HESI MED SURG V1 & V2 FULL 2026 Update
500 Actual Exam Questions and Verified
Answers with detailed rationale
Table of Contents
Med Surg HESI V1 .................................................................................................................. 1
Med Surg HESI V2 ............................................................................................................ 47
Med Surg HESI V1
1. The nurse is caring for a patient with COPD and pneumonia who has an order for arterial
blood gases to be drawn. Which of the following is the minimum length of time the nurse
should plan to hold pressure on the puncture site?
A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes
Correct Answer: B. 5 minutes
Detailed Rationale: Following obtaining an arterial blood gas, the nurse should hold pressure on
the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is
an elastic vessel under higher pressure than veins, and significant blood loss or hematoma
formation could occur if the time is insufficient. This standard applies to all arterial punctures,
including the radial artery, which is the most common site for ABG collection. The nurse should
also monitor for signs of hematoma formation, including swelling, discoloration, and pain at the
puncture site. If the patient is on anticoagulant therapy, pressure should be held longer. Proper
technique ensures patient safety and prevents complications from the procedure.
2. The nurse notices clear nasal drainage in a patient newly admitted with facial trauma,
including a nasal fracture. The nurse should:
A. test the drainage for the presence of glucose.
B. suction the nose to maintain airway clearance.
C. document the findings and continue monitoring.
,D. apply a drip pad and reassure the patient this is normal.
Correct Answer: A. test the drainage for the presence of glucose.
Detailed Rationale: Clear nasal drainage in a patient with facial trauma suggests leakage of
cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which
would indicate the presence of CSF. CSF contains glucose, while normal nasal secretions do not.
The nurse should also observe for the halo sign, where a drop of fluid on gauze forms a clear
ring with a blood-tinged center. Suctioning the nose is contraindicated because it could
introduce bacteria into the CSF and cause meningitis. Documentation and reassurance are
important but do not address the potential serious complication of CSF leak.
3. When caring for a patient who is 3 hours postoperative laryngectomy, the nurse's highest
priority assessment would be:
A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart rate
Correct Answer: A. Airway patency
Detailed Rationale: Remember ABCs with prioritization. Airway patency is always the highest
priority and is essential for a patient undergoing surgery surrounding the upper respiratory
system. A laryngectomy involves removal of the larynx, and the patient will have a new airway
(stoma) that must remain patent. The nurse should assess for adequate air exchange, the
presence of secretions, and any signs of obstruction. While pain management, monitoring
drainage, and vital signs are important, airway takes precedence because inadequate
oxygenation can lead to rapid deterioration. The nurse should have suction equipment readily
available and ensure humidification of the airway.
4. When initially teaching a patient the supraglottic swallow following a radical neck
dissection, with which of the following foods should the nurse begin?
A. Cola
B. Applesauce
C. French fries
D. White grape juice
Correct Answer: A. Cola
Detailed Rationale: When learning the supraglottic swallow, it may be helpful to start with
carbonated beverages because the effervescence provides clues about the liquid's position.
Thin, watery fluids should be avoided because they are difficult to swallow and increase the risk
of aspiration. Nonpourable pureed foods, such as applesauce, would decrease the risk of
aspiration, but carbonated beverages are the better choice to start with. French fries are solid
foods that require more chewing and swallowing coordination, making them inappropriate for
,initial teaching. White grape juice is a thin liquid that poses an aspiration risk. The supraglottic
swallow technique helps protect the airway during swallowing.
5. The nurse is caring for a patient admitted to the hospital with pneumonia. Upon
assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow
sputum and a respiratory rate of 20. Which of the following nursing diagnoses is most
appropriate based upon this assessment?
A. Hyperthermia related to infectious illness
B. Ineffective thermoregulation related to chilling
C. Ineffective breathing pattern related to pneumonia
D. Ineffective airway clearance related to thick secretions
Correct Answer: A. Hyperthermia related to infectious illness
Detailed Rationale: Because the patient has spiked a temperature and has a diagnosis of
pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is
no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths per
minute. There is no evidence of ineffective airway clearance from the information given because
the patient is expectorating sputum. The nurse should monitor the temperature, administer
antipyretics as prescribed, and encourage fluid intake. Monitoring for signs of sepsis is also
important in patients with pneumonia and fever. The other diagnoses may be applicable but are
not supported by the current assessment data.
6. Which of the following physical assessment findings in a patient with pneumonia best
supports the nursing diagnosis of ineffective airway clearance?
A. Oxygen saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D. Basilar crackles
Correct Answer: D. Basilar crackles
Detailed Rationale: The presence of adventitious breath sounds indicates that there is
accumulation of secretions in the lower airways. This would be consistent with a nursing
diagnosis of ineffective airway clearance because the patient is retaining secretions. While
oxygen saturation of 85% indicates hypoxemia and respiratory rate of 28 indicates tachypnea,
these findings reflect impaired gas exchange and ineffective breathing pattern. The presence of
greenish sputum indicates infection but does not directly indicate ineffective airway clearance.
Basilar crackles are caused by fluid or secretions in the alveoli and small airways, confirming the
need for interventions such as coughing, deep breathing, and suctioning.
7. Which of the following clinical manifestations would the nurse expect to find during
assessment of a patient admitted with pneumococcal pneumonia?
, A. Hyperresonance on percussion
B. Fine crackles in all lobes on auscultation
C. Increased vocal fremitus on palpation
D. Vesicular breath sounds in all lobes
Correct Answer: C. Increased vocal fremitus on palpation
Detailed Rationale: A typical physical examination finding for a patient with pneumonia is
increased vocal fremitus on palpation. Consolidation of lung tissue due to infection transmits
sound more effectively, so the nurse feels increased vibration when the patient speaks.
Hyperresonance on percussion is associated with emphysema or pneumothorax. Fine crackles
may be present but are not specific to pneumococcal pneumonia. Vesicular breath sounds are
normal findings. The nurse should also expect dullness on percussion over consolidated areas
and bronchial breath sounds on auscultation. These findings help confirm the diagnosis and
guide nursing interventions.
8. A client with diabetes mellitus is experiencing polyphagia. Which outcome statement is the
priority for this client?
A. Fluid and electrolyte balance.
B. Prevention of water toxicity.
C. Reduced glucose in the urine.
D. Adequate cellular nourishment.
Correct Answer: D. Adequate cellular nourishment.
Detailed Rationale: Diabetes mellitus Type 1 is characterized by hyperglycemia that precipitates
glucosuria and polyuria (frequent urination), polydipsia (excessive thirst), and polyphagia
(excessive hunger). Polyphagia is a consequence of cellular malnourishment when insulin
deficiency prevents utilization of glucose into the cell for energy, so the outcome statement
should include stabilization of adequate cellular nutrition which is done by providing the insulin
supplement the client needs. Fluid and electrolyte balance and prevention of water toxicity are
important but not the priority for polyphagia. Reduced glucose in the urine is a goal but not the
direct outcome for polyphagia.
9. A client who was in a motor vehicle collision was admitted to the hospital and the right
knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the
client's medical record: "Potential for impairment of skin integrity related to immobility from
traction." Which nursing intervention is indicated based on this diagnosis statement?
A. Release the traction q4h to provide skin care.
B. Turn the client for back care while suspending traction.
C. Provide back and skin care while maintaining the traction.
D. Give back care after the client is released from traction.
Correct Answer: C. Provide back and skin care while maintaining the traction.
500 Actual Exam Questions and Verified
Answers with detailed rationale
Table of Contents
Med Surg HESI V1 .................................................................................................................. 1
Med Surg HESI V2 ............................................................................................................ 47
Med Surg HESI V1
1. The nurse is caring for a patient with COPD and pneumonia who has an order for arterial
blood gases to be drawn. Which of the following is the minimum length of time the nurse
should plan to hold pressure on the puncture site?
A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes
Correct Answer: B. 5 minutes
Detailed Rationale: Following obtaining an arterial blood gas, the nurse should hold pressure on
the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is
an elastic vessel under higher pressure than veins, and significant blood loss or hematoma
formation could occur if the time is insufficient. This standard applies to all arterial punctures,
including the radial artery, which is the most common site for ABG collection. The nurse should
also monitor for signs of hematoma formation, including swelling, discoloration, and pain at the
puncture site. If the patient is on anticoagulant therapy, pressure should be held longer. Proper
technique ensures patient safety and prevents complications from the procedure.
2. The nurse notices clear nasal drainage in a patient newly admitted with facial trauma,
including a nasal fracture. The nurse should:
A. test the drainage for the presence of glucose.
B. suction the nose to maintain airway clearance.
C. document the findings and continue monitoring.
,D. apply a drip pad and reassure the patient this is normal.
Correct Answer: A. test the drainage for the presence of glucose.
Detailed Rationale: Clear nasal drainage in a patient with facial trauma suggests leakage of
cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which
would indicate the presence of CSF. CSF contains glucose, while normal nasal secretions do not.
The nurse should also observe for the halo sign, where a drop of fluid on gauze forms a clear
ring with a blood-tinged center. Suctioning the nose is contraindicated because it could
introduce bacteria into the CSF and cause meningitis. Documentation and reassurance are
important but do not address the potential serious complication of CSF leak.
3. When caring for a patient who is 3 hours postoperative laryngectomy, the nurse's highest
priority assessment would be:
A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart rate
Correct Answer: A. Airway patency
Detailed Rationale: Remember ABCs with prioritization. Airway patency is always the highest
priority and is essential for a patient undergoing surgery surrounding the upper respiratory
system. A laryngectomy involves removal of the larynx, and the patient will have a new airway
(stoma) that must remain patent. The nurse should assess for adequate air exchange, the
presence of secretions, and any signs of obstruction. While pain management, monitoring
drainage, and vital signs are important, airway takes precedence because inadequate
oxygenation can lead to rapid deterioration. The nurse should have suction equipment readily
available and ensure humidification of the airway.
4. When initially teaching a patient the supraglottic swallow following a radical neck
dissection, with which of the following foods should the nurse begin?
A. Cola
B. Applesauce
C. French fries
D. White grape juice
Correct Answer: A. Cola
Detailed Rationale: When learning the supraglottic swallow, it may be helpful to start with
carbonated beverages because the effervescence provides clues about the liquid's position.
Thin, watery fluids should be avoided because they are difficult to swallow and increase the risk
of aspiration. Nonpourable pureed foods, such as applesauce, would decrease the risk of
aspiration, but carbonated beverages are the better choice to start with. French fries are solid
foods that require more chewing and swallowing coordination, making them inappropriate for
,initial teaching. White grape juice is a thin liquid that poses an aspiration risk. The supraglottic
swallow technique helps protect the airway during swallowing.
5. The nurse is caring for a patient admitted to the hospital with pneumonia. Upon
assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow
sputum and a respiratory rate of 20. Which of the following nursing diagnoses is most
appropriate based upon this assessment?
A. Hyperthermia related to infectious illness
B. Ineffective thermoregulation related to chilling
C. Ineffective breathing pattern related to pneumonia
D. Ineffective airway clearance related to thick secretions
Correct Answer: A. Hyperthermia related to infectious illness
Detailed Rationale: Because the patient has spiked a temperature and has a diagnosis of
pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is
no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths per
minute. There is no evidence of ineffective airway clearance from the information given because
the patient is expectorating sputum. The nurse should monitor the temperature, administer
antipyretics as prescribed, and encourage fluid intake. Monitoring for signs of sepsis is also
important in patients with pneumonia and fever. The other diagnoses may be applicable but are
not supported by the current assessment data.
6. Which of the following physical assessment findings in a patient with pneumonia best
supports the nursing diagnosis of ineffective airway clearance?
A. Oxygen saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D. Basilar crackles
Correct Answer: D. Basilar crackles
Detailed Rationale: The presence of adventitious breath sounds indicates that there is
accumulation of secretions in the lower airways. This would be consistent with a nursing
diagnosis of ineffective airway clearance because the patient is retaining secretions. While
oxygen saturation of 85% indicates hypoxemia and respiratory rate of 28 indicates tachypnea,
these findings reflect impaired gas exchange and ineffective breathing pattern. The presence of
greenish sputum indicates infection but does not directly indicate ineffective airway clearance.
Basilar crackles are caused by fluid or secretions in the alveoli and small airways, confirming the
need for interventions such as coughing, deep breathing, and suctioning.
7. Which of the following clinical manifestations would the nurse expect to find during
assessment of a patient admitted with pneumococcal pneumonia?
, A. Hyperresonance on percussion
B. Fine crackles in all lobes on auscultation
C. Increased vocal fremitus on palpation
D. Vesicular breath sounds in all lobes
Correct Answer: C. Increased vocal fremitus on palpation
Detailed Rationale: A typical physical examination finding for a patient with pneumonia is
increased vocal fremitus on palpation. Consolidation of lung tissue due to infection transmits
sound more effectively, so the nurse feels increased vibration when the patient speaks.
Hyperresonance on percussion is associated with emphysema or pneumothorax. Fine crackles
may be present but are not specific to pneumococcal pneumonia. Vesicular breath sounds are
normal findings. The nurse should also expect dullness on percussion over consolidated areas
and bronchial breath sounds on auscultation. These findings help confirm the diagnosis and
guide nursing interventions.
8. A client with diabetes mellitus is experiencing polyphagia. Which outcome statement is the
priority for this client?
A. Fluid and electrolyte balance.
B. Prevention of water toxicity.
C. Reduced glucose in the urine.
D. Adequate cellular nourishment.
Correct Answer: D. Adequate cellular nourishment.
Detailed Rationale: Diabetes mellitus Type 1 is characterized by hyperglycemia that precipitates
glucosuria and polyuria (frequent urination), polydipsia (excessive thirst), and polyphagia
(excessive hunger). Polyphagia is a consequence of cellular malnourishment when insulin
deficiency prevents utilization of glucose into the cell for energy, so the outcome statement
should include stabilization of adequate cellular nutrition which is done by providing the insulin
supplement the client needs. Fluid and electrolyte balance and prevention of water toxicity are
important but not the priority for polyphagia. Reduced glucose in the urine is a goal but not the
direct outcome for polyphagia.
9. A client who was in a motor vehicle collision was admitted to the hospital and the right
knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the
client's medical record: "Potential for impairment of skin integrity related to immobility from
traction." Which nursing intervention is indicated based on this diagnosis statement?
A. Release the traction q4h to provide skin care.
B. Turn the client for back care while suspending traction.
C. Provide back and skin care while maintaining the traction.
D. Give back care after the client is released from traction.
Correct Answer: C. Provide back and skin care while maintaining the traction.
