HESI Medical Surgical Nursing COMPREHENSIVE
PREDICTOR TEST BANK EXAM 2026-2027 | COMPLETE
ACCURATE EXAM TESTBANK ACTUAL QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(100% CORRECT VERIFIED SOLUTIONS) CURRENTLY
UPDATED VERSION 2026 EDITION) |GUARANTEED
PASS
The nurse is admitting an older adult with decompensated congestive
heart failure. The nursing assessment reveals adventitious lung sounds,
dyspnea, and orthopnea. The nurse should question which doctor's
order?
A) KCl 20 mEq PO two times per day
B) Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
C) Oxygen via face mask at 8 L/min
D) Furosemide (Lasix) 20 mg PO now
B
A patient with decompensated heart failure has extracellular fluid
volume (ECV) excess. The IV of 0.9% NaCl is normal saline, which should
be questioned because it would expand ECV and place an additional
load on the failing heart. Diuretics such as furosemide are appropriate to
decrease the ECV during heart failure. Increasing the potassium intake
with KCl is appropriate, because furosemide increases potassium
excretion. Oxygen administration is appropriate in this situation of near
pulmonary edema from ECV excess.
,The priority nursing intervention for a patient suspected to be
hypothermic would be to:
A) hydrate with intravenous (IV) fluids.
B) remove wet clothes.
C) assess vital signs.
D) provide a warm blanket.
B
The first thing to do with a patient suspected to be hypothermic is to
remove wet clothes, because heat loss is five times greater when
clothing is wet. Assessing vital signs is important, but the wet clothes
should be removed first. Hydration is very important with hyperthermia
and the associated danger of dehydration, but there is not a similar risk
with hypothermia. A warm blanket over wet clothes would not be an
effective warming strategy.
The nurse admitting a patient to the emergency department on a very
hot summer day would suspect hyperthermia when the patient
demonstrates:
A) slow capillary refill.
B) red, sweaty skin.
C) low pulse rate.
D) decreased respirations.
B
With hyperthermia, vasodilatation occurs causing the skin to appear
flushed and warm or hot to touch. There is an increased respiration rate
with hyperthermia. The heart rate increases with hyperthermia. With
hypothermia there is slow capillary refill.
,Why does the nurse always ask the client his or her pain level after taking
routine vital signs?
A) To follow McCaffery's guidelines on pain management
B) To ensure that pain assessment occurs on a regular basis
C) To determine the need for more frequent vital sign measurement
D) To determine whether pain is influencing blood pressure and heart
rate
B
Making pain the fifth vital sign allows more frequent and accurate
assessment, which can contribute to better pain management.
The nurse observes skin tenting on the back of the older adult client's
hand. Which action by the nurse is most appropriate?
A) Examine dependent body areas.
B) Notify the physician.
C) Document the finding and continue to monitor.
D) Assess turgor on the client's forehead.
D
Skin turgor cannot be accurately assessed on an older adult client's
hands because of age-related loss of tissue elasticity in this area. Areas
that more accurately show skin turgor status on an older client include
the skin of the forehead, chest, and abdomen. These should also be
assessed, rather than merely examining dependent body areas. Further
assessment is needed rather than only documenting, monitoring, and
notifying the physician.
, The nurse is assessing a client who has undergone a transurethral
resection of the prostate (TURP). Which assessment finding requires
immediate action by the nurse?
A) Having the urge to void continuously while the catheter is inserted
B) Passing small blood clots after catheter removal
C) Having bright red drainage with multiple blood clots
D) Experiencing urinary frequency after catheter removal
C
A client who undergoes a TURP is at risk for bleeding during the first 24
hours after surgery. Passage of small blood clots and tissue debris,
urinary frequency and leakage, and the urge to void continuously while
the client still has the catheter inserted are all considered to be
expected complications of the procedure. They will resolve as the client
continues to recover and the catheter is removed. However, the
presence of bright red blood with clots indicates arterial bleeding and
should be reported to the provider.
Which finding puts a client at greatest risk for wound infection?
A) Presence of a deep wound
B) Coexisting medical conditions
C) Immune compromised status
D) Severely reddened skin
C
A compromised immune system puts a client at greatest risk for infection.
Although all the other options might increase the client's susceptibility,
the one with the greatest potential impact is being immune
compromised.
PREDICTOR TEST BANK EXAM 2026-2027 | COMPLETE
ACCURATE EXAM TESTBANK ACTUAL QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(100% CORRECT VERIFIED SOLUTIONS) CURRENTLY
UPDATED VERSION 2026 EDITION) |GUARANTEED
PASS
The nurse is admitting an older adult with decompensated congestive
heart failure. The nursing assessment reveals adventitious lung sounds,
dyspnea, and orthopnea. The nurse should question which doctor's
order?
A) KCl 20 mEq PO two times per day
B) Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
C) Oxygen via face mask at 8 L/min
D) Furosemide (Lasix) 20 mg PO now
B
A patient with decompensated heart failure has extracellular fluid
volume (ECV) excess. The IV of 0.9% NaCl is normal saline, which should
be questioned because it would expand ECV and place an additional
load on the failing heart. Diuretics such as furosemide are appropriate to
decrease the ECV during heart failure. Increasing the potassium intake
with KCl is appropriate, because furosemide increases potassium
excretion. Oxygen administration is appropriate in this situation of near
pulmonary edema from ECV excess.
,The priority nursing intervention for a patient suspected to be
hypothermic would be to:
A) hydrate with intravenous (IV) fluids.
B) remove wet clothes.
C) assess vital signs.
D) provide a warm blanket.
B
The first thing to do with a patient suspected to be hypothermic is to
remove wet clothes, because heat loss is five times greater when
clothing is wet. Assessing vital signs is important, but the wet clothes
should be removed first. Hydration is very important with hyperthermia
and the associated danger of dehydration, but there is not a similar risk
with hypothermia. A warm blanket over wet clothes would not be an
effective warming strategy.
The nurse admitting a patient to the emergency department on a very
hot summer day would suspect hyperthermia when the patient
demonstrates:
A) slow capillary refill.
B) red, sweaty skin.
C) low pulse rate.
D) decreased respirations.
B
With hyperthermia, vasodilatation occurs causing the skin to appear
flushed and warm or hot to touch. There is an increased respiration rate
with hyperthermia. The heart rate increases with hyperthermia. With
hypothermia there is slow capillary refill.
,Why does the nurse always ask the client his or her pain level after taking
routine vital signs?
A) To follow McCaffery's guidelines on pain management
B) To ensure that pain assessment occurs on a regular basis
C) To determine the need for more frequent vital sign measurement
D) To determine whether pain is influencing blood pressure and heart
rate
B
Making pain the fifth vital sign allows more frequent and accurate
assessment, which can contribute to better pain management.
The nurse observes skin tenting on the back of the older adult client's
hand. Which action by the nurse is most appropriate?
A) Examine dependent body areas.
B) Notify the physician.
C) Document the finding and continue to monitor.
D) Assess turgor on the client's forehead.
D
Skin turgor cannot be accurately assessed on an older adult client's
hands because of age-related loss of tissue elasticity in this area. Areas
that more accurately show skin turgor status on an older client include
the skin of the forehead, chest, and abdomen. These should also be
assessed, rather than merely examining dependent body areas. Further
assessment is needed rather than only documenting, monitoring, and
notifying the physician.
, The nurse is assessing a client who has undergone a transurethral
resection of the prostate (TURP). Which assessment finding requires
immediate action by the nurse?
A) Having the urge to void continuously while the catheter is inserted
B) Passing small blood clots after catheter removal
C) Having bright red drainage with multiple blood clots
D) Experiencing urinary frequency after catheter removal
C
A client who undergoes a TURP is at risk for bleeding during the first 24
hours after surgery. Passage of small blood clots and tissue debris,
urinary frequency and leakage, and the urge to void continuously while
the client still has the catheter inserted are all considered to be
expected complications of the procedure. They will resolve as the client
continues to recover and the catheter is removed. However, the
presence of bright red blood with clots indicates arterial bleeding and
should be reported to the provider.
Which finding puts a client at greatest risk for wound infection?
A) Presence of a deep wound
B) Coexisting medical conditions
C) Immune compromised status
D) Severely reddened skin
C
A compromised immune system puts a client at greatest risk for infection.
Although all the other options might increase the client's susceptibility,
the one with the greatest potential impact is being immune
compromised.
