Medical Surgical Hesi Exam Questions and Correct Answers with
Rationale.
The nurse is preparing an adult client for an upper gastrointestinal (UGI) series. Which
information should the nurse include in the teaching plan?
The xray procedure may last for several hours.
A nasogastric tube (NGT) is inserted to instill the barium.
Enemas are given to empty the bowel after the procedure.
Nothing by mouth is allowed for 6 to 8 hours before the study. - Correct Answer Nothing
by mouth is allowed for 6 to 8 hours before the study
rationale: The client should be NPO, to include smoking or chewing gum for at least 6
hours before the UGI study.
A client with acute appendicitis is experiencing anxiety and loss of sleep about missing
final examination week at college. Which outcome is most important for the nurse to
include in the plan of care?
Sleeping six to eight hours.
Achieve a sense of control.
Utilize problem solving skills.
Increased focus of attention. - Correct Answer Achieve a sense of control
rationale:
The experience of psychological discomfort may be as real as physical pain for the
client and should be seen as a priority in care. Because the client is experiencing
anxiety, achieving a sense of control is the overall outcome of this client's nursing care
plan.
The nurse is caring for a client receiving tamoxifen (Nolvadex) for the treatment of
breast cancer. Which action should the nurse include in the client's plan of care?
Increase fluid intake.
Monitor sodium chloride intake.
Assist the client in coping with hot flashes.
,Encourage milk products to increase calcium intake. - Correct Answer Assist the client
in coping with hot flashes.
rationale: Tamoxifen, an estrogen receptor blocking agent, can cause hot flashes, so
client education regarding menopausal-like symptoms should be included in the plan of
care.
The nurse is preparing a teaching plan for a client with newly diagnosed glacoma and a
history of allergic rhinitis. Which information is most important for the nurse to provide
the client about using over-the-counter (OTC) medications for allergies?
Notify your healthcare provider if there is an increase in heart rate.
Increase fluid intake while taking an antihistamine or decongestant.
Avoid allergy medications that contain pseudoephedrine or phenylephrine.
Ophthalmic lubricating drops may be used for eye dryness due to allergy medications. -
Correct Answer Avoid allergy medications that contain pseudoephedrine or
phenylephrine.
rationale:
OTC allergy medications may contain ephedrine, phenylephrine, or pseudoephedrine,
which can cause adrenergic side effects, such as increased intraocular pressure, so a
client with glaucoma should avoid using these OTC medications.
The nurse is caring for a client who is two days postoperative. Which observation
should alert the nurse to call the Rapid Response Team (RRT)?
Fresh bleeding noted on abdominal surgical wound dressing.
Pulse change from 85 to160 beats/minute lasting more than 10 minutes.
Temperature of 103.1 F and white blood cell (WBC) count of 16,000 mm3.
Weakness, diaphoresis, complaints of feeling faint. BP 100/56 mm Hg. - Correct Answer
Pulse change from 85 to160 beats/minute lasting more than 10 minutes.
rationale:
The RRT should be called to intervene for a client with an acute life-threatening change,
such as a pulse change resulting in tachycardia for a prolonged time in a post-operative
client.
A client is admitted to the emergency department after being lost for four days while
hiking in a national forest. Upon review of the laboratory results, the nurse determines
,the client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which
additional assessment should the nurse make?
Body mass index.
Skin elasticity and turgor.
Thought processes and speech.
Exposure to cold environmental temperatures. - Correct Answer Exposure to cold
environment temperatures
rationale:
TSH influences the amount of thyroxine secretion which increases the rate of
metabolism to maintain body temperature near normal. Prolonged exposure to cold
environmental temperatures stimulates the hypothalamus to secrete thyrotropin-
releasing hormone, which increases anterior pituitary serum release of TSH.
A 48-year-old client with endometrial cancer is being discharged after a total
hysterectomy and bilateral salpingo-oophorectomy. Which client statement indicates
that further teaching is needed?
"Well, I don't have to worry about getting pregnant anymore."
"I can't wait to go on the cruise that I have planned for this summer."
"I know I will miss having sexual intercourse with my husband."
"I have asked my daughter to stay with me next week after I am discharged." - Correct
Answer "I know I will miss having sexual intercourse with my husband."
rationale:
Further teaching is needed in response to the client's misunderstanding of not being
able to have sexual intercourse after a hysterectomy, needs to be addressed.
The nurse is providing discharge instructions to a client who has undergone a left
orchiectomy for testicular cancer. Which statement indicates that the client understands
his post-operative care and prognosis?
"I should continue to perform testicular self-examination (TSE) monthly on my remaining
testicle."
"I should wear an athletic supporter and cup to prevent testicular cancer in my
remaining testicle."
, "I should always use a condom because I am at increased risk for acquiring a sexually
transmitted disease."
"I should make sure my sons know how to perform TSE because they are at increased
risk for this type of cancer." - Correct Answer "I should continue to perform testicular
self-examination (TSE) monthly on my remaining testicle."
rationale:
Although testicular cancer protocols, such as surgery, radiation, or chemotherapy, focus
on the primary site of testicular cancer, these treatments do not reduce the risk of
testicular cancer in the remaining testicle, so early recognition is the best prevention.
The client's understanding is reflected in the statement to perform monthly TSE for
changes in size, shape, or consistency of the testis that may indicate early cancer.
The nurse is completing the health assessment of a 79-year-old male client who denies
any significant health problems. Which finding requires the most immediate follow-up
assessment?
Kyphosis with a reduction in height.
Dilated superficial veins on both legs.
External hemorrhoids with itching.
Yellowish discoloration of the sclerae. - Correct Answer Yellowish discoloration of the
sclerae.
rationale: In a geriatric client, a yellowish discoloration (jaundice) of the sclerae is not a
normal finding and may indicate liver damage and requires further assessment.
When teaching a client with breast cancer about the prescribed radiation therapy for
treatment, what information is important to include?
Dry, itchy skin changes may occur.
There is a possibility of long bone pain.
Permanent pigment changes to the breast may result.
A low-residue diet may be ordered to reduce the likelihood of diarrhea. - Correct Answer
Dry, itchy skin changes may occur.
rationale:
Side effects from radiation to the breast most often include temporary skin changes
such as: dryness, tenderness, redness, swelling, and pruritis.
Rationale.
The nurse is preparing an adult client for an upper gastrointestinal (UGI) series. Which
information should the nurse include in the teaching plan?
The xray procedure may last for several hours.
A nasogastric tube (NGT) is inserted to instill the barium.
Enemas are given to empty the bowel after the procedure.
Nothing by mouth is allowed for 6 to 8 hours before the study. - Correct Answer Nothing
by mouth is allowed for 6 to 8 hours before the study
rationale: The client should be NPO, to include smoking or chewing gum for at least 6
hours before the UGI study.
A client with acute appendicitis is experiencing anxiety and loss of sleep about missing
final examination week at college. Which outcome is most important for the nurse to
include in the plan of care?
Sleeping six to eight hours.
Achieve a sense of control.
Utilize problem solving skills.
Increased focus of attention. - Correct Answer Achieve a sense of control
rationale:
The experience of psychological discomfort may be as real as physical pain for the
client and should be seen as a priority in care. Because the client is experiencing
anxiety, achieving a sense of control is the overall outcome of this client's nursing care
plan.
The nurse is caring for a client receiving tamoxifen (Nolvadex) for the treatment of
breast cancer. Which action should the nurse include in the client's plan of care?
Increase fluid intake.
Monitor sodium chloride intake.
Assist the client in coping with hot flashes.
,Encourage milk products to increase calcium intake. - Correct Answer Assist the client
in coping with hot flashes.
rationale: Tamoxifen, an estrogen receptor blocking agent, can cause hot flashes, so
client education regarding menopausal-like symptoms should be included in the plan of
care.
The nurse is preparing a teaching plan for a client with newly diagnosed glacoma and a
history of allergic rhinitis. Which information is most important for the nurse to provide
the client about using over-the-counter (OTC) medications for allergies?
Notify your healthcare provider if there is an increase in heart rate.
Increase fluid intake while taking an antihistamine or decongestant.
Avoid allergy medications that contain pseudoephedrine or phenylephrine.
Ophthalmic lubricating drops may be used for eye dryness due to allergy medications. -
Correct Answer Avoid allergy medications that contain pseudoephedrine or
phenylephrine.
rationale:
OTC allergy medications may contain ephedrine, phenylephrine, or pseudoephedrine,
which can cause adrenergic side effects, such as increased intraocular pressure, so a
client with glaucoma should avoid using these OTC medications.
The nurse is caring for a client who is two days postoperative. Which observation
should alert the nurse to call the Rapid Response Team (RRT)?
Fresh bleeding noted on abdominal surgical wound dressing.
Pulse change from 85 to160 beats/minute lasting more than 10 minutes.
Temperature of 103.1 F and white blood cell (WBC) count of 16,000 mm3.
Weakness, diaphoresis, complaints of feeling faint. BP 100/56 mm Hg. - Correct Answer
Pulse change from 85 to160 beats/minute lasting more than 10 minutes.
rationale:
The RRT should be called to intervene for a client with an acute life-threatening change,
such as a pulse change resulting in tachycardia for a prolonged time in a post-operative
client.
A client is admitted to the emergency department after being lost for four days while
hiking in a national forest. Upon review of the laboratory results, the nurse determines
,the client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which
additional assessment should the nurse make?
Body mass index.
Skin elasticity and turgor.
Thought processes and speech.
Exposure to cold environmental temperatures. - Correct Answer Exposure to cold
environment temperatures
rationale:
TSH influences the amount of thyroxine secretion which increases the rate of
metabolism to maintain body temperature near normal. Prolonged exposure to cold
environmental temperatures stimulates the hypothalamus to secrete thyrotropin-
releasing hormone, which increases anterior pituitary serum release of TSH.
A 48-year-old client with endometrial cancer is being discharged after a total
hysterectomy and bilateral salpingo-oophorectomy. Which client statement indicates
that further teaching is needed?
"Well, I don't have to worry about getting pregnant anymore."
"I can't wait to go on the cruise that I have planned for this summer."
"I know I will miss having sexual intercourse with my husband."
"I have asked my daughter to stay with me next week after I am discharged." - Correct
Answer "I know I will miss having sexual intercourse with my husband."
rationale:
Further teaching is needed in response to the client's misunderstanding of not being
able to have sexual intercourse after a hysterectomy, needs to be addressed.
The nurse is providing discharge instructions to a client who has undergone a left
orchiectomy for testicular cancer. Which statement indicates that the client understands
his post-operative care and prognosis?
"I should continue to perform testicular self-examination (TSE) monthly on my remaining
testicle."
"I should wear an athletic supporter and cup to prevent testicular cancer in my
remaining testicle."
, "I should always use a condom because I am at increased risk for acquiring a sexually
transmitted disease."
"I should make sure my sons know how to perform TSE because they are at increased
risk for this type of cancer." - Correct Answer "I should continue to perform testicular
self-examination (TSE) monthly on my remaining testicle."
rationale:
Although testicular cancer protocols, such as surgery, radiation, or chemotherapy, focus
on the primary site of testicular cancer, these treatments do not reduce the risk of
testicular cancer in the remaining testicle, so early recognition is the best prevention.
The client's understanding is reflected in the statement to perform monthly TSE for
changes in size, shape, or consistency of the testis that may indicate early cancer.
The nurse is completing the health assessment of a 79-year-old male client who denies
any significant health problems. Which finding requires the most immediate follow-up
assessment?
Kyphosis with a reduction in height.
Dilated superficial veins on both legs.
External hemorrhoids with itching.
Yellowish discoloration of the sclerae. - Correct Answer Yellowish discoloration of the
sclerae.
rationale: In a geriatric client, a yellowish discoloration (jaundice) of the sclerae is not a
normal finding and may indicate liver damage and requires further assessment.
When teaching a client with breast cancer about the prescribed radiation therapy for
treatment, what information is important to include?
Dry, itchy skin changes may occur.
There is a possibility of long bone pain.
Permanent pigment changes to the breast may result.
A low-residue diet may be ordered to reduce the likelihood of diarrhea. - Correct Answer
Dry, itchy skin changes may occur.
rationale:
Side effects from radiation to the breast most often include temporary skin changes
such as: dryness, tenderness, redness, swelling, and pruritis.
