HESI - Medical Surgical Nursing
Questions And Answers
Aoclientoasksotheonurseowhyoitoisoimportantotoobeoweighedoeveryodayoifoheohasoright-
sidedoheartofailure.oWhatoisotheonurse'sobestoresponse?
A)o"Theohospitalorequiresothatoalloinpatientsobeoweighedodaily."
B)o"Weightoisotheobestoindicationothatoyouoareogainingoorolosingofluid."
C)o"Youoneedotooloseoweightotoodecreaseotheoincidenceoofoheartofailure."
D)o"Dailyoweightsowillohelpousomakeosureothatoyou'reoeatingoproperly."o-
oCORRECTooANSWER-B
Dailyoweightsoareoneededotoodocumentofluidoretentionoorofluidoloss.oOneoliteroofofluidoequal
so2.2opounds.
Aoclientohasoaodeepowoundocoveredowithoaowet-to-
dampodressing.oWhichointerventionodoesotheonurseoincludeoonothisoclient'socareoplan?
A)oApplyoaonewodressingowhenotheosealobreaksoandotheodressingoleaks.
B)oChangeotheodressingowhenotheocurrentodressingoisosaturated.
C)oLeaveotheodressingointactountilonextoweek.
D)oChangeotheodressingoeveryo6ohoursoaroundotheoclock.o-oCORRECTooANSWER-D
Wet-to-
dampodressingsoareochangedoeveryo4otoo6ohoursotooprovideomaximumodébridement.oSynt
heticodressingsocanobeoleftoinoplaceoforoextendedoperiodsoofotimeobutoneedotoobeochanged
oifotheosealobreaksoandotheoexudateoisoleaking.oDryogauzeodressingsoshouldobeochangedo
whenotheoouterolayerobecomesosaturated.
Aoclientohasoaosmall-
boreonasoentericofeedingotube.oTheonurseoassessesotheofollowingovitalosigns:otemperatur
e,o100.2°oFo(37.8°oC);opulse,o112obeats/min;orespiratoryorate,o22obreaths/min;oandobloodo
pressure,o106/62ommoHg.oWhichoactionobyotheonurseotakesopriority?
A)oAuscultateobowelosoundsoandoslowotheofeedingodown.
B)oRemoveotheotubeoimmediatelyoandonotifyotheoheathocareoprovider.
C)oAuscultateolungosoundsoandoobtainooxygenosaturation.
D)oAddoblueodyeotootheofeedingotubeoformula.o-oCORRECTooANSWER-C
Theoclientomayohaveoaspirated.oTheonurseoshouldofurtheroassessotheoclient'sorespiratoryoa
ndooxygenationostatus.oTheoclientomayohaveoanotheroreasonoforotheoabnormalovitalosigns,
,osootheonurseoshouldonotopullooutotheotubeobeforeoperformingootheroassessments.oAddingo
blueodyeotootheotubeofeedingoformulaoisonotorecommendedotoocheckoforoaspiration.oSlowin
gotheofeedingodownowillonotobeohelpful.
Aoclientohasoaourinaryotractoinfection.oWhichoassessmentobyotheonurseoisomostohelpful?
A)oPalpatingoandopercussingotheokidneysoandobladder
B)oPerformingoaobladderoscanotooassessopost-voidoresidual
C)oAssessingomedicalohistoryoandocurrentomedicaloproblems
D)oInquiringoaboutorecentotravelotooforeignocountrieso-oCORRECTooANSWER-C
Clientsowhooareoseverelyoimmuneocompromisedoorowhoohaveodiabetesomellitusoareomore
oproneotoofungalourinaryotractoinfection.oTheonurseoshouldoassessoforotheseofactors.oAophy
sicaloexaminationoandoaopost-
voidoresidualomayobeoneeded,obutonotountilofurtheroinformationoisoobtained.oTravelotooforei
gnocountriesoprobablyowouldonotobeoasoimportant,obecauseoevenoifoexposed,otheoclientone
edsosomeodegreeoofoimmuneocompromiseotoodevelopoaofungalourinaryotractoinfection.
Aoclientohasoaowoundoonohisoleftotrochanterothatoiso4oinchesoinodiameter,owithoblackotissueo
atotheoperimeter,oandoboneoisoexposed.oWhichoisotheonurse'sobestoaction?
A)oDocumentoasoaostageoIopressureoulceroandoapplyoaotransparentodressing.
B)oDocumentoasoaostageoIIopressureoulceroandostartowet-to-dryogauzeotreatments.
C)oDocumentoasoaostageoIVopressureoulceroandoprepareotheoclientoforodébridement.
D)oDocumentoasoaostageoIIIopressureoulceroandostartoantibioticotherapy.o-
oCORRECTooANSWER-C
AostageoIVoulceroisooneoinowhichoskinolossoisofullothickness,owithoextensiveodestruction,otis
sueonecrosis,oand/orodamageotoomuscle,obone,oorosupportingostructures.oEscharomayobeo
present.oWhenotheoboneoofotheotrochanteroareaoisovisible,otissueolossoincludesomuscleolos
s.oAopotentialointerventionoconsistsoofodébridementoofotheonecroticotissueoandoaopossibleo
graftotoopromoteohealing.
Aoclientohasobeenoadmittedotootheointensiveocareounitowithoworseningopulmonaryomanifest
ationsoofoheartofailure.oWhatoisotheonurse'sobestoaction?
A)oAdministeroloopodiureticsoasoprescribed.
B)oBeginocardiopulmonaryoresuscitationo(CPR).
C)oPromoteorestoandominimizeoactivities.
D)oPlaceotheoclientoinoaohighoFowler'soposition.o-oCORRECTooANSWER-A
Theoclientowithoworseningoheartofailureoisomostoatoriskoforopulmonaryoedemaoasoaoconseq
uenceoofofluidoretention.oAdministeringodiureticsowillodecreaseotheofluidooverload,otherebyo
decreasingotheoincidenceoofopulmonaryoedema.oHighoFowler'sopositionomightohelpotheocli
entobreatheoeasierobutowillonotosolveotheoproblem.oCPRoisonotowarrantedoinothisosituation.o
Restoisoimportantoforoclientsowithoheartofailure,obutothisoisonototheopriority.
,Aoclientohasobeenotaughtotoorestrictodietaryosodium.oWhichofoodoselectionobyotheoclientoind
icatesotootheonurseothatoteachingohasobeenoeffective?
a.oaogrilledocheeseosandwichowithotomatoosoup
b.oChineseotake-out,oincludingosteamedorice
c.oaochickenoleg,ooneosliceoofobreadowithobutter,oandosteamedocarrots
d.oslicesoofohamoandocheeseoonowholeograinocrackerso-oCORRECTooANSWER-C
Clientsoonorestrictedosodiumodietsogenerallyoshouldoavoidoprocessed,osmoked,oandopickle
dofoodsoandothoseowithosaucesoandootherocondiments.oFoodsolowestoinosodiumoincludeofi
sh,opoultry,oandofreshoproduce.oTheochineseofoodolikelyowouldohaveosoyosauce,otheotomat
oosoupoisoprocessed,oandotheocrackersoareoaosnackofoodo-
oaocategoryoofofoodsooftenohighoinosodium.
Aoclientohasonewlyodiagnosedodiabetes.oToodelayotheoonsetoofomicrovascularoandomacrov
ascularocomplicationsoinothisoclient,otheonurseostressesothatotheoclientotakeowhichoaction?
A)oRestrictofluidointake.
B)oPreventoketosis.
C)oControlohyperglycemia.
D)oPreventohypoglycemia.o-oCORRECTooANSWER-C
Hyperglycemiaoisoaocriticalofactoroinotheopathogenesisoofolong-
termodiabeticocomplications.oMaintainingotightoglycemicocontrolowillohelpodelayotheoonseto
ofocomplications.oPreventingohypoglycemiaoandoketosis,oalthoughoimportant,oisonotoasoim
portantoasomaintainingodailyoglycemicocontrol.oRestrictingofluidointakeoisonotopartoofotheotre
atmentoplanoforoclientsowithodiabetes.
Aoclientohasorecentlyobeenoplacedoonoprednisoneo(Deltasone).oWhatoisotheohighestopriorit
yoinstructionotheonurseowilloprovide?
A)o"Takeotheodrugowithofoodooromilk."
B)o"Reportoanyoabdominalopainoorodark-coloredovomit."
C)o"Expectotooexperienceoweightogain."
D)o"Watchoyourodietowhileoonothisomedication."o-oCORRECTooANSWER-B
Alloofotheseodirectionsoareoappropriateotoogiveotheoclient;ohowever,otellingotheoclientotoorep
ortoabdominalopainoandodark-
coloredovomitoisomostoimportantobecauseotheseocouldosignalogastricoulceration.
Aoclientoisoadmittedowithoinfectionoandoaohighofever.oWhichoassessmentsobyotheonurseotak
eopriority?o(Selectoallothatoapply.)
A)oSkinoturgor
B)oPulseoquality
C)oBloodopressure
, D)oBowelosounds
E)oRespiratoryoeffort
F)oMentalostatuso-oCORRECTooANSWER-A,oB,oC,oF
Dehydrationocanoaccompanyofever,oespeciallyoifotheoclientoisosweatingoprofusely.oBloodop
ressure,opulseoquality,oandoskinoturgoroareoassessmentsoofofluidostatus.oMentalostatusoch
angesocanoaccompanyofluidolosses,oespeciallyoinoolderoclients.
Aoclientoisoadmittedowitholeftolowerolungopneumonia.oWhichoassessmentofindingodoesotheo
nurseocorrelateowithothisocondition?
A)oExpiratoryowheezeoonotheorightoside
B)oCracklesoheardoonoexpirationobilaterally
C)oDullnessotoopercussionoonotheoloweroleftoside
D)oCrepitusoofotheoskinoaroundotheoleftolungo-oCORRECTooANSWER-C
Theoclientowithopneumoniaomayohaveodullnessotoopercussionoonotheoaffectedoside.oTheoot
herooptionsoareoalloinconsistentowithopneumonia.
Aoclientoisobeingotreatedoforodehydration.oWhichostatementomadeobyotheoclientoindicatesou
nderstandingoofothisocondition?
a.oIowillouseoaosaltosubstituteowhenomakingoandoeatingomyomeals.
b.oIomustodrinkoaoquartoofowateroorootheroliquidoeachoday.
c.oIowillonotodrinkoliquidsoaftero6oPMosooIowon'tohaveotoogetoupoatonight.
d.oIowilloweighomyselfoeachomorningobeforeoIoeatoorodrink.o-oCORRECTooANSWER-D
Becauseo1oLoofowateroweighso1okg,ochangeoinobodyoweightoisoaogoodomeasureoofoexcesso
fluidolossoorofluidoretention.oWeightolossogreaterothano0.5olbodailyoisoindicativeoofoexcessiv
eofluidoloss.oTheootherostatementsoareonotoindicativeoofopracticesothatowillopreventodehydr
ation.
Aoclientoisohospitalizedowithoaourinaryotractoinfectiono(UTI).oWhichoclinicalomanifestationoal
ertsotheonurseotootheopossibilityoofoaocomplicationofromotheoUTI?
A)oHematuria
B)oFeveroandochills
C)oCloudy,odarkourine
D)oBurningoonourinationo-oCORRECTooANSWER-B
Lowerourinaryotractoinfectionsoareorarelyoassociatedowithosystemicosymptomsoofofeveroand
ochills.oAoclientowithoaoUTIowhoodevelopsofeveroandochillsoshouldobeoassessedoforotheodev
elopmentoofopyelonephritis.oTheootherooptionsocanobeoseenowithoUTI.
Aoclientoisoreceivingoaochemotherapeuticoagentointravenouslyothroughoaoperipheraloline.o
Whatoisotheonurse'sofirstoactionowhenotheoclientoreportsoburningoatotheosite?
Questions And Answers
Aoclientoasksotheonurseowhyoitoisoimportantotoobeoweighedoeveryodayoifoheohasoright-
sidedoheartofailure.oWhatoisotheonurse'sobestoresponse?
A)o"Theohospitalorequiresothatoalloinpatientsobeoweighedodaily."
B)o"Weightoisotheobestoindicationothatoyouoareogainingoorolosingofluid."
C)o"Youoneedotooloseoweightotoodecreaseotheoincidenceoofoheartofailure."
D)o"Dailyoweightsowillohelpousomakeosureothatoyou'reoeatingoproperly."o-
oCORRECTooANSWER-B
Dailyoweightsoareoneededotoodocumentofluidoretentionoorofluidoloss.oOneoliteroofofluidoequal
so2.2opounds.
Aoclientohasoaodeepowoundocoveredowithoaowet-to-
dampodressing.oWhichointerventionodoesotheonurseoincludeoonothisoclient'socareoplan?
A)oApplyoaonewodressingowhenotheosealobreaksoandotheodressingoleaks.
B)oChangeotheodressingowhenotheocurrentodressingoisosaturated.
C)oLeaveotheodressingointactountilonextoweek.
D)oChangeotheodressingoeveryo6ohoursoaroundotheoclock.o-oCORRECTooANSWER-D
Wet-to-
dampodressingsoareochangedoeveryo4otoo6ohoursotooprovideomaximumodébridement.oSynt
heticodressingsocanobeoleftoinoplaceoforoextendedoperiodsoofotimeobutoneedotoobeochanged
oifotheosealobreaksoandotheoexudateoisoleaking.oDryogauzeodressingsoshouldobeochangedo
whenotheoouterolayerobecomesosaturated.
Aoclientohasoaosmall-
boreonasoentericofeedingotube.oTheonurseoassessesotheofollowingovitalosigns:otemperatur
e,o100.2°oFo(37.8°oC);opulse,o112obeats/min;orespiratoryorate,o22obreaths/min;oandobloodo
pressure,o106/62ommoHg.oWhichoactionobyotheonurseotakesopriority?
A)oAuscultateobowelosoundsoandoslowotheofeedingodown.
B)oRemoveotheotubeoimmediatelyoandonotifyotheoheathocareoprovider.
C)oAuscultateolungosoundsoandoobtainooxygenosaturation.
D)oAddoblueodyeotootheofeedingotubeoformula.o-oCORRECTooANSWER-C
Theoclientomayohaveoaspirated.oTheonurseoshouldofurtheroassessotheoclient'sorespiratoryoa
ndooxygenationostatus.oTheoclientomayohaveoanotheroreasonoforotheoabnormalovitalosigns,
,osootheonurseoshouldonotopullooutotheotubeobeforeoperformingootheroassessments.oAddingo
blueodyeotootheotubeofeedingoformulaoisonotorecommendedotoocheckoforoaspiration.oSlowin
gotheofeedingodownowillonotobeohelpful.
Aoclientohasoaourinaryotractoinfection.oWhichoassessmentobyotheonurseoisomostohelpful?
A)oPalpatingoandopercussingotheokidneysoandobladder
B)oPerformingoaobladderoscanotooassessopost-voidoresidual
C)oAssessingomedicalohistoryoandocurrentomedicaloproblems
D)oInquiringoaboutorecentotravelotooforeignocountrieso-oCORRECTooANSWER-C
Clientsowhooareoseverelyoimmuneocompromisedoorowhoohaveodiabetesomellitusoareomore
oproneotoofungalourinaryotractoinfection.oTheonurseoshouldoassessoforotheseofactors.oAophy
sicaloexaminationoandoaopost-
voidoresidualomayobeoneeded,obutonotountilofurtheroinformationoisoobtained.oTravelotooforei
gnocountriesoprobablyowouldonotobeoasoimportant,obecauseoevenoifoexposed,otheoclientone
edsosomeodegreeoofoimmuneocompromiseotoodevelopoaofungalourinaryotractoinfection.
Aoclientohasoaowoundoonohisoleftotrochanterothatoiso4oinchesoinodiameter,owithoblackotissueo
atotheoperimeter,oandoboneoisoexposed.oWhichoisotheonurse'sobestoaction?
A)oDocumentoasoaostageoIopressureoulceroandoapplyoaotransparentodressing.
B)oDocumentoasoaostageoIIopressureoulceroandostartowet-to-dryogauzeotreatments.
C)oDocumentoasoaostageoIVopressureoulceroandoprepareotheoclientoforodébridement.
D)oDocumentoasoaostageoIIIopressureoulceroandostartoantibioticotherapy.o-
oCORRECTooANSWER-C
AostageoIVoulceroisooneoinowhichoskinolossoisofullothickness,owithoextensiveodestruction,otis
sueonecrosis,oand/orodamageotoomuscle,obone,oorosupportingostructures.oEscharomayobeo
present.oWhenotheoboneoofotheotrochanteroareaoisovisible,otissueolossoincludesomuscleolos
s.oAopotentialointerventionoconsistsoofodébridementoofotheonecroticotissueoandoaopossibleo
graftotoopromoteohealing.
Aoclientohasobeenoadmittedotootheointensiveocareounitowithoworseningopulmonaryomanifest
ationsoofoheartofailure.oWhatoisotheonurse'sobestoaction?
A)oAdministeroloopodiureticsoasoprescribed.
B)oBeginocardiopulmonaryoresuscitationo(CPR).
C)oPromoteorestoandominimizeoactivities.
D)oPlaceotheoclientoinoaohighoFowler'soposition.o-oCORRECTooANSWER-A
Theoclientowithoworseningoheartofailureoisomostoatoriskoforopulmonaryoedemaoasoaoconseq
uenceoofofluidoretention.oAdministeringodiureticsowillodecreaseotheofluidooverload,otherebyo
decreasingotheoincidenceoofopulmonaryoedema.oHighoFowler'sopositionomightohelpotheocli
entobreatheoeasierobutowillonotosolveotheoproblem.oCPRoisonotowarrantedoinothisosituation.o
Restoisoimportantoforoclientsowithoheartofailure,obutothisoisonototheopriority.
,Aoclientohasobeenotaughtotoorestrictodietaryosodium.oWhichofoodoselectionobyotheoclientoind
icatesotootheonurseothatoteachingohasobeenoeffective?
a.oaogrilledocheeseosandwichowithotomatoosoup
b.oChineseotake-out,oincludingosteamedorice
c.oaochickenoleg,ooneosliceoofobreadowithobutter,oandosteamedocarrots
d.oslicesoofohamoandocheeseoonowholeograinocrackerso-oCORRECTooANSWER-C
Clientsoonorestrictedosodiumodietsogenerallyoshouldoavoidoprocessed,osmoked,oandopickle
dofoodsoandothoseowithosaucesoandootherocondiments.oFoodsolowestoinosodiumoincludeofi
sh,opoultry,oandofreshoproduce.oTheochineseofoodolikelyowouldohaveosoyosauce,otheotomat
oosoupoisoprocessed,oandotheocrackersoareoaosnackofoodo-
oaocategoryoofofoodsooftenohighoinosodium.
Aoclientohasonewlyodiagnosedodiabetes.oToodelayotheoonsetoofomicrovascularoandomacrov
ascularocomplicationsoinothisoclient,otheonurseostressesothatotheoclientotakeowhichoaction?
A)oRestrictofluidointake.
B)oPreventoketosis.
C)oControlohyperglycemia.
D)oPreventohypoglycemia.o-oCORRECTooANSWER-C
Hyperglycemiaoisoaocriticalofactoroinotheopathogenesisoofolong-
termodiabeticocomplications.oMaintainingotightoglycemicocontrolowillohelpodelayotheoonseto
ofocomplications.oPreventingohypoglycemiaoandoketosis,oalthoughoimportant,oisonotoasoim
portantoasomaintainingodailyoglycemicocontrol.oRestrictingofluidointakeoisonotopartoofotheotre
atmentoplanoforoclientsowithodiabetes.
Aoclientohasorecentlyobeenoplacedoonoprednisoneo(Deltasone).oWhatoisotheohighestopriorit
yoinstructionotheonurseowilloprovide?
A)o"Takeotheodrugowithofoodooromilk."
B)o"Reportoanyoabdominalopainoorodark-coloredovomit."
C)o"Expectotooexperienceoweightogain."
D)o"Watchoyourodietowhileoonothisomedication."o-oCORRECTooANSWER-B
Alloofotheseodirectionsoareoappropriateotoogiveotheoclient;ohowever,otellingotheoclientotoorep
ortoabdominalopainoandodark-
coloredovomitoisomostoimportantobecauseotheseocouldosignalogastricoulceration.
Aoclientoisoadmittedowithoinfectionoandoaohighofever.oWhichoassessmentsobyotheonurseotak
eopriority?o(Selectoallothatoapply.)
A)oSkinoturgor
B)oPulseoquality
C)oBloodopressure
, D)oBowelosounds
E)oRespiratoryoeffort
F)oMentalostatuso-oCORRECTooANSWER-A,oB,oC,oF
Dehydrationocanoaccompanyofever,oespeciallyoifotheoclientoisosweatingoprofusely.oBloodop
ressure,opulseoquality,oandoskinoturgoroareoassessmentsoofofluidostatus.oMentalostatusoch
angesocanoaccompanyofluidolosses,oespeciallyoinoolderoclients.
Aoclientoisoadmittedowitholeftolowerolungopneumonia.oWhichoassessmentofindingodoesotheo
nurseocorrelateowithothisocondition?
A)oExpiratoryowheezeoonotheorightoside
B)oCracklesoheardoonoexpirationobilaterally
C)oDullnessotoopercussionoonotheoloweroleftoside
D)oCrepitusoofotheoskinoaroundotheoleftolungo-oCORRECTooANSWER-C
Theoclientowithopneumoniaomayohaveodullnessotoopercussionoonotheoaffectedoside.oTheoot
herooptionsoareoalloinconsistentowithopneumonia.
Aoclientoisobeingotreatedoforodehydration.oWhichostatementomadeobyotheoclientoindicatesou
nderstandingoofothisocondition?
a.oIowillouseoaosaltosubstituteowhenomakingoandoeatingomyomeals.
b.oIomustodrinkoaoquartoofowateroorootheroliquidoeachoday.
c.oIowillonotodrinkoliquidsoaftero6oPMosooIowon'tohaveotoogetoupoatonight.
d.oIowilloweighomyselfoeachomorningobeforeoIoeatoorodrink.o-oCORRECTooANSWER-D
Becauseo1oLoofowateroweighso1okg,ochangeoinobodyoweightoisoaogoodomeasureoofoexcesso
fluidolossoorofluidoretention.oWeightolossogreaterothano0.5olbodailyoisoindicativeoofoexcessiv
eofluidoloss.oTheootherostatementsoareonotoindicativeoofopracticesothatowillopreventodehydr
ation.
Aoclientoisohospitalizedowithoaourinaryotractoinfectiono(UTI).oWhichoclinicalomanifestationoal
ertsotheonurseotootheopossibilityoofoaocomplicationofromotheoUTI?
A)oHematuria
B)oFeveroandochills
C)oCloudy,odarkourine
D)oBurningoonourinationo-oCORRECTooANSWER-B
Lowerourinaryotractoinfectionsoareorarelyoassociatedowithosystemicosymptomsoofofeveroand
ochills.oAoclientowithoaoUTIowhoodevelopsofeveroandochillsoshouldobeoassessedoforotheodev
elopmentoofopyelonephritis.oTheootherooptionsocanobeoseenowithoUTI.
Aoclientoisoreceivingoaochemotherapeuticoagentointravenouslyothroughoaoperipheraloline.o
Whatoisotheonurse'sofirstoactionowhenotheoclientoreportsoburningoatotheosite?
