HESI RN MED SURG VERSION A & VERSION B
2025-2026 ACTUAL EXAM EACH EXAM
CONTAINS 125 QUESTIONS AND CORRECT
DETAILED ANSWERS
A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which
action should the nurse take first?
A.
Support the client to a sitting position.
B.
Ask the client to walk slowly back to the room.
C.
Administer a sublingual nitroglycerin tablet.
D.
Provide oxygen via nasal cannula. A
Rationale:The nurse should safely assist the client to a resting position and then perform options C and
D. The client must cease all activity immediately, which will decrease the oxygen requirement of the
myocardial muscle. After these interventions are implemented, the client can be escorted back to the
room via wheelchair or stretcher
The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food
items chosen by the client indicate understanding of the teaching? (Select all that apply.)
A.
White bread
B.
Salmon
C.
Broccoli
D.
Whole milk
E.
Banana B, C, E
1|Page
,Rationale:Options B, C, and E provide fresh fruits, lean meats and fish, vegetables, whole grains, and
low-fat dairy products. All are recommended by the American Diabetes Association (ADA) and are a part
of the My Plate guidelines recommended by the U.S. Department of Agriculture (USDA). Whole milk is
high in fat and is not recommended by the ADA. White bread is milled, a process that removes the
essential nutrients. It should be avoided for weight loss and is a poor choice for the client with diabetes.
The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic douloureux). Which
symptoms will the nurse be looking for in the focused assessment related to this condition? (Select all
that apply.)
A.
Facial muscle spasms
B.
Sudden facial pain
C.
Unilateral facial weakness
D.
Difficulty in chewing
E.
Tinnitus
F.
Hearing difficulties A, B
Rationale:Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the
area innervated by one or more branches of the trigeminal nerve (cranial V). The remaining symptoms
are not related to trigeminal neuralgia.
The nurse is counseling a healthy 30-year-old female client regarding osteoporosis prevention. Which
activity would be most beneficial in achieving the client's goal of osteoporosis prevention?
A.
Cross-country skiing
B.
Scuba diving
C.
Horseback riding
D.
2|Page
,Kayaking A
Rationale:Weight-bearing exercise is an important measure to reduce the risk of osteoporosis. Of the
activities listed, cross-country skiing includes the most weight-bearing, whereas options B, C, and D
involve less.
A client with congestive heart failure and atrial fibrillation develops ventricular ectopy with a pattern of
8 ectopic beats/min. Which action should the nurse take based on this observation?
A.
Assess for bilateral jugular vein distention.
B.
Increase oxygen flow via nasal cannula.
C.
Administer PRN furosemide.
D.
Auscultate for a pleural friction rub. B
Rationale:This client should have the oxygen flow immediately increased to promote oxygenation of the
myocardium. Ventricular ectopy, characterized by multiple PVCs, is often caused by myocardial ischemia
exacerbated by hypokalemia. The nurse would expect the client in congestive heart failure to have some
degree of option A, which does not exacerbate the ectopy. Option C could create a more severe
hypokalemia, which could increase the ectopy. The client is not exhibiting signs of option D.
The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless
and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which
action should the nurse take first?
A.
Measure the urine specific gravity.
B.
Obtain IV fluids for infusion per protocol.
C.
Prepare for insertion of a central venous catheter.
D.
Auscultate the client's breath sounds. B
Rationale:The client is at risk for hypovolemic shock because of the postoperative status and is
exhibiting early signs of shock. A priority intervention is the initiation of IV fluids to restore tissue
perfusion. Options A, C, and D are all important interventions but are of lower priority than option B.
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, Which nursing action is necessary for the client with a flail chest?
A.
Withhold prescribed analgesic medications.
B.
Percuss the fractured rib area with light taps.
C.
Avoid implementing pulmonary suctioning.
D.
Encourage coughing and deep breathing. D
Rationale:Treatment of flail chest is focused on preventing atelectasis and related complications of
compromised ventilation by encouraging coughing and deep breathing. This condition is typically
diagnosed in clients with three or more rib fractures, resulting in paradoxic movement of a segment of
the chest wall. Option C should not be avoided because suctioning is necessary to maintain pulmonary
toilet in clients who require mechanical ventilation. Option A should not be withheld. Option B should
not be applied because the fractures are clearly visible on the chest radiograph.
During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion
containing insulin. Which action should the nurse complete first?
A.
Review the client's history for diabetes mellitus.
B.
Observe the extremity distal to the IV site.
C.
Monitor the client's serum potassium and blood glucose levels.
D.
Evaluate the client's oxygen saturation and breath sounds. C
Rationale:Clients with tumor lysis syndrome may experience hyperkalemia, requiring the addition of
insulin to the IV solution to reduce the serum potassium level. It is most important for the nurse to
monitor the client's serum potassium and blood glucose levels to ensure that they are not at dangerous
levels. Options A, B, and D provide valuable assessment data but are of less priority than option C.
The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the
midfoot. Which goal should be included in this client's plan of care?
A.
4|Page
2025-2026 ACTUAL EXAM EACH EXAM
CONTAINS 125 QUESTIONS AND CORRECT
DETAILED ANSWERS
A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which
action should the nurse take first?
A.
Support the client to a sitting position.
B.
Ask the client to walk slowly back to the room.
C.
Administer a sublingual nitroglycerin tablet.
D.
Provide oxygen via nasal cannula. A
Rationale:The nurse should safely assist the client to a resting position and then perform options C and
D. The client must cease all activity immediately, which will decrease the oxygen requirement of the
myocardial muscle. After these interventions are implemented, the client can be escorted back to the
room via wheelchair or stretcher
The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food
items chosen by the client indicate understanding of the teaching? (Select all that apply.)
A.
White bread
B.
Salmon
C.
Broccoli
D.
Whole milk
E.
Banana B, C, E
1|Page
,Rationale:Options B, C, and E provide fresh fruits, lean meats and fish, vegetables, whole grains, and
low-fat dairy products. All are recommended by the American Diabetes Association (ADA) and are a part
of the My Plate guidelines recommended by the U.S. Department of Agriculture (USDA). Whole milk is
high in fat and is not recommended by the ADA. White bread is milled, a process that removes the
essential nutrients. It should be avoided for weight loss and is a poor choice for the client with diabetes.
The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic douloureux). Which
symptoms will the nurse be looking for in the focused assessment related to this condition? (Select all
that apply.)
A.
Facial muscle spasms
B.
Sudden facial pain
C.
Unilateral facial weakness
D.
Difficulty in chewing
E.
Tinnitus
F.
Hearing difficulties A, B
Rationale:Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the
area innervated by one or more branches of the trigeminal nerve (cranial V). The remaining symptoms
are not related to trigeminal neuralgia.
The nurse is counseling a healthy 30-year-old female client regarding osteoporosis prevention. Which
activity would be most beneficial in achieving the client's goal of osteoporosis prevention?
A.
Cross-country skiing
B.
Scuba diving
C.
Horseback riding
D.
2|Page
,Kayaking A
Rationale:Weight-bearing exercise is an important measure to reduce the risk of osteoporosis. Of the
activities listed, cross-country skiing includes the most weight-bearing, whereas options B, C, and D
involve less.
A client with congestive heart failure and atrial fibrillation develops ventricular ectopy with a pattern of
8 ectopic beats/min. Which action should the nurse take based on this observation?
A.
Assess for bilateral jugular vein distention.
B.
Increase oxygen flow via nasal cannula.
C.
Administer PRN furosemide.
D.
Auscultate for a pleural friction rub. B
Rationale:This client should have the oxygen flow immediately increased to promote oxygenation of the
myocardium. Ventricular ectopy, characterized by multiple PVCs, is often caused by myocardial ischemia
exacerbated by hypokalemia. The nurse would expect the client in congestive heart failure to have some
degree of option A, which does not exacerbate the ectopy. Option C could create a more severe
hypokalemia, which could increase the ectopy. The client is not exhibiting signs of option D.
The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless
and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which
action should the nurse take first?
A.
Measure the urine specific gravity.
B.
Obtain IV fluids for infusion per protocol.
C.
Prepare for insertion of a central venous catheter.
D.
Auscultate the client's breath sounds. B
Rationale:The client is at risk for hypovolemic shock because of the postoperative status and is
exhibiting early signs of shock. A priority intervention is the initiation of IV fluids to restore tissue
perfusion. Options A, C, and D are all important interventions but are of lower priority than option B.
3|Page
, Which nursing action is necessary for the client with a flail chest?
A.
Withhold prescribed analgesic medications.
B.
Percuss the fractured rib area with light taps.
C.
Avoid implementing pulmonary suctioning.
D.
Encourage coughing and deep breathing. D
Rationale:Treatment of flail chest is focused on preventing atelectasis and related complications of
compromised ventilation by encouraging coughing and deep breathing. This condition is typically
diagnosed in clients with three or more rib fractures, resulting in paradoxic movement of a segment of
the chest wall. Option C should not be avoided because suctioning is necessary to maintain pulmonary
toilet in clients who require mechanical ventilation. Option A should not be withheld. Option B should
not be applied because the fractures are clearly visible on the chest radiograph.
During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion
containing insulin. Which action should the nurse complete first?
A.
Review the client's history for diabetes mellitus.
B.
Observe the extremity distal to the IV site.
C.
Monitor the client's serum potassium and blood glucose levels.
D.
Evaluate the client's oxygen saturation and breath sounds. C
Rationale:Clients with tumor lysis syndrome may experience hyperkalemia, requiring the addition of
insulin to the IV solution to reduce the serum potassium level. It is most important for the nurse to
monitor the client's serum potassium and blood glucose levels to ensure that they are not at dangerous
levels. Options A, B, and D provide valuable assessment data but are of less priority than option C.
The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the
midfoot. Which goal should be included in this client's plan of care?
A.
4|Page
