• MED SURG HESI 09/11/2026
Exams
MED SURG HESI Exams 3 V1 And V2 - 2026/2027
Update Actual Exam Questions With Verified
Answers, 100% Guaranteed Pass || Complete A+
Guide
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.
P 1
, • MED SURG HESI 09/11/2026
Exams
D.
Auscultate for a pleural friction rub. - Correct Answer :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. - Correct Answer :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.
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.
P 2
, • MED SURG HESI 09/11/2026
Exams
D.
Encourage coughing and deep breathing. - Correct Answer :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. - Correct Answer :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.
Restore skin integrity.
B.
Prevent infection.
C.
P 3
, • MED SURG HESI 09/11/2026
Exams
Promote healing.
D.
Improve nutrition. - Correct Answer :B
Rationale:The prevention of infection is a priority goal for this client. Gangrene is the result of necrosis (tissue
death). If infection develops, there is insufficient circulation to fight the infection and the infection can result in
osteomyelitis or sepsis. Because tissue death has already occurred, options A and C are unattainable goals.
Option D is important but of less priority than option B.
The clinic nurse is teaching a client newly diagnosed with Raynaud's Syndrome. What instructions will the nurse
include in the client's teaching plan? (Select all that apply.)
A.
Place your hands in 130°F/54.4°C water until warmed through.
B.
Wear warm clothing and socks when you are cold.
C.
Use finger guards when using a knife to avoid cutting your hands.
D.
Take your medication only when you feel the tingling in your fingers.
E.
Avoid stressful situations at work and in your home life. - Correct Answer :B, C, E
Rationale:Water at 130°F/54.4°C can cause burns at 30 second exposure. Because of the numbness and tingling
the client may not be able to sense burning. Vasodilators are often prescribed for these clients, especially during
the cold months. The therapy needs to be continuous for the maximum effect. The remaining instructions will
benefit the client with Raynaud's.
During assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear
on auscultation, but jugular vein distention and muffled heart sounds are present. Which action should the nurse
take first?
A.
Prepare the client for a pericardial tap.
B.
P 4
Exams
MED SURG HESI Exams 3 V1 And V2 - 2026/2027
Update Actual Exam Questions With Verified
Answers, 100% Guaranteed Pass || Complete A+
Guide
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.
P 1
, • MED SURG HESI 09/11/2026
Exams
D.
Auscultate for a pleural friction rub. - Correct Answer :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. - Correct Answer :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.
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.
P 2
, • MED SURG HESI 09/11/2026
Exams
D.
Encourage coughing and deep breathing. - Correct Answer :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. - Correct Answer :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.
Restore skin integrity.
B.
Prevent infection.
C.
P 3
, • MED SURG HESI 09/11/2026
Exams
Promote healing.
D.
Improve nutrition. - Correct Answer :B
Rationale:The prevention of infection is a priority goal for this client. Gangrene is the result of necrosis (tissue
death). If infection develops, there is insufficient circulation to fight the infection and the infection can result in
osteomyelitis or sepsis. Because tissue death has already occurred, options A and C are unattainable goals.
Option D is important but of less priority than option B.
The clinic nurse is teaching a client newly diagnosed with Raynaud's Syndrome. What instructions will the nurse
include in the client's teaching plan? (Select all that apply.)
A.
Place your hands in 130°F/54.4°C water until warmed through.
B.
Wear warm clothing and socks when you are cold.
C.
Use finger guards when using a knife to avoid cutting your hands.
D.
Take your medication only when you feel the tingling in your fingers.
E.
Avoid stressful situations at work and in your home life. - Correct Answer :B, C, E
Rationale:Water at 130°F/54.4°C can cause burns at 30 second exposure. Because of the numbness and tingling
the client may not be able to sense burning. Vasodilators are often prescribed for these clients, especially during
the cold months. The therapy needs to be continuous for the maximum effect. The remaining instructions will
benefit the client with Raynaud's.
During assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear
on auscultation, but jugular vein distention and muffled heart sounds are present. Which action should the nurse
take first?
A.
Prepare the client for a pericardial tap.
B.
P 4
