NEWEST DETAILED ANSWERS
AND RATIONALES
MEDSURG HESI EXAM
ALREADY GRADED A+
1) A 48-year-old client with endometrial cancer is being discharged after a total hysterectomy and
bilateral sapling-oophorectomy. Which client statement indicates that further teaching is
needed?
A) Well, I don't have to worry about getting pregnant anymore.
B) I can't wait to go on the cruise that I have planned for this summer.
C) I know I will miss having sexual intercourse with my husband.
D) I have asked my daughter to stay with me next week after I am discharged.
ANSWER: C
Rationale: Further teaching is needed in response to the client's misunderstanding of sexuality after a
hysterectomy that is reflected in statement (C). The client's knowledge about reproduction (A), a positive
outlook with plans for the future (B), and her anticipated need for assistance and support during
recovery (D) indicate she understands the present status of her recovery.
2) A client with a fractured right radius reports severe, diffuse pain that has not responded to the
prescribed analgesics. The pain is greater with passive movement of the limb than with active
movement by the client. The nurse recognizes that the client is most likely exhibiting symptoms
of which condition?
A) Acute compartment syndrome.
B) Fat embolism syndrome.
C) Venous thromboembolism.
D) Aseptic ischemic necrosis.
ANSWER: A
Rationale: These signs are specific indications of Acute Compartment Syndrome (A), and should be
treated as an emergency situation. The signs do not indicate (B, C, or D).
3) A client who had abdominal surgery two days ago has prescriptions for intravenous morphine
sulfate 4 mg every 2 hours and a clear liquid diet. The client complains of feeling distended and
has sharp, cramping gas pains. What nursing intervention should be implemented?
A) Obtain a prescription for a laxative.
B) Withhold all oral fluid and food.
C) Assist the client to ambulate in the hall.
D) Administer the prescribed morphine sulfate.
,ANSWER: C
Rationale: Postoperative abdominal distention is caused by decreased peristalsis as a result of handling
the intestine during surgery, limited dietary intake before and after surgery, and anesthetic and analgesic
agents. Peristalsis is stimulated and distention minimized by implementing early and frequent
ambulation (C). Based on the client's status, laxatives (A) or withholding dietary progression (B) are not
indicated at this time. Although pain management should be implemented (D), another analgesic
prescription may be needed because morphine reduces intestinal motility and contributes to the client's
gas pains.
4) The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse
determines the client's lower abdomen is distended and assesses dullness to percussion. What is
the priority nursing action?
A) Assessment of the client's vital signs.
B) Document the finding as the only action.
C) Determine the time the client last voided.
D) Insert a rectal tube for the passage of flatus.
ANSWER: C
Rationale: Swelling at the surgical site in the immediate postoperative period can impact the bladder and
prostate area causing the client to experience difficulty voiding due to pressure on the urethra. To
provide additional data supporting bladder distention, the last time the client voided (C) should be
determined next. Documentation (B) should be made, but the client's distended bladder requires
additional intervention. (A and D) are not priority actions based on the client's abdominal findings.
5) A client who is receiving a whole blood transfusion develops chills, fever, and a headache 30
minutes after the transfusion is started. The nurse should recognize these symptoms as
characteristic of what reaction?
A) A mild allergic reaction.
B) A febrile transfusion reaction.
C) An anaphylactic transfusion reaction.
D) An acute hemolytic transfusion reaction.
ANSWER: B
Rationale: Symptoms of a febrile reaction (B) include sudden chills, fever, headache, flushing and muscle
pain. An allergic reaction (A) is the response of histamine release which is characterized by flushing,
itching, and urticaria. An anaphylactic reaction (C) exhibits an exaggerated allergic response that
progresses to shock and possible cardiac arrest. An acute hemolytic reaction (D) presents with fever and
chills, but is hallmarked by the onset of low back pain, tachycardia, tachypnea, vascular collapse,
hemoglobinuria, dark urine, acute renal failure, shock, cardiac arrest, and even death.
, 6) A client with a recent history of blood in his stools is scheduled for a proctosigmoidoscopy. The
nurse should implement which protocols to prepare the client for this procedure? (Select all that
apply.)
A) Obtain consent for the procedure.
B) Initiate preoperative sedation.
C) Begin fast the morning of the procedure.
D) Administer an enema before the procedure.
E) Provide a clear-liquid diet 48 hours before the procedure.
ANSWER: A, C, D, E
Rationale: The usual preoperative preparation for proctosigmoidoscopy entails obtaining the client's
consent to the procedure (A), a clear-liquid diet for 24 to 48 hours prior to the procedure (E),
administration of an enema (D), and fasting (C) on the morning of the procedure. Preoperative sedation
is not the norm for this procedure (B), although some healthcare providers administer a mild tranquilizer.
7) A client with osteoarthritis requests information from the nurse about what type of exercise
regimen would be most beneficial for him. The nurse should communicate which information?
A) Low impact exercise, walking, swimming and water aerobics.
B) Repetitive strength-building exercises with weights or resistance bands.
C) Circuit training alternating with frequent rest periods.
D) High-impact aerobic exercise.
ANSWER: A
Rationale: Low impact exercises such as walking or swimming (A), that do not cause further harm to
damaged joints, are most beneficial to clients with osteoarthritis. Strength-building exercises, circuit
training, and high-impact aerobics (B, C and D) may cause too much stress on the joint areas and
subsequently increase inflammation and damage.
8) The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH).
This condition is most often related to which predisposing condition?
A) Small cell lung cancer.
B) Active tuberculosis infection.
C) Hodgkin's lymphoma.
D) Tricyclic antidepressant therapy.
ANSWER: A
Cancer is the most common cause of the syndrome of inappropriate antidiuretic hormone (SIADH), with
small cell lung cancer (A) being the most common cancer that increases ADH, which causes dilutional
hyponatremia and fluid retention. (B, C, and D) are also possible causes, but secondary to CNS trauma or
disease.
AND RATIONALES
MEDSURG HESI EXAM
ALREADY GRADED A+
1) A 48-year-old client with endometrial cancer is being discharged after a total hysterectomy and
bilateral sapling-oophorectomy. Which client statement indicates that further teaching is
needed?
A) Well, I don't have to worry about getting pregnant anymore.
B) I can't wait to go on the cruise that I have planned for this summer.
C) I know I will miss having sexual intercourse with my husband.
D) I have asked my daughter to stay with me next week after I am discharged.
ANSWER: C
Rationale: Further teaching is needed in response to the client's misunderstanding of sexuality after a
hysterectomy that is reflected in statement (C). The client's knowledge about reproduction (A), a positive
outlook with plans for the future (B), and her anticipated need for assistance and support during
recovery (D) indicate she understands the present status of her recovery.
2) A client with a fractured right radius reports severe, diffuse pain that has not responded to the
prescribed analgesics. The pain is greater with passive movement of the limb than with active
movement by the client. The nurse recognizes that the client is most likely exhibiting symptoms
of which condition?
A) Acute compartment syndrome.
B) Fat embolism syndrome.
C) Venous thromboembolism.
D) Aseptic ischemic necrosis.
ANSWER: A
Rationale: These signs are specific indications of Acute Compartment Syndrome (A), and should be
treated as an emergency situation. The signs do not indicate (B, C, or D).
3) A client who had abdominal surgery two days ago has prescriptions for intravenous morphine
sulfate 4 mg every 2 hours and a clear liquid diet. The client complains of feeling distended and
has sharp, cramping gas pains. What nursing intervention should be implemented?
A) Obtain a prescription for a laxative.
B) Withhold all oral fluid and food.
C) Assist the client to ambulate in the hall.
D) Administer the prescribed morphine sulfate.
,ANSWER: C
Rationale: Postoperative abdominal distention is caused by decreased peristalsis as a result of handling
the intestine during surgery, limited dietary intake before and after surgery, and anesthetic and analgesic
agents. Peristalsis is stimulated and distention minimized by implementing early and frequent
ambulation (C). Based on the client's status, laxatives (A) or withholding dietary progression (B) are not
indicated at this time. Although pain management should be implemented (D), another analgesic
prescription may be needed because morphine reduces intestinal motility and contributes to the client's
gas pains.
4) The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse
determines the client's lower abdomen is distended and assesses dullness to percussion. What is
the priority nursing action?
A) Assessment of the client's vital signs.
B) Document the finding as the only action.
C) Determine the time the client last voided.
D) Insert a rectal tube for the passage of flatus.
ANSWER: C
Rationale: Swelling at the surgical site in the immediate postoperative period can impact the bladder and
prostate area causing the client to experience difficulty voiding due to pressure on the urethra. To
provide additional data supporting bladder distention, the last time the client voided (C) should be
determined next. Documentation (B) should be made, but the client's distended bladder requires
additional intervention. (A and D) are not priority actions based on the client's abdominal findings.
5) A client who is receiving a whole blood transfusion develops chills, fever, and a headache 30
minutes after the transfusion is started. The nurse should recognize these symptoms as
characteristic of what reaction?
A) A mild allergic reaction.
B) A febrile transfusion reaction.
C) An anaphylactic transfusion reaction.
D) An acute hemolytic transfusion reaction.
ANSWER: B
Rationale: Symptoms of a febrile reaction (B) include sudden chills, fever, headache, flushing and muscle
pain. An allergic reaction (A) is the response of histamine release which is characterized by flushing,
itching, and urticaria. An anaphylactic reaction (C) exhibits an exaggerated allergic response that
progresses to shock and possible cardiac arrest. An acute hemolytic reaction (D) presents with fever and
chills, but is hallmarked by the onset of low back pain, tachycardia, tachypnea, vascular collapse,
hemoglobinuria, dark urine, acute renal failure, shock, cardiac arrest, and even death.
, 6) A client with a recent history of blood in his stools is scheduled for a proctosigmoidoscopy. The
nurse should implement which protocols to prepare the client for this procedure? (Select all that
apply.)
A) Obtain consent for the procedure.
B) Initiate preoperative sedation.
C) Begin fast the morning of the procedure.
D) Administer an enema before the procedure.
E) Provide a clear-liquid diet 48 hours before the procedure.
ANSWER: A, C, D, E
Rationale: The usual preoperative preparation for proctosigmoidoscopy entails obtaining the client's
consent to the procedure (A), a clear-liquid diet for 24 to 48 hours prior to the procedure (E),
administration of an enema (D), and fasting (C) on the morning of the procedure. Preoperative sedation
is not the norm for this procedure (B), although some healthcare providers administer a mild tranquilizer.
7) A client with osteoarthritis requests information from the nurse about what type of exercise
regimen would be most beneficial for him. The nurse should communicate which information?
A) Low impact exercise, walking, swimming and water aerobics.
B) Repetitive strength-building exercises with weights or resistance bands.
C) Circuit training alternating with frequent rest periods.
D) High-impact aerobic exercise.
ANSWER: A
Rationale: Low impact exercises such as walking or swimming (A), that do not cause further harm to
damaged joints, are most beneficial to clients with osteoarthritis. Strength-building exercises, circuit
training, and high-impact aerobics (B, C and D) may cause too much stress on the joint areas and
subsequently increase inflammation and damage.
8) The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH).
This condition is most often related to which predisposing condition?
A) Small cell lung cancer.
B) Active tuberculosis infection.
C) Hodgkin's lymphoma.
D) Tricyclic antidepressant therapy.
ANSWER: A
Cancer is the most common cause of the syndrome of inappropriate antidiuretic hormone (SIADH), with
small cell lung cancer (A) being the most common cancer that increases ADH, which causes dilutional
hyponatremia and fluid retention. (B, C, and D) are also possible causes, but secondary to CNS trauma or
disease.
