HESI: Medical-Surgical Assignment Exam and Rationale
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1. Which assessment is most impor- A: Respiratory Effort
tant for the nurse to perform on a
client who is hospitalized for Guil- (Guillain-Barre syndrome causes paralysis or weakness
lain-Barre syndrome that is rapidly that typically starts at the feet and progresses upwards.
progressing? As the condition progresses, the nurse must ensure
A: Respiratory effort. that the client is able to breathe effectively.)
B: Unsteady gait.
C: Intensity of pain.
D: Ability to eat.
2. A male client comes into the clin- A: Collect a culture of the penile discharge.
ic with a history of penile dis-
charge with painful, burning uri- (Penile discharge with painful urination is commonly
nation. Which action should the associated with gonorrhea. The nurse should collect a
nurse implement? culture of the penile discharge to determine the cause
A: Collect a culture of the penile of these symptoms. The cause must be determined or
discharge. confirmed through culture to identify the organism and
B: Palpate the inguinal lymph ensure effective treatment.)
nodes gently.
C: Observe for scrotal swelling and
redness.
D: Express the discharge to deter-
mine color.
3. A client with history of atrial fibril- A: Check for a pulse deficit.
lation is admitted to the telemetry
unit with sudden onset of short- (A client with a past history of atrial fibrillation may re-
ness of breath. The nurse observes turn to that rhythm. Any signs of atrial fibrillation, such
a new irregular heart rhythm and as sudden onset shortness of breath, requires further
should perform which assessment investigation. The nurse should assess this client for a
at this time? pulse deficit because this condition occurs with atrial
A: Check for a pulse deficit. fibrillation.)
, HESI: Medical-Surgical Assignment Exam and Rationale
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B: Palpate the apical impulse.
C: Inspect jugular vein pulse.
D: Examine for a carotid bruit.
4. Which client should be further as- A: A 24-year-old with shoulder and lower abdominal
sessed for an ectopic pregnancy? quadrant pain.
A: A 24-year-old with shoulder and
lower abdominal quadrant pain. (A 24-year-old with sudden onset of lower abdominal
B: A 33-year-old with intermittent quadrant pain should be assessed for an ectopic preg-
lower abdominal cramping. nancy. The pain can also be referred to the shoulder
C: A 20-year-old with fever and and may be associated with vaginal bleeding.)
right lower abdominal colic.
D: A 40-year-old with jaundice and
right lower abdominal pain.
5. Which dietary assessment finding A: Drinks a six pack of beer every day.
is most important for the nurse to
address when caring for a client (Drinking six beers every day is the dietary assessment
with diabetic nephropathy? finding most important for the nurse to address when
A: Drinks a six pack of beer every caring for a client with diabetic nephropathy. The usual
day. can of beer is 12 ounces (355 mL). Clients with diabetes
B: Enjoys a hamburger once a are recommended to drink no more than 12 ounces of
month. beer per day because beer contains carbohydrates that
C: Eats fortified breakfast cereal can create unhealthy fluctuations in blood glucose and
daily. promote poorglucose control. Nephropathy is exacer-
D: Consumes beans and rice every bated by poor blood glucose control.)
day.
6. Which assessment finding is of A: Cough brought on by swallowing.
greatest concern to the nurse who
is caring for a client with stomati- A cough brought on by swallowing is a sign of dys-
tis? phagia, which is a finding of particular concern in a
client with stomatitis. Dysphagia can cause numerous
, HESI: Medical-Surgical Assignment Exam and Rationale
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A: Cough brought on by swallow- problems, including airway obstruction, and should be
ing. reported to the healthcare provider immediately.
B: Sore throat caused by speaking.
C: Painful and dry oral cavity.
D: Unintended weight loss.
7. The nurse is teaching a client diag- A: Altered sexual response.
nosed with peripheral arterial dis-
ease. Which genitourinary system Peripheral arterial disease (PAD) is a cardiovascular
complication should the nurse in- condition characterized by narrowing of the arteries
clude in the teaching? and reduced blood flow to the extremities. PAD is
A: Altered sexual response. known to alter the blood flow to the male's penis and
B: Sterility. is associated with erectile dysfunction in men.
C: Urinary incontinence.
D: Decreased pelvic muscle tone.
8. A 40-year-old female client has a A: Oral contraceptives.
history of smoking. Which finding
should the nurse identify as a risk Women older than 35 years old who smoke and take
factor for myocardia infarction? oral contraceptives have an increased risk of myocardial
A: Oral contraceptives. infarction or stroke.
B: Senile osteopenia.
C: Levothyroxine therapy.
D: Pernicious anemia.
9. A client has been told that there is A: Decreased color perception.
cataract formation over both eyes.
Which finding should the nurse ex- Decreased color perception occurs with cataract forma-
pect when assessing the client? tion. Cataract formation is also associated with blurred
A: Decreased color perception. vision and a global loss of vision so gradual that the
B: Presence of floaters. client may not be aware of it.
, HESI: Medical-Surgical Assignment Exam and Rationale
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C: Loss of central vision.
D: Reduced peripheral vision.
10. Which assessment finding should A: New onset of coughing.
most concern the nurse who is
monitoring a client two hours after A pneumothorax (partial or complete lung collapse)
a thoracentesis? is the potential complication of a thoracentesis. Man-
A: New onset of coughing. ifestations of a pneumothorax include new onset of a
B: Low resting heart rate. nagging cough, tachycardia, and an increased shallow
C: Distended neck veins. respiration rate.
D: Decreased shallow respirations.
11. While caring for a client who has A: Monitor infusing IV fluids and any replacement
esophageal varices, which nursing blood products
intervention is most important for
the registered nurse (RN) to imple- (Maintaining hemodynamic stability in a client with
ment? esophageal varices can precipitate a life-threatening
A: Monitor infusing IV fluids and crisis if esophageal varies leak or rupture and can result
any replacement blood products. in hemorrhage. The priority is assessing and monitor-
B: Prepare for esophagogastro- ing infusions of IV fluids and any replacement blood
duodenoscopy (EGD). products.)
C: Maintain the client on strict
bedrest.
D: Insert a nasogastric tube (NGT)
for intermittent suction.
12. The registered nurse (RN) is car- A: Urine output of 40 mL/hour.
ing for a client who developed
oliguria and was diagnosed with A decrease in urinary output is a sign of dehydration.
sepsis and dehydration 48 hours When the urine output returns to a normal range, 40
ago. Which assessment finding in- mL/hour, the client's kidneys are perfusing adequately
dicates to the RN that the client is and indicates the client's status is stablizing
Study online at https://quizlet.com/_a29qqk
1. Which assessment is most impor- A: Respiratory Effort
tant for the nurse to perform on a
client who is hospitalized for Guil- (Guillain-Barre syndrome causes paralysis or weakness
lain-Barre syndrome that is rapidly that typically starts at the feet and progresses upwards.
progressing? As the condition progresses, the nurse must ensure
A: Respiratory effort. that the client is able to breathe effectively.)
B: Unsteady gait.
C: Intensity of pain.
D: Ability to eat.
2. A male client comes into the clin- A: Collect a culture of the penile discharge.
ic with a history of penile dis-
charge with painful, burning uri- (Penile discharge with painful urination is commonly
nation. Which action should the associated with gonorrhea. The nurse should collect a
nurse implement? culture of the penile discharge to determine the cause
A: Collect a culture of the penile of these symptoms. The cause must be determined or
discharge. confirmed through culture to identify the organism and
B: Palpate the inguinal lymph ensure effective treatment.)
nodes gently.
C: Observe for scrotal swelling and
redness.
D: Express the discharge to deter-
mine color.
3. A client with history of atrial fibril- A: Check for a pulse deficit.
lation is admitted to the telemetry
unit with sudden onset of short- (A client with a past history of atrial fibrillation may re-
ness of breath. The nurse observes turn to that rhythm. Any signs of atrial fibrillation, such
a new irregular heart rhythm and as sudden onset shortness of breath, requires further
should perform which assessment investigation. The nurse should assess this client for a
at this time? pulse deficit because this condition occurs with atrial
A: Check for a pulse deficit. fibrillation.)
, HESI: Medical-Surgical Assignment Exam and Rationale
Study online at https://quizlet.com/_a29qqk
B: Palpate the apical impulse.
C: Inspect jugular vein pulse.
D: Examine for a carotid bruit.
4. Which client should be further as- A: A 24-year-old with shoulder and lower abdominal
sessed for an ectopic pregnancy? quadrant pain.
A: A 24-year-old with shoulder and
lower abdominal quadrant pain. (A 24-year-old with sudden onset of lower abdominal
B: A 33-year-old with intermittent quadrant pain should be assessed for an ectopic preg-
lower abdominal cramping. nancy. The pain can also be referred to the shoulder
C: A 20-year-old with fever and and may be associated with vaginal bleeding.)
right lower abdominal colic.
D: A 40-year-old with jaundice and
right lower abdominal pain.
5. Which dietary assessment finding A: Drinks a six pack of beer every day.
is most important for the nurse to
address when caring for a client (Drinking six beers every day is the dietary assessment
with diabetic nephropathy? finding most important for the nurse to address when
A: Drinks a six pack of beer every caring for a client with diabetic nephropathy. The usual
day. can of beer is 12 ounces (355 mL). Clients with diabetes
B: Enjoys a hamburger once a are recommended to drink no more than 12 ounces of
month. beer per day because beer contains carbohydrates that
C: Eats fortified breakfast cereal can create unhealthy fluctuations in blood glucose and
daily. promote poorglucose control. Nephropathy is exacer-
D: Consumes beans and rice every bated by poor blood glucose control.)
day.
6. Which assessment finding is of A: Cough brought on by swallowing.
greatest concern to the nurse who
is caring for a client with stomati- A cough brought on by swallowing is a sign of dys-
tis? phagia, which is a finding of particular concern in a
client with stomatitis. Dysphagia can cause numerous
, HESI: Medical-Surgical Assignment Exam and Rationale
Study online at https://quizlet.com/_a29qqk
A: Cough brought on by swallow- problems, including airway obstruction, and should be
ing. reported to the healthcare provider immediately.
B: Sore throat caused by speaking.
C: Painful and dry oral cavity.
D: Unintended weight loss.
7. The nurse is teaching a client diag- A: Altered sexual response.
nosed with peripheral arterial dis-
ease. Which genitourinary system Peripheral arterial disease (PAD) is a cardiovascular
complication should the nurse in- condition characterized by narrowing of the arteries
clude in the teaching? and reduced blood flow to the extremities. PAD is
A: Altered sexual response. known to alter the blood flow to the male's penis and
B: Sterility. is associated with erectile dysfunction in men.
C: Urinary incontinence.
D: Decreased pelvic muscle tone.
8. A 40-year-old female client has a A: Oral contraceptives.
history of smoking. Which finding
should the nurse identify as a risk Women older than 35 years old who smoke and take
factor for myocardia infarction? oral contraceptives have an increased risk of myocardial
A: Oral contraceptives. infarction or stroke.
B: Senile osteopenia.
C: Levothyroxine therapy.
D: Pernicious anemia.
9. A client has been told that there is A: Decreased color perception.
cataract formation over both eyes.
Which finding should the nurse ex- Decreased color perception occurs with cataract forma-
pect when assessing the client? tion. Cataract formation is also associated with blurred
A: Decreased color perception. vision and a global loss of vision so gradual that the
B: Presence of floaters. client may not be aware of it.
, HESI: Medical-Surgical Assignment Exam and Rationale
Study online at https://quizlet.com/_a29qqk
C: Loss of central vision.
D: Reduced peripheral vision.
10. Which assessment finding should A: New onset of coughing.
most concern the nurse who is
monitoring a client two hours after A pneumothorax (partial or complete lung collapse)
a thoracentesis? is the potential complication of a thoracentesis. Man-
A: New onset of coughing. ifestations of a pneumothorax include new onset of a
B: Low resting heart rate. nagging cough, tachycardia, and an increased shallow
C: Distended neck veins. respiration rate.
D: Decreased shallow respirations.
11. While caring for a client who has A: Monitor infusing IV fluids and any replacement
esophageal varices, which nursing blood products
intervention is most important for
the registered nurse (RN) to imple- (Maintaining hemodynamic stability in a client with
ment? esophageal varices can precipitate a life-threatening
A: Monitor infusing IV fluids and crisis if esophageal varies leak or rupture and can result
any replacement blood products. in hemorrhage. The priority is assessing and monitor-
B: Prepare for esophagogastro- ing infusions of IV fluids and any replacement blood
duodenoscopy (EGD). products.)
C: Maintain the client on strict
bedrest.
D: Insert a nasogastric tube (NGT)
for intermittent suction.
12. The registered nurse (RN) is car- A: Urine output of 40 mL/hour.
ing for a client who developed
oliguria and was diagnosed with A decrease in urinary output is a sign of dehydration.
sepsis and dehydration 48 hours When the urine output returns to a normal range, 40
ago. Which assessment finding in- mL/hour, the client's kidneys are perfusing adequately
dicates to the RN that the client is and indicates the client's status is stablizing
