Page 1 of 58
MED SURG 266 HESI Exam Compilation | Nightingale
College | 2025–2026 Certified Q&A Review | 55
Consolidated Multiple Choice Questions
When planning care for a client with right renal calculi, which
nursing diagnosis has the highest priority? ......ANSWER........Acute
pain related to movement of the stone.
The nurse is caring for a client with non-hodgkin's lymphoma who
is receiving chemotherapy. Laboratory results reveal a platelet
count of 10,000/ml. What action should the nurse implement?
......ANSWER........Check stools for occult blood
Platelet counts less than 100,000/mm3 are indicative of
thrombocytopenia, a common side effect of chemotherapy. A
client with thrombocytopenia should be assessed frequently for
occult bleeding in the emesis, sputum, feces, urine, nasogastric
secretions, or wounds.
A client with acute osteomyelitis has undergone surgical
debridement of the diseased bone and asks the nurse how long
will antibiotics have to be administered. Which information
should the nurse communicate? ......ANSWER........Parenteral
antibiotics for 4-8 weeks, then oral antibiotics for 4-8 weeks
The UAP reports that an 87-year old female client who is sitting
in a chair at the bedside has an oral temperature of 97.2 f,
which intervention should the nurse implement?
......ANSWER........Document the temperature reading on the vital
sign graphic sheet
When teaching a client with breast cancer about the prescribed
radiation therapy for treatment, what information is important to
include? ......ANSWER........Dry, itchy skin changes may occur.
-
,Page 2 of 58
Side effects from radiation to the breast most often include
temporary skin changes such as: dryness, tenderness, redness,
swelling, and pruritis.
The nurse is assessing a middle-aged male client for risk factors
related to chronic illness. Which finding should the nurse assess
further? ......ANSWER........Increase in abdominal fat deposits.
An increase in the abdominal girth is a risk factor for the
development of metabolic syndrome. According to the American
Heart Association, men with a waist size 40 inches or larger and
women 35 inches or larger double their risk factor of developing
CAD and increase their chances 5Xs of developing DMII.
A male client with chronic atrial fibrillation and a slow ventricular
response is scheduled for surgical placement of a permanent
pacemaker. The client asks the nurse how this device will help
him. How should the nurse explain the action of a synchronous
pacemaker? ......ANSWER........An electrical stimulus is discharged
when no ventricular response is sensed.
-
The artificial cardiac pacemaker is an electronic device used to
pace the heart when the normal conduction pathway is damaged
or diseased, such as a symptomatic dysrhythmias like atrial
fibrillation with a slow ventricular response. Pacing modes that
are synchronous (impulse generated on demand or as needed
according to the patient's intrinsic rhythm) send an electrical
signal from the pacemaker to the wall of the myocardium
stimulating it to contract when no ventricular depolarization is
sensed.
Which intervention should the nurse implement that best confirms
placement of an endotracheal tube? ......ANSWER........Use an
end-tital CO2 detector
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A female client with type 2 diabetes mellitus reports dysuria.
Which assessment finding is most important for the nurse to
report to the healthcare provider? ......ANSWER........fingerstick
glucose of 300 mg/dl
a client with acute appendicitis is experiencing anxiety and loss
of sleep about missing final examination week at college. Which
outcome is most important for the nurse to include in the plan of
care? ......ANSWER........achieve a sense of control
a client with osteoarthritis requests information from the nurse
about what type of exercise regimen would be most beneficial
for him. The nurse should communicate which information?
......ANSWER........low impact exercise, walking, swimming, and
water aerobics
the nurse is assessing a client with a cuffed tracheostomy tube in
place who is breathing spontaneously. To evaluate if the client
can tolerate cuff deflation to promote speaking and swallowing,
what action should the nurse implement?
......ANSWER........observe the client for coughing colored sputum
after drinking a small amount of colored water.
a client with a history of hypertension, myocardial infarction, and
heart failure is admitted to the surgical intensive care unit after
coronary artery bypass surgery graft. the nurse determines the
client's serum potassium level is 4.5 mEq/l. What action should
the nurse implement? ......ANSWER........document the finding as
the only action. potassium level is within normal range.
the nurse is caring for a client with multiple traumas after a motor
vehicle collision. The nurse learns that the client has secondary
, Page 4 of 58
syphilis. What precaution should the nurse implement?
......ANSWER........gloves should be worn during contact with the
client's skin.
secondary stage of syphilis is a systemic blood-borne disease
that presents with skin lesions and rashes that may drain the
highly contagious spirochete.
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? ......ANSWER........teach measures to avoid the
Valsalve maneuver (straining with bowel movements while
holding one's breath, increases intracerebral pressure, which may
induce bleeding or rupture of cerebral blood vessels.
a man who smokes two packs of cigarettes a day wants to know
if smoking is contributing to the difficulty that he and his wife are
having getting pregnant. what information is best for the nurse to
provide? SATA ......ANSWER........smoking can decrease the
quantity and quality of sperm
cessation of smoking improves general health and fertility
in planning care for a client with an acute stroke resulting in
right-sided hemiplegia, which positioning should the nurse use to
maintain optimal functioning? ......ANSWER........left lateral,
supine, brief periods on the right side, and prone.
after an acute stroke, a positioning and turning schedule that
minimizes lying on the affected side, which can impair circulation
and cause pain.
MED SURG 266 HESI Exam Compilation | Nightingale
College | 2025–2026 Certified Q&A Review | 55
Consolidated Multiple Choice Questions
When planning care for a client with right renal calculi, which
nursing diagnosis has the highest priority? ......ANSWER........Acute
pain related to movement of the stone.
The nurse is caring for a client with non-hodgkin's lymphoma who
is receiving chemotherapy. Laboratory results reveal a platelet
count of 10,000/ml. What action should the nurse implement?
......ANSWER........Check stools for occult blood
Platelet counts less than 100,000/mm3 are indicative of
thrombocytopenia, a common side effect of chemotherapy. A
client with thrombocytopenia should be assessed frequently for
occult bleeding in the emesis, sputum, feces, urine, nasogastric
secretions, or wounds.
A client with acute osteomyelitis has undergone surgical
debridement of the diseased bone and asks the nurse how long
will antibiotics have to be administered. Which information
should the nurse communicate? ......ANSWER........Parenteral
antibiotics for 4-8 weeks, then oral antibiotics for 4-8 weeks
The UAP reports that an 87-year old female client who is sitting
in a chair at the bedside has an oral temperature of 97.2 f,
which intervention should the nurse implement?
......ANSWER........Document the temperature reading on the vital
sign graphic sheet
When teaching a client with breast cancer about the prescribed
radiation therapy for treatment, what information is important to
include? ......ANSWER........Dry, itchy skin changes may occur.
-
,Page 2 of 58
Side effects from radiation to the breast most often include
temporary skin changes such as: dryness, tenderness, redness,
swelling, and pruritis.
The nurse is assessing a middle-aged male client for risk factors
related to chronic illness. Which finding should the nurse assess
further? ......ANSWER........Increase in abdominal fat deposits.
An increase in the abdominal girth is a risk factor for the
development of metabolic syndrome. According to the American
Heart Association, men with a waist size 40 inches or larger and
women 35 inches or larger double their risk factor of developing
CAD and increase their chances 5Xs of developing DMII.
A male client with chronic atrial fibrillation and a slow ventricular
response is scheduled for surgical placement of a permanent
pacemaker. The client asks the nurse how this device will help
him. How should the nurse explain the action of a synchronous
pacemaker? ......ANSWER........An electrical stimulus is discharged
when no ventricular response is sensed.
-
The artificial cardiac pacemaker is an electronic device used to
pace the heart when the normal conduction pathway is damaged
or diseased, such as a symptomatic dysrhythmias like atrial
fibrillation with a slow ventricular response. Pacing modes that
are synchronous (impulse generated on demand or as needed
according to the patient's intrinsic rhythm) send an electrical
signal from the pacemaker to the wall of the myocardium
stimulating it to contract when no ventricular depolarization is
sensed.
Which intervention should the nurse implement that best confirms
placement of an endotracheal tube? ......ANSWER........Use an
end-tital CO2 detector
,Page 3 of 58
A female client with type 2 diabetes mellitus reports dysuria.
Which assessment finding is most important for the nurse to
report to the healthcare provider? ......ANSWER........fingerstick
glucose of 300 mg/dl
a client with acute appendicitis is experiencing anxiety and loss
of sleep about missing final examination week at college. Which
outcome is most important for the nurse to include in the plan of
care? ......ANSWER........achieve a sense of control
a client with osteoarthritis requests information from the nurse
about what type of exercise regimen would be most beneficial
for him. The nurse should communicate which information?
......ANSWER........low impact exercise, walking, swimming, and
water aerobics
the nurse is assessing a client with a cuffed tracheostomy tube in
place who is breathing spontaneously. To evaluate if the client
can tolerate cuff deflation to promote speaking and swallowing,
what action should the nurse implement?
......ANSWER........observe the client for coughing colored sputum
after drinking a small amount of colored water.
a client with a history of hypertension, myocardial infarction, and
heart failure is admitted to the surgical intensive care unit after
coronary artery bypass surgery graft. the nurse determines the
client's serum potassium level is 4.5 mEq/l. What action should
the nurse implement? ......ANSWER........document the finding as
the only action. potassium level is within normal range.
the nurse is caring for a client with multiple traumas after a motor
vehicle collision. The nurse learns that the client has secondary
, Page 4 of 58
syphilis. What precaution should the nurse implement?
......ANSWER........gloves should be worn during contact with the
client's skin.
secondary stage of syphilis is a systemic blood-borne disease
that presents with skin lesions and rashes that may drain the
highly contagious spirochete.
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? ......ANSWER........teach measures to avoid the
Valsalve maneuver (straining with bowel movements while
holding one's breath, increases intracerebral pressure, which may
induce bleeding or rupture of cerebral blood vessels.
a man who smokes two packs of cigarettes a day wants to know
if smoking is contributing to the difficulty that he and his wife are
having getting pregnant. what information is best for the nurse to
provide? SATA ......ANSWER........smoking can decrease the
quantity and quality of sperm
cessation of smoking improves general health and fertility
in planning care for a client with an acute stroke resulting in
right-sided hemiplegia, which positioning should the nurse use to
maintain optimal functioning? ......ANSWER........left lateral,
supine, brief periods on the right side, and prone.
after an acute stroke, a positioning and turning schedule that
minimizes lying on the affected side, which can impair circulation
and cause pain.
