MEDICAL SURGICAL HESI PRACTICE EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 160
QUESTIONS AND CORRECT DETAILED ANSWERS
1. The nurse is caring for a client receiving tamoxifen for the treatment of breast cancer. Which action
should the nurse include in the client's plan of care?
a. Increase fluid intake.
b. Monitor sodium chloride intake.
c. Assist the client in coping with hot flashes.
d. Encourage milk products to increase calcium intake. - (answer) c. Assist the client in coping with hot
flashes.
Tamoxifen, an estrogen receptor blocking agent, can cause hot flashes, so client education regarding
menopausal-like symptoms should be included in the plan of care.
2. The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action
should be included in the plan of care? a. Perform active range of motion three times daily.
b. Monitor for Battle's sign every four hours.
c. Teach measures to avoid the Valsalva maneuver.
d. Maintain the head of bed in a flat position. - (answer) c. Teach measures to avoid the Valsalva
maneuver.
The Valsalva maneuver, straining with bowel movements while holding one's breath, increases
intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral blood vessels.
3. The nurse is caring for a client with multiple trauma after a motor vehicle collision. The nurse learns
that the client has secondary syphilis. Which precaution should the nurse implement?
a. A mask should be worn by anyone entering the client's room.
b. Handwashing is required before and after contact with the client.
c. Gloves should be worn during direct contact with the client's skin.
d. No precautions in addition to standard precautions are necessary. - (answer) c. Gloves should be
worn during direct contact with the client's skin.
, MEDICAL SURGICAL HESI PRACTICE EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 160
QUESTIONS AND CORRECT DETAILED ANSWERS
The secondary stage of syphilis is a systemic blood-borne disease that presents with skin lesions and
rashes that may drain the highly contagious spirochete, so gloves should be worn during direct contact
with the client's skin. The client should be placed on contact precautions.
4. The nurse is providing discharge instructions to a client who has undergone a left orchiectomy for
testicular cancer. Which statement indicates that the client understands his post-operative care and
prognosis?
a. "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle."
b. "I should wear an athletic supporter and cup to prevent testicular cancer in my remaining testicle."
c. "I should always use a condom because I am at increased risk for acquiring a sexually transmitted
disease."
d. "I should make sure my sons know how to perform TSE because they are at increased risk for this type
of cancer." - (answer) a. "I should continue to perform testicular self-examination (TSE) monthly on my
remaining testicle."
Although testicular cancer protocols, such as surgery, radiation, or chemotherapy, focus on the primary
site of testicular cancer, these treatments do not reduce the risk of testicular cancer in the remaining
testicle, so early recognition is the best prevention. The client's understanding is reflected in the
statement to perform monthly TSE for changes in size, shape, or consistency of the testis that may
indicate early cancer.
5. A client with heart failure is prescribed digoxin 0.125 mg PO. The client's apical heart rate is70 beats
per minute, blood pressure is 125/75 mmHg, and respirations are 18 breaths per minute. Which action
should the nurse implement next?
a. Administer the medication.
b. Inform the healthcare provider.
c. Review the vital sign flowsheet.
d. Reassess the apical heart rate. - (answer) a. Administer the medication.
Obtaining the apical heart rate is a common parameter prior to administering digoxin, which may
indicate early digoxin toxicity if the heart rate is less than 60 beats per minute, so the dose should be
administered since the client is not demonstrating any signs of toxicity.
QUESTIONS AND CORRECT DETAILED ANSWERS
1. The nurse is caring for a client receiving tamoxifen for the treatment of breast cancer. Which action
should the nurse include in the client's plan of care?
a. Increase fluid intake.
b. Monitor sodium chloride intake.
c. Assist the client in coping with hot flashes.
d. Encourage milk products to increase calcium intake. - (answer) c. Assist the client in coping with hot
flashes.
Tamoxifen, an estrogen receptor blocking agent, can cause hot flashes, so client education regarding
menopausal-like symptoms should be included in the plan of care.
2. The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action
should be included in the plan of care? a. Perform active range of motion three times daily.
b. Monitor for Battle's sign every four hours.
c. Teach measures to avoid the Valsalva maneuver.
d. Maintain the head of bed in a flat position. - (answer) c. Teach measures to avoid the Valsalva
maneuver.
The Valsalva maneuver, straining with bowel movements while holding one's breath, increases
intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral blood vessels.
3. The nurse is caring for a client with multiple trauma after a motor vehicle collision. The nurse learns
that the client has secondary syphilis. Which precaution should the nurse implement?
a. A mask should be worn by anyone entering the client's room.
b. Handwashing is required before and after contact with the client.
c. Gloves should be worn during direct contact with the client's skin.
d. No precautions in addition to standard precautions are necessary. - (answer) c. Gloves should be
worn during direct contact with the client's skin.
, MEDICAL SURGICAL HESI PRACTICE EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 160
QUESTIONS AND CORRECT DETAILED ANSWERS
The secondary stage of syphilis is a systemic blood-borne disease that presents with skin lesions and
rashes that may drain the highly contagious spirochete, so gloves should be worn during direct contact
with the client's skin. The client should be placed on contact precautions.
4. The nurse is providing discharge instructions to a client who has undergone a left orchiectomy for
testicular cancer. Which statement indicates that the client understands his post-operative care and
prognosis?
a. "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle."
b. "I should wear an athletic supporter and cup to prevent testicular cancer in my remaining testicle."
c. "I should always use a condom because I am at increased risk for acquiring a sexually transmitted
disease."
d. "I should make sure my sons know how to perform TSE because they are at increased risk for this type
of cancer." - (answer) a. "I should continue to perform testicular self-examination (TSE) monthly on my
remaining testicle."
Although testicular cancer protocols, such as surgery, radiation, or chemotherapy, focus on the primary
site of testicular cancer, these treatments do not reduce the risk of testicular cancer in the remaining
testicle, so early recognition is the best prevention. The client's understanding is reflected in the
statement to perform monthly TSE for changes in size, shape, or consistency of the testis that may
indicate early cancer.
5. A client with heart failure is prescribed digoxin 0.125 mg PO. The client's apical heart rate is70 beats
per minute, blood pressure is 125/75 mmHg, and respirations are 18 breaths per minute. Which action
should the nurse implement next?
a. Administer the medication.
b. Inform the healthcare provider.
c. Review the vital sign flowsheet.
d. Reassess the apical heart rate. - (answer) a. Administer the medication.
Obtaining the apical heart rate is a common parameter prior to administering digoxin, which may
indicate early digoxin toxicity if the heart rate is less than 60 beats per minute, so the dose should be
administered since the client is not demonstrating any signs of toxicity.
