HESI: Medical-Surgical Assignment Exam and Rationale Questions and Correct Answers

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1. Which assessment is most important for the nurse to perform on a client wh
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o is hospitalized for Guillain-
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Barre syndrome that is rapidly progressing? A: Respiratory effort.
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B: Unsteady gait. C
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: Intensity of pain.
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D: Ability to eat.: A: Respiratory Ettort
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(Guillain-
Barre syndrome causes paralysis or weakness that typically starts at the feet and progresses upwards. As the condition
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progresses, the nurse must ensure that the client is able to breathe ettectively.)
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2. A male client comes into the clinic with a history of penile discharge with
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painful, burning urination. Which action should the nurse implement?
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g A: Collect a culture of the penile discharge.
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B: Palpate the inguinal lymph nodes gently.
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C: Observe for scrotal swelling and redness.
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D: Express the discharge to determine color.: A: Collect a culture of the penile discharge.
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(Penile discharge with painful urination is commonly associated with gonorrhea. The nurse should collect a culture of t
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he penile discharge to determine the cause of these symptoms. The cause must be determined or confirmed throug
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h culture to identify the organism and ensure ettective treatment.)
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3. A client with history of atrial fibrillation is admitted to the telemetry unit
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with sudden onset of shortness of breath. The nurse observes a new irregular
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heart rhythm and should perform which assessment at this time?
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A: Check for a pulse deficit. B
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: Palpate the apical impulse. C
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: Inspect jugular vein pulse.
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D: Examine for a carotid bruit.: A: Check for a pulse deficit.
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(A client with a past history of atrial fibrillation may return to that rhythm. Any signs of atrial fibrillation, such as sudden onse
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t shortness of breath, requires further investigation. The nurse should assess this client for a pulse deficit because this condi
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tion occurs with atrial fibrillation.)
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4. Which client should be further assessed for an ectopic pregnancy?
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A: A 24-year-old with shoulder and lower abdominal quadrant pain.
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, HESI: Medical-Surgical Assignment Exam and Rational
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B: A 33-year- g v g v




old with intermittent lower abdominal cramping. C: A 20-year-
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old with fever and right lower abdominal colic.
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D: A 40-year-old with jaundice and right lower abdominal pain.: A:A24-year-
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oldwith shoulder and lower abdominal quadrant pain.
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(A 24-year-
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old with sudden onset of lower abdominal quadrant pain should be assessed for an ectopic pregnancy. The pain can al
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so be referred to the shoulder and may be associated with vaginal bleeding.)
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5. Which dietary assessment finding is most important for the nurse to address
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when caring for a client with diabetic nephropathy? A
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: Drinks a six pack of beer every day.
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B: Enjoys a hamburger once a month. C
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: Eats fortified breakfast cereal daily.
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D: Consumes beans and rice every day.: A: Drinks a six pack of beer every day.
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(Drinking six beers every day is the dietary assessment finding most important for the nurse to address when caring for a
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client with diabetic nephropathy. The usual can of beer is 12 ounces (355 mL). Clients with diabetes are recommended
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to drink no more than 12 ounces of beer per day because beer contains carbohydrates that can create unhealthyfluctuatio
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nsinblood glucoseandpromotepoorglucosecontrol.Nephropathy isexacerbatedbypoorblood glucose control.)
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6. Which assessment finding is of greatest concern to the nurse who is carin
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for a client with stomatitis?
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A: Cough brought on by swallowing. B
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: Sore throat caused by speaking.
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C: Painful and dry oral cavity.
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D: Unintended weight loss.: A: Cough brought on by swallowing.
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A cough brought on by swallowing is a sign of dysphagia, which is a finding of particular concern in a client with stom
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atitis. Dysphagia can cause numerous problems, including airway obstruction, and should be reported to the healthcar
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e provider immediately.
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7. The nurse is teaching a client diagnosed with peripheral arterial disease.
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Which genitourinary system complication should the nurse include in the tea
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, HESI: Medical-Surgical Assignment Exam and Rational
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ching?




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, HESI: Medical-Surgical Assignment Exam and Rational
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A: Altered sexual response. B
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: Sterility.
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C: Urinary incontinence.
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D: Decreased pelvic muscle tone.: A: Altered sexual response.
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Peripheral arterial disease (PAD) is a cardiovascular condition characterized by narrowing of the arteries and reduced blo
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od flow to the extremities. PAD is known to alter the blood flow to the male's penis and is associated with erectile dysfunct
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8. A 40-year-old female client has a history of smoking. Which finding should
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the nurse identify as a risk factor for myocardia infarction? A
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: Oral contraceptives.
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B: Senile osteopenia.gv gv




C: Levothyroxine therapy.
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D: Pernicious anemia.: A: Oral contraceptives.
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Women older than 35 years old who smoke and take oral contraceptives have an increased risk of myocardial infarction or str
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oke.
9. A client has been told that there is cataract formation over both eyes. Which
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finding should the nurse expect when assessing the client?
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A: Decreased color perception.
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B: Presence of floaters.
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C: Loss of central vision.
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D: Reduced peripheral vision.: A: Decreased color perception.
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Decreased color perception occurs with cataract formation. Cataract formation is also associated with blurred vision an
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d a global loss of vision so gradual that the client may not be aware of it.
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10. Which assessment finding should most concern the nurse who is monitor
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-
ing a client two hours after a thoracentesis?
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A: New onset of coughing.
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B: Low resting heart rate. C
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: Distended neck veins.
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D: Decreased shallow respirations.: A: New onset of coughing.
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