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HESI - MEDICAL SURGICAL NURSING TEST 2024/2025 ACTUAL
EXAM COMPLETE QUESTIONS AND CORRECT DETAILED
ANSWERS
The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified
the physician. Nursing assessment indicates that heart rhythm is regular. What is the most
important nursing intervention for this patient now?
A) Examine sacral area and patient's heels for skin breakdown due to potential edema.
B) Establish seizure precautions due to potential muscle twitching, cramps, and seizures.
C) Institute fall precautions due to potential postural hypotension and weak leg muscles.
D) Raise bed side rails due to potential decreased level of consciousness and confusion. -
ANSWER-C
Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the
lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema,
decreased level of consciousness, or seizures.
A nurse is assessing clients for fluid and electrolyte imbalances. Which client is at greatest risk
for developing hyponatremia?
A) Client taking digoxin (Lanoxin)
B) Client who is NPO receiving intravenous D5W
C) Client taking ibuprofen (Motrin)
D) Client taking a sulfonamide antibiotic - ANSWER-B
D5W contains no electrolytes. Because the client is not taking any food or fluids by mouth,
normal sodium excretion can lead to hyponatremia. The antibiotic, Motrin, and digoxin will not
put a client at risk for hyponatremia.
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The nurse accidentally administers 10 mg of morphine intravenously to a client who had been
given another dose of morphine, 5 mg IV, about 30 minutes earlier. What action must the nurse
be prepared to take?
A) Assist with intubation.
B) Monitor pain level.
C) Administer oxygen.
D) Administer naloxone (Narcan). - ANSWER-D
A combined dose of 15 mg of morphine may cause severe respiratory depression in some
clients. Naloxone is an opioid antagonist that can be used (intravenously) as the first
intervention to reverse respiratory depression due to a morphine overdose. Then administration
of oxygen may be needed if the client's oxygen saturation decreases. Intubation may occur if the
client does not respond to the Narcan, and respiratory depression becomes a respiratory arrest.
Naloxone may be repeated, but the pain level of the client needs to be monitored because
Narcan can promote withdrawal symptoms.
Which action does the nurse teach a client to reduce the risk for dehydration?
A) Avoiding the use of glycerin suppositories to manage constipation
B) Maintaining a daily oral intake approximately equal to daily fluid loss
C) Restricting sodium intake to no greater than 4 g/day
D) Maintaining an oral intake of at least 1500 mL/day - ANSWER-B
Although a fixed oral intake of 1500 mL daily is good, the key to prevention of dehydration is to
match all fluid losses with the same volume for fluid intake. This is especially true in warm or
dry environments, or when conditions result in greater than usual fluid loss through
perspiration or ventilation.
A client is taking furosemide (Lasix) and becomes confused. Which potassium level does the
nurse correlate with this condition?
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A) 2.9 mEq/L
B) 5.0 mEq/L
C) 6.0 mEq/L
D) 3.8 mEq/L - ANSWER-A
Hypokalemia decreases cerebral function and is manifested by lethargy, confusion, inability to
perform problem-solving tasks, disorientation, and coma. Normal potassium levels are 3.5 to
5.0 mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to neurologic manifestations.
The most appropriate measure for a nurse to use in assessing core body temperature when
there are suspected problems with thermoregulation is a(n)
A) rectal thermometer.
B) tympanic membrane sensor.
C) temporal thermometer scan.
D) oral thermometer. - ANSWER-A
The most reliable means available for assessing core temperature is a rectal temperature, which
is considered the standard of practice. An oral temperature is a common measure but not the
most reliable. A temporal thermometer scan has some limitations and is not the standard. The
tympanic membrane sensor could be used as a second source for temperature assessment.
A client presents to the emergency department after prolonged exposure to the cold. The client
is shivering, has slurred speech, and is slow to respond to questions. Which intervention will the
nurse prepare for this client FIRST?
A) Continuous arteriovenous rewarming
B) Dry clothing and warm blankets
C) Peritoneal lavage with warmed normal saline
D) Administration of warmed IV fluids - ANSWER-B
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Mild hypothermia is manifested by shivering, slurred speech, poor muscular coordination, and
impaired cognitive abilities. Mild hypothermia may be treated with dry clothing and warm
blankets. Rewarming should occur slowly by removing wet clothing and providing dry warm
blankets first. Other treatments are secondary and should be used to treat moderate to severe
hypothermia.
The Joint Commission focuses on safety in health care. Which action by the nurse reflects The
Joint Commission's main objective?
A) Performing range-of-motion exercises on the client three times each day
B) Assessing the client's respirations when administering opioids
C) Delegating to the nursing assistant to give the client a complete bath daily
D) Ensuring that the client is eating 100% of the meals served to him or her - ANSWER-B
It is important for the nurse to assess respirations of the client when administering opioids
because of the possibility of respiratory depression. The other interventions may or may not be
necessary in the care of the client and do not focus on safety.
What is a priority nursing intervention to prevent falls for an older adult client with multiple
chronic diseases?
A) Requesting that a family member remain with the client to assist in ambulation
B) Keeping all four siderails up while the client is in bed
C) Placing the client in restraints to prevent movement without assistance
D) Providing assistance to the client in getting out of the bed or chair - ANSWER-D
Advanced age and multiple illnesses, particularly those that result in alterations in sensation,
such as diabetes, predispose this client to falls. The nurse should provide assistance to the client
with transfer and ambulation to prevent falls. The client should not be restrained or maintained
on bedrest without adequate indication. Although family members are encouraged to visit, their
presence around the clock is not necessary at this point.
HESI - MEDICAL SURGICAL NURSING TEST 2024/2025 ACTUAL
EXAM COMPLETE QUESTIONS AND CORRECT DETAILED
ANSWERS
The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified
the physician. Nursing assessment indicates that heart rhythm is regular. What is the most
important nursing intervention for this patient now?
A) Examine sacral area and patient's heels for skin breakdown due to potential edema.
B) Establish seizure precautions due to potential muscle twitching, cramps, and seizures.
C) Institute fall precautions due to potential postural hypotension and weak leg muscles.
D) Raise bed side rails due to potential decreased level of consciousness and confusion. -
ANSWER-C
Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the
lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema,
decreased level of consciousness, or seizures.
A nurse is assessing clients for fluid and electrolyte imbalances. Which client is at greatest risk
for developing hyponatremia?
A) Client taking digoxin (Lanoxin)
B) Client who is NPO receiving intravenous D5W
C) Client taking ibuprofen (Motrin)
D) Client taking a sulfonamide antibiotic - ANSWER-B
D5W contains no electrolytes. Because the client is not taking any food or fluids by mouth,
normal sodium excretion can lead to hyponatremia. The antibiotic, Motrin, and digoxin will not
put a client at risk for hyponatremia.
,2|Page
The nurse accidentally administers 10 mg of morphine intravenously to a client who had been
given another dose of morphine, 5 mg IV, about 30 minutes earlier. What action must the nurse
be prepared to take?
A) Assist with intubation.
B) Monitor pain level.
C) Administer oxygen.
D) Administer naloxone (Narcan). - ANSWER-D
A combined dose of 15 mg of morphine may cause severe respiratory depression in some
clients. Naloxone is an opioid antagonist that can be used (intravenously) as the first
intervention to reverse respiratory depression due to a morphine overdose. Then administration
of oxygen may be needed if the client's oxygen saturation decreases. Intubation may occur if the
client does not respond to the Narcan, and respiratory depression becomes a respiratory arrest.
Naloxone may be repeated, but the pain level of the client needs to be monitored because
Narcan can promote withdrawal symptoms.
Which action does the nurse teach a client to reduce the risk for dehydration?
A) Avoiding the use of glycerin suppositories to manage constipation
B) Maintaining a daily oral intake approximately equal to daily fluid loss
C) Restricting sodium intake to no greater than 4 g/day
D) Maintaining an oral intake of at least 1500 mL/day - ANSWER-B
Although a fixed oral intake of 1500 mL daily is good, the key to prevention of dehydration is to
match all fluid losses with the same volume for fluid intake. This is especially true in warm or
dry environments, or when conditions result in greater than usual fluid loss through
perspiration or ventilation.
A client is taking furosemide (Lasix) and becomes confused. Which potassium level does the
nurse correlate with this condition?
,3|Page
A) 2.9 mEq/L
B) 5.0 mEq/L
C) 6.0 mEq/L
D) 3.8 mEq/L - ANSWER-A
Hypokalemia decreases cerebral function and is manifested by lethargy, confusion, inability to
perform problem-solving tasks, disorientation, and coma. Normal potassium levels are 3.5 to
5.0 mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to neurologic manifestations.
The most appropriate measure for a nurse to use in assessing core body temperature when
there are suspected problems with thermoregulation is a(n)
A) rectal thermometer.
B) tympanic membrane sensor.
C) temporal thermometer scan.
D) oral thermometer. - ANSWER-A
The most reliable means available for assessing core temperature is a rectal temperature, which
is considered the standard of practice. An oral temperature is a common measure but not the
most reliable. A temporal thermometer scan has some limitations and is not the standard. The
tympanic membrane sensor could be used as a second source for temperature assessment.
A client presents to the emergency department after prolonged exposure to the cold. The client
is shivering, has slurred speech, and is slow to respond to questions. Which intervention will the
nurse prepare for this client FIRST?
A) Continuous arteriovenous rewarming
B) Dry clothing and warm blankets
C) Peritoneal lavage with warmed normal saline
D) Administration of warmed IV fluids - ANSWER-B
, 4|Page
Mild hypothermia is manifested by shivering, slurred speech, poor muscular coordination, and
impaired cognitive abilities. Mild hypothermia may be treated with dry clothing and warm
blankets. Rewarming should occur slowly by removing wet clothing and providing dry warm
blankets first. Other treatments are secondary and should be used to treat moderate to severe
hypothermia.
The Joint Commission focuses on safety in health care. Which action by the nurse reflects The
Joint Commission's main objective?
A) Performing range-of-motion exercises on the client three times each day
B) Assessing the client's respirations when administering opioids
C) Delegating to the nursing assistant to give the client a complete bath daily
D) Ensuring that the client is eating 100% of the meals served to him or her - ANSWER-B
It is important for the nurse to assess respirations of the client when administering opioids
because of the possibility of respiratory depression. The other interventions may or may not be
necessary in the care of the client and do not focus on safety.
What is a priority nursing intervention to prevent falls for an older adult client with multiple
chronic diseases?
A) Requesting that a family member remain with the client to assist in ambulation
B) Keeping all four siderails up while the client is in bed
C) Placing the client in restraints to prevent movement without assistance
D) Providing assistance to the client in getting out of the bed or chair - ANSWER-D
Advanced age and multiple illnesses, particularly those that result in alterations in sensation,
such as diabetes, predispose this client to falls. The nurse should provide assistance to the client
with transfer and ambulation to prevent falls. The client should not be restrained or maintained
on bedrest without adequate indication. Although family members are encouraged to visit, their
presence around the clock is not necessary at this point.
