BSN 266 MED SURG
HESI QUESTIONS WITH
VERIFIED ANSWERS
1.
A nurse is reinforcing teaching with a client who has HIV and is being
discharged to home. Which of the following instructions should the nurse
include in the teaching?
A. Avoid contact with pets
B. Take temperature once a day
C. Limit fluid intake
D. Avoid all vaccinations
Correct Answer: B. Take temperature once a day
Rationale:
Clients with HIV are immunocompromised and at increased risk for infection.
Monitoring temperature daily allows early detection of infection so prompt
treatment can begin. Fever may be the first sign of an opportunistic
infection. Avoiding pets or vaccines is not routinely required.
2.
A nurse is caring for a client who is postoperative following a tracheostomy
and has copious, tenacious secretions. Which intervention is appropriate to
thin the secretions?
A. Provide humidified oxygen
B. Limit oral fluids
C. Encourage coughing only
D. Use dry oxygen delivery
Correct Answer: A. Provide humidified oxygen
,Rationale:
Humidified oxygen adds moisture to the airway, which helps loosen thick
secretions and makes them easier to expectorate. Dry oxygen can worsen
secretion thickness. Adequate hydration and humidification are key airway
interventions.
3.
A client with a vascular occlusion of the right lower extremity reports
difficulty sleeping due to cold feet. Which nursing action promotes comfort?
A. Apply a heating pad
B. Obtain slipper socks
C. Elevate the extremity
D. Massage the foot
Correct Answer: B. Obtain slipper socks
Rationale:
Slipper socks provide warmth without compromising circulation. Heating
pads and massage can cause tissue injury in clients with impaired
circulation. Elevating the extremity can further decrease arterial blood flow.
4.
A nurse is caring for a client who is 4 hours postoperative following a TURP.
Which finding should be reported immediately?
A. Pink-tinged urine
B. Urinary urgency
C. Thick, red-colored urine
D. Small clots in urine
Correct Answer: C. Thick, red-colored urine
Rationale:
Thick, bright red urine suggests active hemorrhage, a serious postoperative
complication of TURP. Pink-tinged urine and small clots are expected initially.
Rapid reporting is necessary to prevent hypovolemia.
,5.
A client with a temperature of 39.7°C (103.5°F) is placed on a hypothermia
blanket. Which adverse effect should the nurse monitor for?
A. Shivering
B. Bradycardia
C. Hypotension
D. Cyanosis
Correct Answer: A. Shivering
Rationale:
Shivering increases metabolic demand and oxygen consumption,
counteracting cooling efforts. It is a common adverse effect of hypothermia
therapy. The nurse may need to administer prescribed antishivering
medications.
6.
A nurse is reinforcing teaching about exercise with a client who has type 1
diabetes mellitus. Which statement indicates understanding?
A. “I should exercise when my glucose is over 300.”
B. “I will skip insulin on exercise days.”
C. “I should avoid fluids during exercise.”
D. “I will not exercise if my urine is positive for ketones.”
Correct Answer: D. “I will not exercise if my urine is positive for
ketones.”
Rationale:
Ketones indicate fat breakdown and possible impending diabetic
ketoacidosis. Exercise in this state can worsen hyperglycemia and acidosis.
Clients should exercise only when glucose and ketones are controlled.
, 7.
A nurse notes bowel protruding from an abdominal incision in a
postoperative client. After calling for help, which action should the nurse
take first?
A. Cover the wound with a moist sterile dressing
B. Place the client in Trendelenburg position
C. Attempt to reinsert the bowel
D. Apply pressure to the incision
Correct Answer: A. Cover the wound with a moist sterile dressing
8.
A nurse is collecting data from a client who has alcohol use disorder and is
experiencing metabolic acidosis. Which manifestation should the nurse
expect?
A. Slow, shallow respirations
B. Hyperventilation
C. Bradycardia
D. Decreased urine output
Correct Answer: B. Hyperventilation
Rationale:
Hyperventilation occurs as the body attempts to compensate for metabolic
acidosis by blowing off excess carbon dioxide. This respiratory compensation
helps raise blood pH toward normal. It is commonly seen as deep, rapid
breathing. Slow respirations would worsen acidosis.
9.
HESI QUESTIONS WITH
VERIFIED ANSWERS
1.
A nurse is reinforcing teaching with a client who has HIV and is being
discharged to home. Which of the following instructions should the nurse
include in the teaching?
A. Avoid contact with pets
B. Take temperature once a day
C. Limit fluid intake
D. Avoid all vaccinations
Correct Answer: B. Take temperature once a day
Rationale:
Clients with HIV are immunocompromised and at increased risk for infection.
Monitoring temperature daily allows early detection of infection so prompt
treatment can begin. Fever may be the first sign of an opportunistic
infection. Avoiding pets or vaccines is not routinely required.
2.
A nurse is caring for a client who is postoperative following a tracheostomy
and has copious, tenacious secretions. Which intervention is appropriate to
thin the secretions?
A. Provide humidified oxygen
B. Limit oral fluids
C. Encourage coughing only
D. Use dry oxygen delivery
Correct Answer: A. Provide humidified oxygen
,Rationale:
Humidified oxygen adds moisture to the airway, which helps loosen thick
secretions and makes them easier to expectorate. Dry oxygen can worsen
secretion thickness. Adequate hydration and humidification are key airway
interventions.
3.
A client with a vascular occlusion of the right lower extremity reports
difficulty sleeping due to cold feet. Which nursing action promotes comfort?
A. Apply a heating pad
B. Obtain slipper socks
C. Elevate the extremity
D. Massage the foot
Correct Answer: B. Obtain slipper socks
Rationale:
Slipper socks provide warmth without compromising circulation. Heating
pads and massage can cause tissue injury in clients with impaired
circulation. Elevating the extremity can further decrease arterial blood flow.
4.
A nurse is caring for a client who is 4 hours postoperative following a TURP.
Which finding should be reported immediately?
A. Pink-tinged urine
B. Urinary urgency
C. Thick, red-colored urine
D. Small clots in urine
Correct Answer: C. Thick, red-colored urine
Rationale:
Thick, bright red urine suggests active hemorrhage, a serious postoperative
complication of TURP. Pink-tinged urine and small clots are expected initially.
Rapid reporting is necessary to prevent hypovolemia.
,5.
A client with a temperature of 39.7°C (103.5°F) is placed on a hypothermia
blanket. Which adverse effect should the nurse monitor for?
A. Shivering
B. Bradycardia
C. Hypotension
D. Cyanosis
Correct Answer: A. Shivering
Rationale:
Shivering increases metabolic demand and oxygen consumption,
counteracting cooling efforts. It is a common adverse effect of hypothermia
therapy. The nurse may need to administer prescribed antishivering
medications.
6.
A nurse is reinforcing teaching about exercise with a client who has type 1
diabetes mellitus. Which statement indicates understanding?
A. “I should exercise when my glucose is over 300.”
B. “I will skip insulin on exercise days.”
C. “I should avoid fluids during exercise.”
D. “I will not exercise if my urine is positive for ketones.”
Correct Answer: D. “I will not exercise if my urine is positive for
ketones.”
Rationale:
Ketones indicate fat breakdown and possible impending diabetic
ketoacidosis. Exercise in this state can worsen hyperglycemia and acidosis.
Clients should exercise only when glucose and ketones are controlled.
, 7.
A nurse notes bowel protruding from an abdominal incision in a
postoperative client. After calling for help, which action should the nurse
take first?
A. Cover the wound with a moist sterile dressing
B. Place the client in Trendelenburg position
C. Attempt to reinsert the bowel
D. Apply pressure to the incision
Correct Answer: A. Cover the wound with a moist sterile dressing
8.
A nurse is collecting data from a client who has alcohol use disorder and is
experiencing metabolic acidosis. Which manifestation should the nurse
expect?
A. Slow, shallow respirations
B. Hyperventilation
C. Bradycardia
D. Decreased urine output
Correct Answer: B. Hyperventilation
Rationale:
Hyperventilation occurs as the body attempts to compensate for metabolic
acidosis by blowing off excess carbon dioxide. This respiratory compensation
helps raise blood pH toward normal. It is commonly seen as deep, rapid
breathing. Slow respirations would worsen acidosis.
9.
