HESI: Medical-Surgical Assignment Exam and Rationale
1. Which assessment is most important for the nurse to perform on a client who is
hospitalized for Guillain-Barre syndrome that is rapidly progressing?
A: Respiratory effort.
B: Unsteady gait.
C: Intensity of pain.
D: Ability to eat.: A: Respiratory Effort
(Guillain-Barre syndrome causes paralysis or weakness that typically starts at the feet and
progresses upwards. As the condition progresses, the nurse must ensure that the client is
able to breathe effectively.)
2. A male client comes into the clinic with a history of penile discharge with painful,
burning urination. Which action should the nurse implement?
A: Collect a culture of the penile discharge.
B: Palpate the inguinal lymph nodes gently.
C: Observe for scrotal swelling and redness.
D: Express the discharge to determine color.: A: Collect a culture of the penile discharge.
(Penile discharge with painful urination is commonly associated with gonorrhea. The nurse
should collect a culture of the penile discharge to determine the cause of these symptoms.
The cause must be determined or confirmed through culture to identify the organism and
ensure effective treatment.)
3. A client with history of atrial fibrillation is admitted to the telemetry unit with
sudden onset of shortness of breath. The nurse observes a new irregular heart rhythm
and should perform which assessment at this time?
A: Check for a pulse deficit.
B: Palpate the apical impulse.
C: Inspect jugular vein pulse.
D: Examine for a carotid bruit.: A: Check for a pulse deficit.
(A client with a past history of atrial fibrillation may return to that rhythm. Any signs of
atrial fibrillation, such as sudden onset shortness of breath, requires further investigation.
,HESI: Medical-Surgical Assignment Exam and Rationale
The nurse should assess this client for a pulse deficit because this condition occurs with
atrial fibrillation.)
4. Which client should be further assessed for an ectopic pregnancy?
A: A 24-year-old with shoulder and lower abdominal quadrant pain.
B: A 33-year-old with intermittent lower abdominal cramping.
C: A 20-year-old with fever and right lower abdominal colic.
D: A 40-year-old with jaundice and right lower abdominal pain.: A: A 24-year-old with
shoulder and lower abdominal quadrant pain.
(A 24-year-old with sudden onset of lower abdominal quadrant pain should be assessed for
an ectopic pregnancy. The pain can also be referred to the shoulder and may be associated
with vaginal bleeding.)
5. Which dietary assessment finding is most important for the nurse to address when
caring for a client with diabetic nephropathy?
A: Drinks a six pack of beer every day. B: Enjoys
a hamburger once a month.
C: Eats fortified breakfast cereal daily.
D: Consumes beans and rice every day.: A: Drinks a six pack of beer every day.
(Drinking six beers every day is the dietary assessment finding most important for the nurse
to address when caring for a client with diabetic nephropathy. The usual can of beer is 12
ounces (355 mL). Clients with diabetes are recommended to drink no more than 12 ounces
of beer per day because beer contains carbohydrates that can create unhealthy fluctuations
in blood glucose and promote poorglucose control. Nephropathy is exacerbated by poor
blood glucose control.)
6. Which assessment finding is of greatest concern to the nurse who is caring for a
client with stomatitis?
A: Cough brought on by swallowing.
B: Sore throat caused by speaking.
C: Painful and dry oral cavity.
D: Unintended weight loss.: A: Cough brought on by swallowing.
,HESI: Medical-Surgical Assignment Exam and Rationale
A cough brought on by swallowing is a sign of dysphagia, which is a finding of particular
concern in a client with stomatitis. Dysphagia can cause numerous problems, including
airway obstruction, and should be reported to the healthcare provider immediately.
7. The nurse is teaching a client diagnosed with peripheral arterial disease. Which
genitourinary system complication should the nurse include in the teaching?
A: Altered sexual response.
B: Sterility.
C: Urinary incontinence.
D: Decreased pelvic muscle tone.: A: Altered sexual response.
Peripheral arterial disease (PAD) is a cardiovascular condition characterized by narrowing
of the arteries and reduced blood flow to the extremities. PAD is known to alter the blood
flow to the male's penis and is associated with erectile dysfunction in men.
8. A 40-year-old female client has a history of smoking. Which finding should the nurse
identify as a risk factor for myocardia infarction?
A: Oral contraceptives.
B: Senile osteopenia.
C: Levothyroxine therapy.
D: Pernicious anemia.: A: Oral contraceptives.
Women older than 35 years old who smoke and take oral contraceptives have an increased
risk of myocardial infarction or stroke.
9. A client has been told that there is cataract formation over both eyes. Which finding
should the nurse expect when assessing the client?
A: Decreased color perception.
B: Presence of floaters.
C: Loss of central vision.
D: Reduced peripheral vision.: A: Decreased color perception.
, HESI: Medical-Surgical Assignment Exam and Rationale
Decreased color perception occurs with cataract formation. Cataract formation is also
associated with blurred vision and a global loss of vision so gradual that the client may not
be aware of it.
10. Which assessment finding should most concern the nurse who is monitoring a client
two hours after a thoracentesis?
A: New onset of coughing.
B: Low resting heart rate.
C: Distended neck veins.
D: Decreased shallow respirations.: A: New onset of coughing.
A pneumothorax (partial or complete lung collapse) is the potential complication of a
thoracentesis. Manifestations of a pneumothorax include new onset of a nagging cough,
tachycardia, and an increased shallow respiration rate.
11. While caring for a client who has esophageal varices, which nursing intervention is
most important for the registered nurse (RN) to implement?
A: Monitor infusing IV fluids and any replacement blood products.
B: Prepare for esophagogastroduodenoscopy (EGD).
C: Maintain the client on strict bedrest.
D: Insert a nasogastric tube (NGT) for intermittent suction.: A: Monitor infusing IV fluids
and any replacement blood products
(Maintaining hemodynamic stability in a client with esophageal varices can precipitate a
life-threatening crisis if esophageal varies leak or rupture and can result in hemorrhage.
The priority is assessing and monitoring infusions of IV fluids and any replacement blood
products.)
12. The registered nurse (RN) is caring for a client who developed oliguria and was
diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding
indicates to the RN that the client is stabilizing?
A: Urine output of 40 mL/hour.
B: Apical pulse 100 and blood pressure 76/42.
C: Urine specific gravity 1.001.
D: Tented skin on dorsal surface of hands.: A: Urine output of 40 mL/hour.
1. Which assessment is most important for the nurse to perform on a client who is
hospitalized for Guillain-Barre syndrome that is rapidly progressing?
A: Respiratory effort.
B: Unsteady gait.
C: Intensity of pain.
D: Ability to eat.: A: Respiratory Effort
(Guillain-Barre syndrome causes paralysis or weakness that typically starts at the feet and
progresses upwards. As the condition progresses, the nurse must ensure that the client is
able to breathe effectively.)
2. A male client comes into the clinic with a history of penile discharge with painful,
burning urination. Which action should the nurse implement?
A: Collect a culture of the penile discharge.
B: Palpate the inguinal lymph nodes gently.
C: Observe for scrotal swelling and redness.
D: Express the discharge to determine color.: A: Collect a culture of the penile discharge.
(Penile discharge with painful urination is commonly associated with gonorrhea. The nurse
should collect a culture of the penile discharge to determine the cause of these symptoms.
The cause must be determined or confirmed through culture to identify the organism and
ensure effective treatment.)
3. A client with history of atrial fibrillation is admitted to the telemetry unit with
sudden onset of shortness of breath. The nurse observes a new irregular heart rhythm
and should perform which assessment at this time?
A: Check for a pulse deficit.
B: Palpate the apical impulse.
C: Inspect jugular vein pulse.
D: Examine for a carotid bruit.: A: Check for a pulse deficit.
(A client with a past history of atrial fibrillation may return to that rhythm. Any signs of
atrial fibrillation, such as sudden onset shortness of breath, requires further investigation.
,HESI: Medical-Surgical Assignment Exam and Rationale
The nurse should assess this client for a pulse deficit because this condition occurs with
atrial fibrillation.)
4. Which client should be further assessed for an ectopic pregnancy?
A: A 24-year-old with shoulder and lower abdominal quadrant pain.
B: A 33-year-old with intermittent lower abdominal cramping.
C: A 20-year-old with fever and right lower abdominal colic.
D: A 40-year-old with jaundice and right lower abdominal pain.: A: A 24-year-old with
shoulder and lower abdominal quadrant pain.
(A 24-year-old with sudden onset of lower abdominal quadrant pain should be assessed for
an ectopic pregnancy. The pain can also be referred to the shoulder and may be associated
with vaginal bleeding.)
5. Which dietary assessment finding is most important for the nurse to address when
caring for a client with diabetic nephropathy?
A: Drinks a six pack of beer every day. B: Enjoys
a hamburger once a month.
C: Eats fortified breakfast cereal daily.
D: Consumes beans and rice every day.: A: Drinks a six pack of beer every day.
(Drinking six beers every day is the dietary assessment finding most important for the nurse
to address when caring for a client with diabetic nephropathy. The usual can of beer is 12
ounces (355 mL). Clients with diabetes are recommended to drink no more than 12 ounces
of beer per day because beer contains carbohydrates that can create unhealthy fluctuations
in blood glucose and promote poorglucose control. Nephropathy is exacerbated by poor
blood glucose control.)
6. Which assessment finding is of greatest concern to the nurse who is caring for a
client with stomatitis?
A: Cough brought on by swallowing.
B: Sore throat caused by speaking.
C: Painful and dry oral cavity.
D: Unintended weight loss.: A: Cough brought on by swallowing.
,HESI: Medical-Surgical Assignment Exam and Rationale
A cough brought on by swallowing is a sign of dysphagia, which is a finding of particular
concern in a client with stomatitis. Dysphagia can cause numerous problems, including
airway obstruction, and should be reported to the healthcare provider immediately.
7. The nurse is teaching a client diagnosed with peripheral arterial disease. Which
genitourinary system complication should the nurse include in the teaching?
A: Altered sexual response.
B: Sterility.
C: Urinary incontinence.
D: Decreased pelvic muscle tone.: A: Altered sexual response.
Peripheral arterial disease (PAD) is a cardiovascular condition characterized by narrowing
of the arteries and reduced blood flow to the extremities. PAD is known to alter the blood
flow to the male's penis and is associated with erectile dysfunction in men.
8. A 40-year-old female client has a history of smoking. Which finding should the nurse
identify as a risk factor for myocardia infarction?
A: Oral contraceptives.
B: Senile osteopenia.
C: Levothyroxine therapy.
D: Pernicious anemia.: A: Oral contraceptives.
Women older than 35 years old who smoke and take oral contraceptives have an increased
risk of myocardial infarction or stroke.
9. A client has been told that there is cataract formation over both eyes. Which finding
should the nurse expect when assessing the client?
A: Decreased color perception.
B: Presence of floaters.
C: Loss of central vision.
D: Reduced peripheral vision.: A: Decreased color perception.
, HESI: Medical-Surgical Assignment Exam and Rationale
Decreased color perception occurs with cataract formation. Cataract formation is also
associated with blurred vision and a global loss of vision so gradual that the client may not
be aware of it.
10. Which assessment finding should most concern the nurse who is monitoring a client
two hours after a thoracentesis?
A: New onset of coughing.
B: Low resting heart rate.
C: Distended neck veins.
D: Decreased shallow respirations.: A: New onset of coughing.
A pneumothorax (partial or complete lung collapse) is the potential complication of a
thoracentesis. Manifestations of a pneumothorax include new onset of a nagging cough,
tachycardia, and an increased shallow respiration rate.
11. While caring for a client who has esophageal varices, which nursing intervention is
most important for the registered nurse (RN) to implement?
A: Monitor infusing IV fluids and any replacement blood products.
B: Prepare for esophagogastroduodenoscopy (EGD).
C: Maintain the client on strict bedrest.
D: Insert a nasogastric tube (NGT) for intermittent suction.: A: Monitor infusing IV fluids
and any replacement blood products
(Maintaining hemodynamic stability in a client with esophageal varices can precipitate a
life-threatening crisis if esophageal varies leak or rupture and can result in hemorrhage.
The priority is assessing and monitoring infusions of IV fluids and any replacement blood
products.)
12. The registered nurse (RN) is caring for a client who developed oliguria and was
diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding
indicates to the RN that the client is stabilizing?
A: Urine output of 40 mL/hour.
B: Apical pulse 100 and blood pressure 76/42.
C: Urine specific gravity 1.001.
D: Tented skin on dorsal surface of hands.: A: Urine output of 40 mL/hour.
