HESI MED SURG Questions and
Answers(Version-2)(NEW-2020/2021,
Answers)(50 Q/A)
1. A client is scheduled for surgery in 2 hours. The nurse reviews the consent form and notices
the client signed it but the surgeon has not. What is the nurse's priority action?
A. Have the client sign a new consent form
B. Notify the surgeon to sign the consent form before surgery
C. Proceed with preoperative preparations as ordered
D. Ask the client if they understand the procedure
Correct Answer: B
Rationale: The consent form must be signed by the surgeon, the client, and the witness
before surgery. If the surgeon has not signed, the nurse must notify the surgeon immediately.
The nurse cannot proceed with surgery until the consent is complete. Option A is incorrect
because the client already signed. Option C is incorrect because surgery cannot proceed
without a complete consent. Option D is important but not the priority when the form is
incomplete.
2. A postoperative client reports sudden shortness of breath, chest pain, and has an oxygen
saturation of 86% on room air. What is the nurse's first action?
A. Administer prescribed pain medication
B. Raise the head of the bed and apply oxygen
C. Notify the surgeon immediately
D. Encourage the client to cough and deep breathe
Correct Answer: B
Rationale: These signs suggest a pulmonary embolism. The nurse's first action is to raise the
head of the bed to improve ventilation and apply oxygen to address hypoxemia. Option A is
incorrect because pain medication may mask symptoms and does not address the emergent
issue. Option C is important but should occur after immediate interventions. Option D is not
appropriate for suspected PE.
,3. Which of the following are risk factors for malignant hyperthermia during surgery? (SATA)
A. Family history of malignant hyperthermia
B. Use of succinylcholine
C. Use of volatile inhalation anesthetics
D. History of hypertension
E. Male gender
Correct Answers: A, B, C
Rationale: Malignant hyperthermia is a genetic disorder triggered by succinylcholine and
volatile inhalation anesthetics. A family history is a significant risk factor. Hypertension and male
gender are not risk factors for MH.
4. A nurse is caring for a client in the PACU. Which assessment finding requires immediate
intervention?
A. Blood pressure 110/70 mmHg
B. Respiratory rate of 8 breaths/min and shallow
C. Temperature 37.2°C (99°F)
D. Pain level of 4/10
Correct Answer: B
Rationale: A respiratory rate of 8 breaths/min with shallow breathing indicates respiratory
depression, likely from anesthesia or opioids. This requires immediate intervention. The other
findings are within normal limits or expected.
5. A client is 24 hours postoperative following abdominal surgery. The nurse notes the
dressing has a small amount of serosanguineous drainage. What is the appropriate nursing
action?
A. Notify the surgeon immediately
B. Mark the drainage and monitor for changes
C. Change the dressing every 2 hours
D. Apply pressure to the wound
Correct Answer: B
Rationale: Serosanguineous drainage is expected in small amounts 24 hours
postoperatively. The nurse should mark the drainage, note the time, and monitor for increases.
,Option A is unnecessary unless drainage is excessive. Option C is not indicated. Option D is not
appropriate for expected drainage.
6. Which instruction should the nurse include in discharge teaching for a client who had a
cataract extraction with lens implantation?
A. Sleep on the operative side
B. Avoid bending at the waist
C. Expect immediate clear vision
D. Resume driving within 24 hours
Correct Answer: B
Rationale: Bending at the waist increases intraocular pressure and should be avoided after
cataract surgery. Option A is incorrect; the client should sleep on the non-operative side. Option
C is incorrect because vision may be blurry initially. Option D is incorrect; driving is usually
restricted until cleared by the surgeon.
7. A client is scheduled for an appendectomy. The nurse notes the client's platelet count is
45,000/mm³. What is the priority nursing action?
A. Prepare the client for surgery as scheduled
B. Notify the surgeon of the lab value
C. Administer vitamin K as prescribed
D. Document the finding and continue monitoring
Correct Answer: B
Rationale: A platelet count of 45,000/mm³ is critically low and places the client at high risk
for bleeding during surgery. The surgeon must be notified. Option A is unsafe. Option C requires
a prescription. Option D delays necessary intervention.
8. A postoperative client has not voided 8 hours after surgery. The bladder is distended. What
is the nurse's first action?
A. Insert an indwelling urinary catheter
B. Assist the client to the bathroom or use a bedpan
C. Administer a diuretic as prescribed
D. Restrict oral fluids
, Correct Answer: B
Rationale: The first action is to assist the client to void naturally. If unsuccessful, further
interventions such as catheterization may be needed. Option A requires a prescription. Option C
is not appropriate. Option D is incorrect.
9. Which findings indicate the client is experiencing anaphylaxis during a blood transfusion?
(SATA)
A. Urticaria
B. Wheezing
C. Hypotension
D. Bradycardia
E. Fever
Correct Answers: A, B, C
Rationale: Anaphylaxis during transfusion presents with urticaria, wheezing, and
hypotension. Tachycardia (not bradycardia) is expected. Fever is more indicative of a febrile
reaction.
10. A nurse is teaching a client about using an incentive spirometer. Which statement
indicates understanding?
A. "I will use it once a day."
B. "I will inhale slowly and deeply to raise the piston."
C. "I will exhale forcefully into the device."
D. "I will lie flat while using it."
Correct Answer: B
Rationale: The incentive spirometer is used by inhaling slowly and deeply to raise the piston
and hold it. Option A is incorrect; it should be used 10 times per hour while awake. Option C is
incorrect; it is an inhalation device. Option D is incorrect; the client should be in a semi-Fowler's
or upright position.
11. A client is 6 hours postoperative from a total hip replacement. Which intervention is
priority?
Answers(Version-2)(NEW-2020/2021,
Answers)(50 Q/A)
1. A client is scheduled for surgery in 2 hours. The nurse reviews the consent form and notices
the client signed it but the surgeon has not. What is the nurse's priority action?
A. Have the client sign a new consent form
B. Notify the surgeon to sign the consent form before surgery
C. Proceed with preoperative preparations as ordered
D. Ask the client if they understand the procedure
Correct Answer: B
Rationale: The consent form must be signed by the surgeon, the client, and the witness
before surgery. If the surgeon has not signed, the nurse must notify the surgeon immediately.
The nurse cannot proceed with surgery until the consent is complete. Option A is incorrect
because the client already signed. Option C is incorrect because surgery cannot proceed
without a complete consent. Option D is important but not the priority when the form is
incomplete.
2. A postoperative client reports sudden shortness of breath, chest pain, and has an oxygen
saturation of 86% on room air. What is the nurse's first action?
A. Administer prescribed pain medication
B. Raise the head of the bed and apply oxygen
C. Notify the surgeon immediately
D. Encourage the client to cough and deep breathe
Correct Answer: B
Rationale: These signs suggest a pulmonary embolism. The nurse's first action is to raise the
head of the bed to improve ventilation and apply oxygen to address hypoxemia. Option A is
incorrect because pain medication may mask symptoms and does not address the emergent
issue. Option C is important but should occur after immediate interventions. Option D is not
appropriate for suspected PE.
,3. Which of the following are risk factors for malignant hyperthermia during surgery? (SATA)
A. Family history of malignant hyperthermia
B. Use of succinylcholine
C. Use of volatile inhalation anesthetics
D. History of hypertension
E. Male gender
Correct Answers: A, B, C
Rationale: Malignant hyperthermia is a genetic disorder triggered by succinylcholine and
volatile inhalation anesthetics. A family history is a significant risk factor. Hypertension and male
gender are not risk factors for MH.
4. A nurse is caring for a client in the PACU. Which assessment finding requires immediate
intervention?
A. Blood pressure 110/70 mmHg
B. Respiratory rate of 8 breaths/min and shallow
C. Temperature 37.2°C (99°F)
D. Pain level of 4/10
Correct Answer: B
Rationale: A respiratory rate of 8 breaths/min with shallow breathing indicates respiratory
depression, likely from anesthesia or opioids. This requires immediate intervention. The other
findings are within normal limits or expected.
5. A client is 24 hours postoperative following abdominal surgery. The nurse notes the
dressing has a small amount of serosanguineous drainage. What is the appropriate nursing
action?
A. Notify the surgeon immediately
B. Mark the drainage and monitor for changes
C. Change the dressing every 2 hours
D. Apply pressure to the wound
Correct Answer: B
Rationale: Serosanguineous drainage is expected in small amounts 24 hours
postoperatively. The nurse should mark the drainage, note the time, and monitor for increases.
,Option A is unnecessary unless drainage is excessive. Option C is not indicated. Option D is not
appropriate for expected drainage.
6. Which instruction should the nurse include in discharge teaching for a client who had a
cataract extraction with lens implantation?
A. Sleep on the operative side
B. Avoid bending at the waist
C. Expect immediate clear vision
D. Resume driving within 24 hours
Correct Answer: B
Rationale: Bending at the waist increases intraocular pressure and should be avoided after
cataract surgery. Option A is incorrect; the client should sleep on the non-operative side. Option
C is incorrect because vision may be blurry initially. Option D is incorrect; driving is usually
restricted until cleared by the surgeon.
7. A client is scheduled for an appendectomy. The nurse notes the client's platelet count is
45,000/mm³. What is the priority nursing action?
A. Prepare the client for surgery as scheduled
B. Notify the surgeon of the lab value
C. Administer vitamin K as prescribed
D. Document the finding and continue monitoring
Correct Answer: B
Rationale: A platelet count of 45,000/mm³ is critically low and places the client at high risk
for bleeding during surgery. The surgeon must be notified. Option A is unsafe. Option C requires
a prescription. Option D delays necessary intervention.
8. A postoperative client has not voided 8 hours after surgery. The bladder is distended. What
is the nurse's first action?
A. Insert an indwelling urinary catheter
B. Assist the client to the bathroom or use a bedpan
C. Administer a diuretic as prescribed
D. Restrict oral fluids
, Correct Answer: B
Rationale: The first action is to assist the client to void naturally. If unsuccessful, further
interventions such as catheterization may be needed. Option A requires a prescription. Option C
is not appropriate. Option D is incorrect.
9. Which findings indicate the client is experiencing anaphylaxis during a blood transfusion?
(SATA)
A. Urticaria
B. Wheezing
C. Hypotension
D. Bradycardia
E. Fever
Correct Answers: A, B, C
Rationale: Anaphylaxis during transfusion presents with urticaria, wheezing, and
hypotension. Tachycardia (not bradycardia) is expected. Fever is more indicative of a febrile
reaction.
10. A nurse is teaching a client about using an incentive spirometer. Which statement
indicates understanding?
A. "I will use it once a day."
B. "I will inhale slowly and deeply to raise the piston."
C. "I will exhale forcefully into the device."
D. "I will lie flat while using it."
Correct Answer: B
Rationale: The incentive spirometer is used by inhaling slowly and deeply to raise the piston
and hold it. Option A is incorrect; it should be used 10 times per hour while awake. Option C is
incorrect; it is an inhalation device. Option D is incorrect; the client should be in a semi-Fowler's
or upright position.
11. A client is 6 hours postoperative from a total hip replacement. Which intervention is
priority?
