HESI MED SURG STANDARDIZED EXAM 2025/2026
QUESTIONS WITH SOLUTIONS GRADED A+
✔✔The nurse working in a postoperative surgical clinic is assessing a woman who had
a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk
for developing lymphedema? - ✔✔She sustained an insect bite to her left arm
yesterday.
Rationale
A radical mastectomy interrupts lymph flow, and the increased lymph flow that occurs in
response to the insect bite increases the risk for the occurrence of lymphedema.
✔✔The nurse is assessing a client with bacterial meningitis. Which assessment finding
indicates the client may have developed septic emboli? - ✔✔Cyanosis of the fingertips.
Rationale
Septic emboli secondary to meningitis commonly lodge in the small arterioles of the
extremities, causing a decrease in circulation to the hands which may lead to gangrene.
✔✔During suctioning, a client with an uncuffed tracheostomy tube begins to cough
violently and dislodges the tracheostomy tube. Which action should the nurse
implement first? - ✔✔Attempt to reinsert the tracheostomy tube.
Rationale
The nurse should attempt to reinsert the tracheostomy tube by using a hemostat to
open the tracheostomy or by grasping the retention sutures (if present) to spread the
opening in insert a replacement tube (with its obturator) into the stoma. Once in place,
the obturator should immediately be removed.
✔✔In preparing to administer intravenous albumin to a client following surgery, what is
the priority nursing intervention? (Select all that apply.) - ✔✔Set the infusion pump to
infuse the albumin within four hours.
Administer through a large gauge catheter.
Monitor hemoglobin and hematocrit levels.
Assess for increased bleeding after administration.
Rationale
Albumin should be infused within four hours because it does not contain any
preservatives. Any fluid remaining after four hours should be discarded. Albumin
administration does not require blood typing. Vital signs should be monitored
periodically to assess for fluid volume overload. A large gauge catheter allows for fast
infusion rate, which may be necessary. Hemodilution may decrease hemoglobin (HgB)
,and hematocrit (HCT) levels, so the HgB and HCT levels should be monitored. While
monitoring for bleeding because of the increased blood volume and blood pressure.
✔✔Which description of symptoms is characteristic of a client diagnosed with trigeminal
neuralgia (tic douloureux)? - ✔✔Sudden, stabbing, severe pain over the lip and chin.
Rationale
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock,
in the area innervated by one or more branches of the trigeminal nerve (5th cranial).
Women are more often afflicted with this condition and generally occurs in clients over
the age of 50 years old.
✔✔The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1
tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of
indigestion. What intervention should the nurse implement? - ✔✔Question the
healthcare provider's prescription.
Rationale
Magnesium agents are not usually used for clients with CKD due to the risk of
hypermagnesemia, so this prescription should be questioned by the nurse.
✔✔During a health fair, a 72-year-old male client tells the nurse that he is experiencing
shortness of breath. Auscultation reveals crackles and wheezing in both lungs.
Suspecting that the client might have chronic bronchitis, which classic symptom would
the nurse expect this client to have? - ✔✔Productive cough with grayish-white sputum.
Rationale
Smoking is the most common cause of chronic bronchitis, one of the diseases
comprising the diagnosis of COPD, it is characterized by a productive cough with
grayish-white sputum. Smokers generally experience this cough when they first awaken
and rise in the morning.
✔✔A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair
falling out each day?" Which response by the nurse best explains the reason for
alopecia? - ✔✔"Chemotherapy affects the cells of the body that grow rapidly, both
normal and malignant."
Rationale
The common adverse effects of chemotherapy (nausea, vomiting, alopecia, bone
marrow depression) are due to chemotherapy's effect on the rapidly reproducing cells,
both normal and malignant.
, ✔✔The nurse notes that the only ECG for a 55-year-old male client scheduled for
surgery in two hours is dated two years ago. The client reports that he has a history of
"heart trouble," but has no problems at present. Hospital protocol requires that those
over 50 years of age have a recent ECG prior to surgery. What nursing action is best for
the nurse to implement? - ✔✔Call for an ECG to be performed immediately.
Rationale
According to the hospital policy, clients over the age of 50 and/or with a history of
cardiovascular disease, should receive ECG evaluation prior to surgery, generally 24
hours to two weeks before. The nurse needs to first arrange for an ECG to be
performed immediately prior to surgery.
✔✔What discharge instruction is most important for a client after a kidney transplant? -
✔✔Use daily reminders to take immunosuppressants.
Rationale
After a renal transplantation, acute rejection is a high risk for several months. The organ
recipient will have to take immunosuppressive therapy for the rest of their lives, such as
corticosteroids and azathioprine (Imuran), to prevent organ transplant rejection.
Discharge instructions include measures, such as daily reminders, to ensure the client
takes these medications regularly to prevent organ rejection from occurring.
✔✔The nurse is completing an admission interview and assessment on a client with a
history of Parkinson's disease. Which question provides information relevant to the
client's plan of care? - ✔✔"Have you ever been 'frozen' in one spot, unable to move?"
Rationale
Clients with Parkinson's disease frequently experience difficulty in initiating, maintaining,
and performing motor activities. They may even experience being rooted to a spot and
unable to move, refer to as being "frozen" in one spot.
✔✔A client with gastroesophageal reflux disease (GERD) has been experiencing
severe reflux during sleep. Which recommendation by the nurse is most effective to
assist the client? - ✔✔Raising the head of the bed on blocks.
Rationale
Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce reflux
and subsequent aspiration is the most non-pharmacological effective recommendation
for a client experiencing severe gastroesophageal reflux during sleep.
QUESTIONS WITH SOLUTIONS GRADED A+
✔✔The nurse working in a postoperative surgical clinic is assessing a woman who had
a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk
for developing lymphedema? - ✔✔She sustained an insect bite to her left arm
yesterday.
Rationale
A radical mastectomy interrupts lymph flow, and the increased lymph flow that occurs in
response to the insect bite increases the risk for the occurrence of lymphedema.
✔✔The nurse is assessing a client with bacterial meningitis. Which assessment finding
indicates the client may have developed septic emboli? - ✔✔Cyanosis of the fingertips.
Rationale
Septic emboli secondary to meningitis commonly lodge in the small arterioles of the
extremities, causing a decrease in circulation to the hands which may lead to gangrene.
✔✔During suctioning, a client with an uncuffed tracheostomy tube begins to cough
violently and dislodges the tracheostomy tube. Which action should the nurse
implement first? - ✔✔Attempt to reinsert the tracheostomy tube.
Rationale
The nurse should attempt to reinsert the tracheostomy tube by using a hemostat to
open the tracheostomy or by grasping the retention sutures (if present) to spread the
opening in insert a replacement tube (with its obturator) into the stoma. Once in place,
the obturator should immediately be removed.
✔✔In preparing to administer intravenous albumin to a client following surgery, what is
the priority nursing intervention? (Select all that apply.) - ✔✔Set the infusion pump to
infuse the albumin within four hours.
Administer through a large gauge catheter.
Monitor hemoglobin and hematocrit levels.
Assess for increased bleeding after administration.
Rationale
Albumin should be infused within four hours because it does not contain any
preservatives. Any fluid remaining after four hours should be discarded. Albumin
administration does not require blood typing. Vital signs should be monitored
periodically to assess for fluid volume overload. A large gauge catheter allows for fast
infusion rate, which may be necessary. Hemodilution may decrease hemoglobin (HgB)
,and hematocrit (HCT) levels, so the HgB and HCT levels should be monitored. While
monitoring for bleeding because of the increased blood volume and blood pressure.
✔✔Which description of symptoms is characteristic of a client diagnosed with trigeminal
neuralgia (tic douloureux)? - ✔✔Sudden, stabbing, severe pain over the lip and chin.
Rationale
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock,
in the area innervated by one or more branches of the trigeminal nerve (5th cranial).
Women are more often afflicted with this condition and generally occurs in clients over
the age of 50 years old.
✔✔The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1
tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of
indigestion. What intervention should the nurse implement? - ✔✔Question the
healthcare provider's prescription.
Rationale
Magnesium agents are not usually used for clients with CKD due to the risk of
hypermagnesemia, so this prescription should be questioned by the nurse.
✔✔During a health fair, a 72-year-old male client tells the nurse that he is experiencing
shortness of breath. Auscultation reveals crackles and wheezing in both lungs.
Suspecting that the client might have chronic bronchitis, which classic symptom would
the nurse expect this client to have? - ✔✔Productive cough with grayish-white sputum.
Rationale
Smoking is the most common cause of chronic bronchitis, one of the diseases
comprising the diagnosis of COPD, it is characterized by a productive cough with
grayish-white sputum. Smokers generally experience this cough when they first awaken
and rise in the morning.
✔✔A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair
falling out each day?" Which response by the nurse best explains the reason for
alopecia? - ✔✔"Chemotherapy affects the cells of the body that grow rapidly, both
normal and malignant."
Rationale
The common adverse effects of chemotherapy (nausea, vomiting, alopecia, bone
marrow depression) are due to chemotherapy's effect on the rapidly reproducing cells,
both normal and malignant.
, ✔✔The nurse notes that the only ECG for a 55-year-old male client scheduled for
surgery in two hours is dated two years ago. The client reports that he has a history of
"heart trouble," but has no problems at present. Hospital protocol requires that those
over 50 years of age have a recent ECG prior to surgery. What nursing action is best for
the nurse to implement? - ✔✔Call for an ECG to be performed immediately.
Rationale
According to the hospital policy, clients over the age of 50 and/or with a history of
cardiovascular disease, should receive ECG evaluation prior to surgery, generally 24
hours to two weeks before. The nurse needs to first arrange for an ECG to be
performed immediately prior to surgery.
✔✔What discharge instruction is most important for a client after a kidney transplant? -
✔✔Use daily reminders to take immunosuppressants.
Rationale
After a renal transplantation, acute rejection is a high risk for several months. The organ
recipient will have to take immunosuppressive therapy for the rest of their lives, such as
corticosteroids and azathioprine (Imuran), to prevent organ transplant rejection.
Discharge instructions include measures, such as daily reminders, to ensure the client
takes these medications regularly to prevent organ rejection from occurring.
✔✔The nurse is completing an admission interview and assessment on a client with a
history of Parkinson's disease. Which question provides information relevant to the
client's plan of care? - ✔✔"Have you ever been 'frozen' in one spot, unable to move?"
Rationale
Clients with Parkinson's disease frequently experience difficulty in initiating, maintaining,
and performing motor activities. They may even experience being rooted to a spot and
unable to move, refer to as being "frozen" in one spot.
✔✔A client with gastroesophageal reflux disease (GERD) has been experiencing
severe reflux during sleep. Which recommendation by the nurse is most effective to
assist the client? - ✔✔Raising the head of the bed on blocks.
Rationale
Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce reflux
and subsequent aspiration is the most non-pharmacological effective recommendation
for a client experiencing severe gastroesophageal reflux during sleep.
