MS HESI / HESI Med-Surg RN V1
55-Question & Answer with
Rationale
1) A patient had abdominal surgery and states that after coughing it feels like his guts
have spilled out. What should the nurse do first?
Answer: Visualize the abdominal area
Rationale: First priority is assessment to confirm evisceration before covering and notifying
provider.
2) A patient has been taking Kenalog (corticosteroid) and has increased redness.
What should the nurse do?
Answer: Schedule an appointment
Rationale: May indicate infection or adverse steroid reaction requiring evaluation.
3) A patient had a BDP. What finding warrants further intervention?
Answer: Positive gastro-ocult emesis
Rationale: Indicates GI bleeding requiring urgent follow-up.
4) A patient taking Vitamin B12 reports fatigue. What lab should be monitored?
Answer: CBC
Rationale: Evaluates improvement in anemia (Hgb, Hct, RBC).
5) A patient with Parkinson’s disease is walking. What indicates treatment is
effective?
Answer: Improved mobility
Rationale: Increased motor function indicates therapeutic response.
6) What is priority for a patient allergic to bananas?
Answer: Replace latex products
Rationale: Banana allergy is associated with latex cross-reactivity.
7) How can renal calculi be prevented?
Answer: Limit tea and chocolate
Rationale: Reduces oxalate intake and stone formation risk.
,8) A patient is in F-vib. What medication should be given?
Answer: Defibrillation (NOT adenosine)
Rationale: Ventricular fibrillation requires immediate defibrillation.
9) A nurse cannot palpate a pedal pulse. What should the nurse do next?
Answer: Use Doppler ultrasound
Rationale: Detects weak or absent pulses.
10) A COPD patient has started a walking program. How do we know it is effective?
Answer: Cardiovascular improvement
Rationale: Increased endurance indicates improvement.
11) A post-op patient says they know how to breathe. What should the nurse do?
Answer: Request return demonstration
Rationale: Confirms understanding of teaching.
12) Order: 100 units in 250 mL at 12 units/hr. What is the infusion rate?
Answer: 30 mL/hr
Rationale: (12 ÷ 100) × 250 = 30 mL/hr.
13) A patient complains of right calf pain. What is the nurse’s priority?
Answer: Remain in bed
Rationale: Suspected DVT—prevents embolus movement.
14) A patient returns after TURP with clots. What should the nurse do?
Answer: Slowly irrigate catheter
Rationale: Maintains catheter patency.
15) Priority for multiple sclerosis patient with urinary retention?
Answer: Self-catheterization
Rationale: Promotes bladder emptying and independence.
16) What lab should be monitored for abscess drainage?
Answer: WBC count
Rationale: Indicates infection severity.
17) CHF intervention?
Answer: Use bedside commode
Rationale: Reduces cardiac workload.
,18) Post-op cataract extraction intervention?
Answer: Deep breathing exercises
Rationale: Prevents respiratory complications.
19) Patient on Prednisolone should report what?
Answer: Weight gain
Rationale: Indicates fluid retention.
20) Priority for pyelonephritis?
Answer: IV antibiotics
Rationale: Treats infection and prevents sepsis.
21) Diet for osteomalacia?
Answer: Milk and cereal
Rationale: Provides calcium and vitamin D.
22) Raynaud’s syndrome at work—what should patient do?
Answer: Use space heater
Rationale: Prevents vasospasm.
23) What should be reported after bronchoscopy?
Answer: Monitor airway, oxygenation, bleeding
Rationale: Risk of respiratory compromise.
24) Unstable angina after cardiac cath—priority?
Answer: Monitor chest pain and ECG changes
Rationale: Detects ischemia early.
25) Acute glomerulonephritis teaching?
Answer: Restrict sodium
Rationale: Reduces edema and hypertension.
26) GERD teaching?
Answer: Wear loose clothing
Rationale: Decreases abdominal pressure.
27) COPD breathing technique?
Answer: Pursed-lip breathing
Rationale: Improves oxygenation and prevents air trapping.
, 28) Patient with Type 2 diabetes feels shaky. What is priority?
Answer: Obtain blood glucose level
Rationale: Confirms hypoglycemia.
29) Hypothyroidism patient with depression and insomnia—what should nurse do?
Answer: Request PRN medication from provider
Rationale: Manages symptoms.
30) Ulcerative colitis patient should report what?
Answer: Fatty stools
Rationale: Indicates malabsorption.
31) MRSA interventions?
Answer: Contact precautions, culture, monitor WBC
Rationale: Prevents spread and tracks infection.
32) CKD lab to report?
Answer: Potassium 6.5
Rationale: Life-threatening hyperkalemia.
33) Positive guaiac stool—what lab should be reviewed?
Answer: Platelets
Rationale: Evaluates bleeding risk.
34) Pheochromocytoma with headache—priority?
Answer: Assess blood pressure
Rationale: Risk of hypertensive crisis.
35) Suprapubic prostatectomy concern?
Answer: Urine leakage
Rationale: Indicates complication.
36) Abdominal cramping after surgery—what should nurse do?
Answer: Assess for complications
Rationale: Could indicate ileus or bleeding.
37) Cancer biopsy shows well-differentiated cells—what should nurse do?
Answer: Notify provider for interpretation
Rationale: Requires medical evaluation.
55-Question & Answer with
Rationale
1) A patient had abdominal surgery and states that after coughing it feels like his guts
have spilled out. What should the nurse do first?
Answer: Visualize the abdominal area
Rationale: First priority is assessment to confirm evisceration before covering and notifying
provider.
2) A patient has been taking Kenalog (corticosteroid) and has increased redness.
What should the nurse do?
Answer: Schedule an appointment
Rationale: May indicate infection or adverse steroid reaction requiring evaluation.
3) A patient had a BDP. What finding warrants further intervention?
Answer: Positive gastro-ocult emesis
Rationale: Indicates GI bleeding requiring urgent follow-up.
4) A patient taking Vitamin B12 reports fatigue. What lab should be monitored?
Answer: CBC
Rationale: Evaluates improvement in anemia (Hgb, Hct, RBC).
5) A patient with Parkinson’s disease is walking. What indicates treatment is
effective?
Answer: Improved mobility
Rationale: Increased motor function indicates therapeutic response.
6) What is priority for a patient allergic to bananas?
Answer: Replace latex products
Rationale: Banana allergy is associated with latex cross-reactivity.
7) How can renal calculi be prevented?
Answer: Limit tea and chocolate
Rationale: Reduces oxalate intake and stone formation risk.
,8) A patient is in F-vib. What medication should be given?
Answer: Defibrillation (NOT adenosine)
Rationale: Ventricular fibrillation requires immediate defibrillation.
9) A nurse cannot palpate a pedal pulse. What should the nurse do next?
Answer: Use Doppler ultrasound
Rationale: Detects weak or absent pulses.
10) A COPD patient has started a walking program. How do we know it is effective?
Answer: Cardiovascular improvement
Rationale: Increased endurance indicates improvement.
11) A post-op patient says they know how to breathe. What should the nurse do?
Answer: Request return demonstration
Rationale: Confirms understanding of teaching.
12) Order: 100 units in 250 mL at 12 units/hr. What is the infusion rate?
Answer: 30 mL/hr
Rationale: (12 ÷ 100) × 250 = 30 mL/hr.
13) A patient complains of right calf pain. What is the nurse’s priority?
Answer: Remain in bed
Rationale: Suspected DVT—prevents embolus movement.
14) A patient returns after TURP with clots. What should the nurse do?
Answer: Slowly irrigate catheter
Rationale: Maintains catheter patency.
15) Priority for multiple sclerosis patient with urinary retention?
Answer: Self-catheterization
Rationale: Promotes bladder emptying and independence.
16) What lab should be monitored for abscess drainage?
Answer: WBC count
Rationale: Indicates infection severity.
17) CHF intervention?
Answer: Use bedside commode
Rationale: Reduces cardiac workload.
,18) Post-op cataract extraction intervention?
Answer: Deep breathing exercises
Rationale: Prevents respiratory complications.
19) Patient on Prednisolone should report what?
Answer: Weight gain
Rationale: Indicates fluid retention.
20) Priority for pyelonephritis?
Answer: IV antibiotics
Rationale: Treats infection and prevents sepsis.
21) Diet for osteomalacia?
Answer: Milk and cereal
Rationale: Provides calcium and vitamin D.
22) Raynaud’s syndrome at work—what should patient do?
Answer: Use space heater
Rationale: Prevents vasospasm.
23) What should be reported after bronchoscopy?
Answer: Monitor airway, oxygenation, bleeding
Rationale: Risk of respiratory compromise.
24) Unstable angina after cardiac cath—priority?
Answer: Monitor chest pain and ECG changes
Rationale: Detects ischemia early.
25) Acute glomerulonephritis teaching?
Answer: Restrict sodium
Rationale: Reduces edema and hypertension.
26) GERD teaching?
Answer: Wear loose clothing
Rationale: Decreases abdominal pressure.
27) COPD breathing technique?
Answer: Pursed-lip breathing
Rationale: Improves oxygenation and prevents air trapping.
, 28) Patient with Type 2 diabetes feels shaky. What is priority?
Answer: Obtain blood glucose level
Rationale: Confirms hypoglycemia.
29) Hypothyroidism patient with depression and insomnia—what should nurse do?
Answer: Request PRN medication from provider
Rationale: Manages symptoms.
30) Ulcerative colitis patient should report what?
Answer: Fatty stools
Rationale: Indicates malabsorption.
31) MRSA interventions?
Answer: Contact precautions, culture, monitor WBC
Rationale: Prevents spread and tracks infection.
32) CKD lab to report?
Answer: Potassium 6.5
Rationale: Life-threatening hyperkalemia.
33) Positive guaiac stool—what lab should be reviewed?
Answer: Platelets
Rationale: Evaluates bleeding risk.
34) Pheochromocytoma with headache—priority?
Answer: Assess blood pressure
Rationale: Risk of hypertensive crisis.
35) Suprapubic prostatectomy concern?
Answer: Urine leakage
Rationale: Indicates complication.
36) Abdominal cramping after surgery—what should nurse do?
Answer: Assess for complications
Rationale: Could indicate ileus or bleeding.
37) Cancer biopsy shows well-differentiated cells—what should nurse do?
Answer: Notify provider for interpretation
Rationale: Requires medical evaluation.
