HESI PN MEDICAL SURGICAL NURSING EXAM LATEST 2025 WITH COMPLETE
QUESTIONS AND CORRECT DESCRIPTIVE ANSWERS WITH EXPLANATIONS
(CONFIRMED ANSWERS) ALREADY GRADED A+
1. The nurse admitting a patient to the emergency department on a very hot summer day would suspect
hyperthermia when the patient demonstrates:
A) slow capillary refill.
B) red, sweaty skin.
C) low pulse rate.
D) decreased respirations.
B
2. With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch.
There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With
hypothermia there is slow capillary refill.
Why does the nurse always ask the client his or her pain level after taking routine vital signs?
A) To follow McCaffery's guidelines on pain management
B) To ensure that pain assessment occurs on a regular basis
C) To determine the need for more frequent vital sign measurement
D) To determine whether pain is influencing blood pressure and heart rate
B
Making pain the fifth vital sign allows more frequent and accurate assessment, which can contribute to
better pain management.
3. The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse
is most appropriate?
A) Examine dependent body areas.
B) Notify the physician.
C) Document the finding and continue to monitor.
D) Assess turgor on the client's forehead.
D
Skin turgor cannot be accurately assessed on an older adult client's hands because of age-related loss of
tissue elasticity in this area. Areas that more accurately show skin turgor status on an older client include
the skin of the forehead, chest, and abdomen. These should also be assessed, rather than merely
,examining dependent body areas. Further assessment is needed rather than only documenting, monitoring,
and notifying the physician.
4. Which action demonstrates that the nurse understands the purpose of the Rapid Response Team?
A) Documenting all changes observed in the client and maintaining a postoperative flow sheet
B) Monitoring the client for changes in postoperative status such as wound infection
C) Notifying the physician of the client's change in blood pressure from 140 to 88 mm Hg systolic
D) Notifying the physician of the client's increase in restlessness after medication change
C
The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to clients
before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code Team, which
responds to client arrests, it intervenes rapidly for those who are beginning to decline clinically. It would
be appropriate for the RRT to intervene when the client has experienced a 52-point drop in blood
pressure. Monitoring the client's postoperative status, maintaining a postoperative flow sheet, and
notifying the physician of a change in the client's status after a medication change would not be
considered activities of the Rapid Response Team.
5. An older client just returned from surgery and is rating pain as "8" on a 0 to 10 scale. Which
medications are unsafe choices for treatment of severe pain in this older adult? (Select all that apply.)
A) Morphine (Durmorph)
B) Meperidine (Demerol)
C) Propoxyphene (Darvocet)
D) Methadone (Dolophine)
E) Codeine
B, C, D, E
Meperidine, propoxyphene, and codeine are not recommended for older clients because toxic metabolites
may accumulate. Codeine may cause constipation as well. Methadone has an extremely long half-life (24
to 36 hours) and has a high potential for sedation and respiratory depression. Morphine is considered the
gold standard and may be used in the older adult while monitoring for sedation and respiratory depression
is conducted.
6. An emergency department (ED) nurse gives report on a client who is being transferred to the medical-
surgical floor. Because of an identified risk for suicide, the ED nurse suggests that the floor nurse contact
a sitter and behavioral health. This statement represents which part of the SBAR hand-off?
A) Situation
B) Recommendation
C) Background
D) Assessment
B
The ED nurse is giving recommendations to the medical-surgical floor nurse about interventions to start
,for the client who is being transferred. No communication is provided in the SBAR report about the
situation, background, or assessment.
7. Understanding classifications of pain helps nurses develop a plan of care. A 62-year-old male has fallen
while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing
back. This is characteristic of:
A) mixed pain syndrome.
B) chronic pain.
C) neuropathic pain.
D) nociceptive pain.
D
Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of
noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or
throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the
nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this
type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain
associated with cancer. Mixed pain syndrome is not easily recognized, is unique with multiple underlying
and poorly understood mechanisms like fibromyalgia and low back pain.
8. The new nurse is caring for a client with a high temperature. Which action should the nurse perform
FIRST?
A) Obtaining a fan from central supply for the client's room
B) Monitoring the client's temperature more often than ordered
C) Sponging the client while monitoring for shivering
D) Apply cool packs to the client's axillae and groin
D
The use of fans is discouraged to promote cooling in a febrile client because the fan can disperse
pathogens. The other actions are appropriate.
9. A patient has been newly diagnosed with hypertension. The nurse assesses the need to develop a
collaborative plan of care that includes a goal of adhering to the prescribed regimen. When the nurse is
planning teaching for the patient, which is the most important initial learning goal?
A) The patient will demonstrate coping skills needed to manage hypertension.
B) The patient will verbalize the side effects of treatment.
C) The patient will select the type of learning materials they prefer.
D) The patient will verbalize an understanding of the importance of following the regimen.
C
Adults learn best when given information they can understand that is tailored to their learning styles and
needs. Verbalizing an understanding is important; however, the nurse will first need to teach the patient.
, 10. When reviewing the purposes of a family assessment, the nurse educator would identify a need for
further teaching if the student responded that family assessment is used to gain an understanding of the
family.
A) development.
B) function.
C) structure.
D) political views.
D
An understanding of the political views of family members is not a primary purpose of a family
assessment. A family assessment provides the nurse with information and an understanding of family
dynamics. This is important to nurses for the provision of quality health care. A family assessment
provides an understanding of family development, function, and structure.
11. The client was given 15 mg of morphine IM for postsurgical pain. When the nurse checks the client
for pain relief 1 hour later, the client is sleeping and has a respiratory rate of 10 breaths/min. What is the
nurse’s first action?
A) Administering oxygen by nasal cannula
B) Documenting the findings and continuing to monitor
C) Arousing the client by calling his or her name
D) Administering naloxone (Narcan) IV push
C
Many clients experience some degree of respiratory depression with opioid analgesics. If the client can be
aroused with minimally intrusive techniques and the rate of respiration is increased spontaneously, no
further intervention is required.
12. The physician orders Lanoxin(digoxin)0.375 mg po every day. On hand you have 0.25mg/5 Ml. How
many Ml would you give your patient?
A) 8 Ml
B) 7.5 Ml
C) 7 mL
D) 5.5 mL
B
13. The nurse is admitting an older adult with decompensated congestive heart failure. The nursing
assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which
doctor’s order?
A) KCl 20 mEq PO two times per day
B) Intravenous (IV) 500 Ml of 0.9% NaCl at 125 Ml/hr.
C) Oxygen via face mask at 8 L/min
D) Furosemide (Lasix) 20 mg PO now
QUESTIONS AND CORRECT DESCRIPTIVE ANSWERS WITH EXPLANATIONS
(CONFIRMED ANSWERS) ALREADY GRADED A+
1. The nurse admitting a patient to the emergency department on a very hot summer day would suspect
hyperthermia when the patient demonstrates:
A) slow capillary refill.
B) red, sweaty skin.
C) low pulse rate.
D) decreased respirations.
B
2. With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch.
There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With
hypothermia there is slow capillary refill.
Why does the nurse always ask the client his or her pain level after taking routine vital signs?
A) To follow McCaffery's guidelines on pain management
B) To ensure that pain assessment occurs on a regular basis
C) To determine the need for more frequent vital sign measurement
D) To determine whether pain is influencing blood pressure and heart rate
B
Making pain the fifth vital sign allows more frequent and accurate assessment, which can contribute to
better pain management.
3. The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse
is most appropriate?
A) Examine dependent body areas.
B) Notify the physician.
C) Document the finding and continue to monitor.
D) Assess turgor on the client's forehead.
D
Skin turgor cannot be accurately assessed on an older adult client's hands because of age-related loss of
tissue elasticity in this area. Areas that more accurately show skin turgor status on an older client include
the skin of the forehead, chest, and abdomen. These should also be assessed, rather than merely
,examining dependent body areas. Further assessment is needed rather than only documenting, monitoring,
and notifying the physician.
4. Which action demonstrates that the nurse understands the purpose of the Rapid Response Team?
A) Documenting all changes observed in the client and maintaining a postoperative flow sheet
B) Monitoring the client for changes in postoperative status such as wound infection
C) Notifying the physician of the client's change in blood pressure from 140 to 88 mm Hg systolic
D) Notifying the physician of the client's increase in restlessness after medication change
C
The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to clients
before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code Team, which
responds to client arrests, it intervenes rapidly for those who are beginning to decline clinically. It would
be appropriate for the RRT to intervene when the client has experienced a 52-point drop in blood
pressure. Monitoring the client's postoperative status, maintaining a postoperative flow sheet, and
notifying the physician of a change in the client's status after a medication change would not be
considered activities of the Rapid Response Team.
5. An older client just returned from surgery and is rating pain as "8" on a 0 to 10 scale. Which
medications are unsafe choices for treatment of severe pain in this older adult? (Select all that apply.)
A) Morphine (Durmorph)
B) Meperidine (Demerol)
C) Propoxyphene (Darvocet)
D) Methadone (Dolophine)
E) Codeine
B, C, D, E
Meperidine, propoxyphene, and codeine are not recommended for older clients because toxic metabolites
may accumulate. Codeine may cause constipation as well. Methadone has an extremely long half-life (24
to 36 hours) and has a high potential for sedation and respiratory depression. Morphine is considered the
gold standard and may be used in the older adult while monitoring for sedation and respiratory depression
is conducted.
6. An emergency department (ED) nurse gives report on a client who is being transferred to the medical-
surgical floor. Because of an identified risk for suicide, the ED nurse suggests that the floor nurse contact
a sitter and behavioral health. This statement represents which part of the SBAR hand-off?
A) Situation
B) Recommendation
C) Background
D) Assessment
B
The ED nurse is giving recommendations to the medical-surgical floor nurse about interventions to start
,for the client who is being transferred. No communication is provided in the SBAR report about the
situation, background, or assessment.
7. Understanding classifications of pain helps nurses develop a plan of care. A 62-year-old male has fallen
while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing
back. This is characteristic of:
A) mixed pain syndrome.
B) chronic pain.
C) neuropathic pain.
D) nociceptive pain.
D
Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of
noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or
throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the
nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this
type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain
associated with cancer. Mixed pain syndrome is not easily recognized, is unique with multiple underlying
and poorly understood mechanisms like fibromyalgia and low back pain.
8. The new nurse is caring for a client with a high temperature. Which action should the nurse perform
FIRST?
A) Obtaining a fan from central supply for the client's room
B) Monitoring the client's temperature more often than ordered
C) Sponging the client while monitoring for shivering
D) Apply cool packs to the client's axillae and groin
D
The use of fans is discouraged to promote cooling in a febrile client because the fan can disperse
pathogens. The other actions are appropriate.
9. A patient has been newly diagnosed with hypertension. The nurse assesses the need to develop a
collaborative plan of care that includes a goal of adhering to the prescribed regimen. When the nurse is
planning teaching for the patient, which is the most important initial learning goal?
A) The patient will demonstrate coping skills needed to manage hypertension.
B) The patient will verbalize the side effects of treatment.
C) The patient will select the type of learning materials they prefer.
D) The patient will verbalize an understanding of the importance of following the regimen.
C
Adults learn best when given information they can understand that is tailored to their learning styles and
needs. Verbalizing an understanding is important; however, the nurse will first need to teach the patient.
, 10. When reviewing the purposes of a family assessment, the nurse educator would identify a need for
further teaching if the student responded that family assessment is used to gain an understanding of the
family.
A) development.
B) function.
C) structure.
D) political views.
D
An understanding of the political views of family members is not a primary purpose of a family
assessment. A family assessment provides the nurse with information and an understanding of family
dynamics. This is important to nurses for the provision of quality health care. A family assessment
provides an understanding of family development, function, and structure.
11. The client was given 15 mg of morphine IM for postsurgical pain. When the nurse checks the client
for pain relief 1 hour later, the client is sleeping and has a respiratory rate of 10 breaths/min. What is the
nurse’s first action?
A) Administering oxygen by nasal cannula
B) Documenting the findings and continuing to monitor
C) Arousing the client by calling his or her name
D) Administering naloxone (Narcan) IV push
C
Many clients experience some degree of respiratory depression with opioid analgesics. If the client can be
aroused with minimally intrusive techniques and the rate of respiration is increased spontaneously, no
further intervention is required.
12. The physician orders Lanoxin(digoxin)0.375 mg po every day. On hand you have 0.25mg/5 Ml. How
many Ml would you give your patient?
A) 8 Ml
B) 7.5 Ml
C) 7 mL
D) 5.5 mL
B
13. The nurse is admitting an older adult with decompensated congestive heart failure. The nursing
assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which
doctor’s order?
A) KCl 20 mEq PO two times per day
B) Intravenous (IV) 500 Ml of 0.9% NaCl at 125 Ml/hr.
C) Oxygen via face mask at 8 L/min
D) Furosemide (Lasix) 20 mg PO now
