible, and the nurse needs to rely on client behaviors or surrogate
reporting.
Before surgery, the nurse observes the client listening to music on the radio. Based on this
observation, the nurse may try which nonpharmacologic intervention for pain relief in the
postoperative setting?
A) Cutaneous skin stimulation
B) Imagery
C) Radiofrequency ablation
D) Hypnosis - ANSWER-B
Imagery is a form of distraction in which the client is encouraged to visualize about some
pleasant or desirable feeling, sensation, or event. Behaviors that are helpful in assessing a
client's capacity for imagery include being able to listen to music or other auditory stimuli.
The nurse is assessing a group of clients. Which clients are at greater risk for hypothermia or
frostbite? (select all that apply)
a. an older woman with hypertension
b. a young man with a body mass index of 42
c. a young many who has just consumed six martinis
, 4|Page
d. an older man who smokes a pack of cigarettes a day
e. a young woman who is anorexic
f. a young woman who is diabetic - ANSWER-C, D, E, F
clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk for
hypothermia. Clients who smoke, consume alcohol, or have impaired peripheral circulation have
a higher incidence of frostbite.
The nurse is caring for four clients. Which client assessment is the most indicative of having
pain?
A) Client stating that he is "anxious"
B) Heart rate of 105 beats/min and restlessness
C) Blood pressure 150/70 mm Hg and sleeping
D) Postoperative client with a neck incision - ANSWER-B
At times clients are unable to verbalize that they are in pain but there are indicators that the
client may have acute pain such as increased heart rate, increased blood pressure, increased
respirations, sweating, restlessness, and overall distress. All the other distractors could indicate
clients who have the potential for being in pain, but restlessness with tachycardia is the most
indicative.
When describing patient education approaches, the nurse educator would explain that informal
teaching is an approach that
a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs - ANSWER-C.
Informal teaching is individualized one on one teaching which represents the majority of patient
education done by nurses that occurs when an intervention is explained or a question is
