Page 1 of 182
HESI Med Surg Exit Exam V2 ALL 200 QUESTIONS
AND CORRECT ANSWERS LATEST UPDATE THIS
YEAR
QUESTION: A client with benign prostatic hyperplasia (BPH) is preparing for discharge following
a transurethral needle ablation (TUNA). Which information should the nurse include in the
discharge instructions?
A Restrict physical activities.
B Use incentive spirometer.
C Report when hematuria becomes pink tinged.
D Monitor urinary stream for decrease in output. - ANSWER-D Monitor urinary stream for
decrease in output.
After TUNA, clients need to be vigilant about their urinary output because a decrease can
indicate complications such as re-obstruction, which is a significant concern following the
procedure. Monitoring urinary stream is essential for detecting potential issues early, making
this the best choice for discharge instructions.
1
, Page 2 of 182
QUESTION: The nurse is caring for a client receiving thrombolytic therapy following an acute
myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this
client?
A Risk for injury related to effects of thrombolysis.
B Activity intolerance related to ischemia.
C Ineffective breathing pattern related to adverse drug effects.
D Deficient knowledge related to a new medication regimen. - ANSWER-A Risk for injury related
to effects of thrombolysis.
Clients receiving thrombolytic therapy are at an increased risk of bleeding, which can manifest
as internal bleeding, hemorrhage at vascular access sites, gastrointestinal bleeding, or
intracranial bleeding. The nurse's priority is to closely monitor the client for signs and
symptoms of bleeding, such as sudden onset or worsening of headache, changes in level of
consciousness, hematuria, melena, ecchymosis, or hematoma formation.
QUESTION: The nurse is caring for a client who had an appendectomy 4 hours ago. Which
finding requires immediate action by the nurse?
A High-pitched sound heard upon inspiration.
B Apical heart rate of 100 to 110 beats/minute.
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, Page 3 of 182
C Redness and edema noted at the incision site.
D Pain rating of 8 on a scale of 0 to 10. - ANSWER-A High-pitched sound heard upon inspiration.
A high-pitched sound heard upon inspiration, known as a "stridor," can indicate airway
obstruction or respiratory distress. In the postoperative period following an appendectomy,
airway patency and adequate ventilation are essential for the client's oxygenation and recovery
QUESTION: An adult client newly diagnosed with left ventricular dysfunction is admitted to the
hospital with fine rales and wheezing. When assessing this client, which additional finding is the
nurse likely to obtain?
A Fatigue.
B Lower extremity edema.
C Hepatomegaly.
D Jugular vein distension. - ANSWER-A Fatigue.
Left ventricular dysfunction leads to inadequate stroke volume and cardiac output to the
systemic circulation. This leads to fatigue and exertional dyspnea.
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, Page 4 of 182
QUESTION: A client with a right ulnar fracture and cast placement reports an increase in arm
pain. Which action should the nurse take next?
A Implement distraction techniques.
B Assess right radial pulse volume.
C Administer a PRN analgesic.
D Measure the blood pressure. - ANSWER-B Assess right radial pulse volume.
An increase in pain after cast placement could indicate complications such as compartment
syndrome, which is a serious condition that occurs when increased pressure within a confined
space (such as the area within the cast) compromises circulation and tissue perfusion. Assessing
the radial pulse volume on the affected arm is crucial to evaluate perfusion distal to the
fracture site.
Q; Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic
encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory
findings show an elevated serum ammonia (NH) level of 220 μg/dL (157.1 μmol/dL). Which
action should the nurse take? Reference Range: Ammonia [10 to 80 μg/dL (6 to 47 μmol/L)]
A Hold the next dose of lactulose.
B Continue the prescribed dose of lactulose.
C Replace total volume voided with oral or IV fluids.
4
HESI Med Surg Exit Exam V2 ALL 200 QUESTIONS
AND CORRECT ANSWERS LATEST UPDATE THIS
YEAR
QUESTION: A client with benign prostatic hyperplasia (BPH) is preparing for discharge following
a transurethral needle ablation (TUNA). Which information should the nurse include in the
discharge instructions?
A Restrict physical activities.
B Use incentive spirometer.
C Report when hematuria becomes pink tinged.
D Monitor urinary stream for decrease in output. - ANSWER-D Monitor urinary stream for
decrease in output.
After TUNA, clients need to be vigilant about their urinary output because a decrease can
indicate complications such as re-obstruction, which is a significant concern following the
procedure. Monitoring urinary stream is essential for detecting potential issues early, making
this the best choice for discharge instructions.
1
, Page 2 of 182
QUESTION: The nurse is caring for a client receiving thrombolytic therapy following an acute
myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this
client?
A Risk for injury related to effects of thrombolysis.
B Activity intolerance related to ischemia.
C Ineffective breathing pattern related to adverse drug effects.
D Deficient knowledge related to a new medication regimen. - ANSWER-A Risk for injury related
to effects of thrombolysis.
Clients receiving thrombolytic therapy are at an increased risk of bleeding, which can manifest
as internal bleeding, hemorrhage at vascular access sites, gastrointestinal bleeding, or
intracranial bleeding. The nurse's priority is to closely monitor the client for signs and
symptoms of bleeding, such as sudden onset or worsening of headache, changes in level of
consciousness, hematuria, melena, ecchymosis, or hematoma formation.
QUESTION: The nurse is caring for a client who had an appendectomy 4 hours ago. Which
finding requires immediate action by the nurse?
A High-pitched sound heard upon inspiration.
B Apical heart rate of 100 to 110 beats/minute.
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, Page 3 of 182
C Redness and edema noted at the incision site.
D Pain rating of 8 on a scale of 0 to 10. - ANSWER-A High-pitched sound heard upon inspiration.
A high-pitched sound heard upon inspiration, known as a "stridor," can indicate airway
obstruction or respiratory distress. In the postoperative period following an appendectomy,
airway patency and adequate ventilation are essential for the client's oxygenation and recovery
QUESTION: An adult client newly diagnosed with left ventricular dysfunction is admitted to the
hospital with fine rales and wheezing. When assessing this client, which additional finding is the
nurse likely to obtain?
A Fatigue.
B Lower extremity edema.
C Hepatomegaly.
D Jugular vein distension. - ANSWER-A Fatigue.
Left ventricular dysfunction leads to inadequate stroke volume and cardiac output to the
systemic circulation. This leads to fatigue and exertional dyspnea.
3
, Page 4 of 182
QUESTION: A client with a right ulnar fracture and cast placement reports an increase in arm
pain. Which action should the nurse take next?
A Implement distraction techniques.
B Assess right radial pulse volume.
C Administer a PRN analgesic.
D Measure the blood pressure. - ANSWER-B Assess right radial pulse volume.
An increase in pain after cast placement could indicate complications such as compartment
syndrome, which is a serious condition that occurs when increased pressure within a confined
space (such as the area within the cast) compromises circulation and tissue perfusion. Assessing
the radial pulse volume on the affected arm is crucial to evaluate perfusion distal to the
fracture site.
Q; Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic
encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory
findings show an elevated serum ammonia (NH) level of 220 μg/dL (157.1 μmol/dL). Which
action should the nurse take? Reference Range: Ammonia [10 to 80 μg/dL (6 to 47 μmol/L)]
A Hold the next dose of lactulose.
B Continue the prescribed dose of lactulose.
C Replace total volume voided with oral or IV fluids.
4
