MED SURGE HESI REAL EXAM 1 & 2 (2 VERSIONS)
WITH ALL 200 QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES/ MEDICAL SURGICAL
HESI EXAM TEST BANK
VERSION 1
An older male client comes to the outpatient clinic complaining of pain in his left calf. The nurse
notices a reddened area on the calf of his right leg that is warm to the touch, and the nurse suspects
that the client may have thrombophlebitis. Which additional assessment is most important for the
nurse to perform?
A. Measure the client's calf circumference
B. Auscultate the client's breath sounds
C. Observe for ecchymosis and petechiae
D. Obtain the client's blood pressure - CORRECT ANSWER-B. Auscultate the client's breath sounds
All these techniques provide useful assessment data. The most important is to auscultate the
client's breath sounds because the client may have a pulmonary embolus secondary to the
thrombophlebitis. Option A may provide data that support the nurse's suspicion of
thrombophlebitis. Option C is the least helpful assessment because bruising is not a typical finding
associated with thrombophlebitis. Option D is always useful in evaluating the client's response to a
problem but is of less immediate priority than breath sound auscultation.
The nurse is assessing a client who presents with jaundice. Which assessment finding is most
important for the nurse to follow up?
A. Urine specific gravity of 1.03
B. Frothy, tea-colored urine
C. Clay-colored stools
D. Elevated serum amylase and lipase levels - CORRECT ANSWER-D. Elevated serum amylase and
lipase levels
Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and elevated
serum amylase and lipase levels indicate pancreatic injury. Option A is a normal finding. Options B
and C are expected findings related to jaundice.
The nurse is assessing a male client with acute pancreatitis. Which finding requires the most
immediate intervention by the nurse?
,A. The client's amylase level is three times higher than the normal level
B. While the nurse is taking the client's blood pressure, he has a carpal spasm
C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7
D. The client states that he will continue to drink alcohol after going home - CORRECT ANSWER-B.
While the nurse is taking the client's blood pressure, he has a carpal spasm
A positive Trousseau sign indicates hypocalcemia and always requires further assessment and
intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience
hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is
serum amylase and lipase levels that are two to five times higher than the normal value. Severe
boring pain is an expected symptom for this diagnosis, but dealing with the hypocalcemia is a
priority over administering an analgesic. Long-term planning and teaching do not have the same
immediate importance as a positive Trousseau sign.
The nurse is reviewing routine medications taken by a client with chronic angle-closure glaucoma.
Which medication prescription should the nurse question?
A. Antianginal with a therapeutic effect of vasodilation
B. Anticholinergic with a side effect of pupillary dilation
C. Antihistamine with a side effect of sedation
D. Corticosteroid with a side effect of hyperglycemia - CORRECT ANSWER-B. Anticholinergic with a
side effect of pupillary dilation
Clients with angle-closure glaucoma should not take medications that dilate the pupil because this
can precipitate acute and severely increased intraocular pressure. Options A, C, and D do not cause
increased intracranial pressure, which is the primary concern with angle-closure glaucoma.
In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse
notes the absence of a thrill or bruit at the shunt site. What action should the nurse take?
A. Advise the client that the shunt is intact and ready for dialysis as scheduled
B. Encourage the client to keep the shunt site elevated above the level of the heart
C. Notify the health care provider of the findings immediately
D. Flush the site at least once with a heparinized saline solution - CORRECT ANSWER-C. Notify the
health care provider of the findings immediately
Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse should notify the
health care provider so that intervention can be initiated to restore function of the shunt. Option A
is incorrect. Option B will not resolve the obstruction. An AV shunt is internal and cannot be flushed
without access using special needles.
, A 43-year-old homeless, malnourished female client with a history of alcoholism is transferred to the
ICU. She is placed on telemetry, and the rhythm strip shown is obtained. The nurse palpates a heart
rate of 160 beats/min, and the client's blood pressure is 90/54 mm Hg. Based on these findings,
which IV medication should the nurse administer?
A. Amiodarone (Cordarone)
B. Magnesium sulfate
C. Lidocaine (Xylocaine)
D. Procainamide (Pronestyl) - CORRECT ANSWER-B. Magnesium sulfate
Because the client has chronic alcoholism, she is likely to have hypomagnesemia. Option B is the
recommended drug for torsades de pointes, which is a form of polymorphic ventricular tachycardia
(VT) usually associated with a prolonged QT interval that occurs with hypomagnesemia. Options A
and D increase the QT interval, which can cause the torsades to worsen. Option C is the
antiarrhythmic of choice in most cases of drug-induced monomorphic VT, not torsades.
Which statement reflects the highest priority nursing diagnosis for an older client recently admitted
to the hospital for a new-onset cardiac dysrhythmia?
A. Diarrhea related to mediation side effects
B. Anxiety related to fear of recurrent anginal episodes
C. Altered nutrition related to high serum lipid levels
D. Risk for injury related to syncope and confusion - CORRECT ANSWER-D. Risk for injury related to
syncope and confusion
The loss of cardiac function in aging decreases cardiac output, so dysrhythmias, particularly
tachycardias, are poorly tolerated. With onset of a tachycardic or bradycardic dysrhythmia, cardiac
output is compromised further, placing the client at risk of syncope and falling, as well as confusion.
Option A is of high priority but less so than maintaining client safety. Clients may experience option
B as a result of a newly diagnosed cardiac condition, but this nursing diagnosis does not have the
priority of option D. Option C also does not have the priority of option D.
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-D. Reassign the PN until the resident can be assessed more completely for reality
orientation
WITH ALL 200 QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES/ MEDICAL SURGICAL
HESI EXAM TEST BANK
VERSION 1
An older male client comes to the outpatient clinic complaining of pain in his left calf. The nurse
notices a reddened area on the calf of his right leg that is warm to the touch, and the nurse suspects
that the client may have thrombophlebitis. Which additional assessment is most important for the
nurse to perform?
A. Measure the client's calf circumference
B. Auscultate the client's breath sounds
C. Observe for ecchymosis and petechiae
D. Obtain the client's blood pressure - CORRECT ANSWER-B. Auscultate the client's breath sounds
All these techniques provide useful assessment data. The most important is to auscultate the
client's breath sounds because the client may have a pulmonary embolus secondary to the
thrombophlebitis. Option A may provide data that support the nurse's suspicion of
thrombophlebitis. Option C is the least helpful assessment because bruising is not a typical finding
associated with thrombophlebitis. Option D is always useful in evaluating the client's response to a
problem but is of less immediate priority than breath sound auscultation.
The nurse is assessing a client who presents with jaundice. Which assessment finding is most
important for the nurse to follow up?
A. Urine specific gravity of 1.03
B. Frothy, tea-colored urine
C. Clay-colored stools
D. Elevated serum amylase and lipase levels - CORRECT ANSWER-D. Elevated serum amylase and
lipase levels
Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and elevated
serum amylase and lipase levels indicate pancreatic injury. Option A is a normal finding. Options B
and C are expected findings related to jaundice.
The nurse is assessing a male client with acute pancreatitis. Which finding requires the most
immediate intervention by the nurse?
,A. The client's amylase level is three times higher than the normal level
B. While the nurse is taking the client's blood pressure, he has a carpal spasm
C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7
D. The client states that he will continue to drink alcohol after going home - CORRECT ANSWER-B.
While the nurse is taking the client's blood pressure, he has a carpal spasm
A positive Trousseau sign indicates hypocalcemia and always requires further assessment and
intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience
hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is
serum amylase and lipase levels that are two to five times higher than the normal value. Severe
boring pain is an expected symptom for this diagnosis, but dealing with the hypocalcemia is a
priority over administering an analgesic. Long-term planning and teaching do not have the same
immediate importance as a positive Trousseau sign.
The nurse is reviewing routine medications taken by a client with chronic angle-closure glaucoma.
Which medication prescription should the nurse question?
A. Antianginal with a therapeutic effect of vasodilation
B. Anticholinergic with a side effect of pupillary dilation
C. Antihistamine with a side effect of sedation
D. Corticosteroid with a side effect of hyperglycemia - CORRECT ANSWER-B. Anticholinergic with a
side effect of pupillary dilation
Clients with angle-closure glaucoma should not take medications that dilate the pupil because this
can precipitate acute and severely increased intraocular pressure. Options A, C, and D do not cause
increased intracranial pressure, which is the primary concern with angle-closure glaucoma.
In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse
notes the absence of a thrill or bruit at the shunt site. What action should the nurse take?
A. Advise the client that the shunt is intact and ready for dialysis as scheduled
B. Encourage the client to keep the shunt site elevated above the level of the heart
C. Notify the health care provider of the findings immediately
D. Flush the site at least once with a heparinized saline solution - CORRECT ANSWER-C. Notify the
health care provider of the findings immediately
Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse should notify the
health care provider so that intervention can be initiated to restore function of the shunt. Option A
is incorrect. Option B will not resolve the obstruction. An AV shunt is internal and cannot be flushed
without access using special needles.
, A 43-year-old homeless, malnourished female client with a history of alcoholism is transferred to the
ICU. She is placed on telemetry, and the rhythm strip shown is obtained. The nurse palpates a heart
rate of 160 beats/min, and the client's blood pressure is 90/54 mm Hg. Based on these findings,
which IV medication should the nurse administer?
A. Amiodarone (Cordarone)
B. Magnesium sulfate
C. Lidocaine (Xylocaine)
D. Procainamide (Pronestyl) - CORRECT ANSWER-B. Magnesium sulfate
Because the client has chronic alcoholism, she is likely to have hypomagnesemia. Option B is the
recommended drug for torsades de pointes, which is a form of polymorphic ventricular tachycardia
(VT) usually associated with a prolonged QT interval that occurs with hypomagnesemia. Options A
and D increase the QT interval, which can cause the torsades to worsen. Option C is the
antiarrhythmic of choice in most cases of drug-induced monomorphic VT, not torsades.
Which statement reflects the highest priority nursing diagnosis for an older client recently admitted
to the hospital for a new-onset cardiac dysrhythmia?
A. Diarrhea related to mediation side effects
B. Anxiety related to fear of recurrent anginal episodes
C. Altered nutrition related to high serum lipid levels
D. Risk for injury related to syncope and confusion - CORRECT ANSWER-D. Risk for injury related to
syncope and confusion
The loss of cardiac function in aging decreases cardiac output, so dysrhythmias, particularly
tachycardias, are poorly tolerated. With onset of a tachycardic or bradycardic dysrhythmia, cardiac
output is compromised further, placing the client at risk of syncope and falling, as well as confusion.
Option A is of high priority but less so than maintaining client safety. Clients may experience option
B as a result of a newly diagnosed cardiac condition, but this nursing diagnosis does not have the
priority of option D. Option C also does not have the priority of option D.
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-D. Reassign the PN until the resident can be assessed more completely for reality
orientation
