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NSG233/ NSG 233 HESI FINAL (NEW 2025/
2026 UPDATE) MEDICAL-SURGICAL NURSING II
REVIEW| QUESTIONS & ANSWERS| GRADE A| 100%
CORRECT (VERIFIED SOLUTIONS)
1. A client with end stage liver disease is scheduled to receive a
liver transplant tomorrow. While completing preoperative
teaching with the client and the client's spouse, the nurse
determines that the client is becoming increasingly confused.
Which action should the nurse implement first?: C) Review the
client's most recent serum laboratory values.
2. A client is admitted to the emergency department (ED) with
slurred speech and severe lethargy after being found semi-
conscious by a roommate. The roommate voices concern about
the client's involvement in using drugs.
Which approach is best for the nurse to take when the client is
alert to answer questions about substance use?: D) Begin with
questions that are less sensitive in nature.
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3. Following a motor vehicle accident, an unconscious client is
admitted to the emergency department via ambulance. Vital signs
on arrival are a heart rate of 100 beats/minute, respirations of 16
breaths/minute, and a blood pressure of 130/76 mm Hg. The nurse
plans to monitor the client for complications associated with a
basilar skull fracture. Which finding confirms this complication?:
C) Halo around blood dropped on gauze.
4. The nurse plans to assess urine in the Cather bag of a client
who is receiving bladder irrigation of fluid following a
transuthethral resection of the prostate (TURP). Which
observation indicates a possible postoperative complication and
should be reported to the healthcare provider immediately?: D)
Thick, amber colored fluid in the urinary drainage bag 24 hours
postoperative.
5. The nurse performs a postoperative assessment of a client
following an abdominal gunshot wound repair and finds the
dressing saturated with blood and petechiae is observed on the
extensor surfaces of the extremities. The client's current blood
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pressure is 80/40 mm Hg and the heart rate is 130 beats/minute.
Which laboratory result should the nurse expect to find
confirming the presence of disseminated intravascular
coagulopathy (DIC)?: D) Positive D-dimer.
6. A client involved in a motor vehicle collision is admitted to
the trauma intensive care unit. Which assessment finding
warrants immediate intervention by the nurse?: D) Diminished
peripheral capillary refill.
7. The nurse is developing a plan of care for a client with
dementia caused by AIDS. Which nursing problem has the
highest priority?: B) Risk for injury
8. 1. A client is admitted to the psychiatric unit for alcohol
detoxification. On the second day of hospitalization, the client is
nauseated, confused, incontinent, has visible hand tremors, and a
blood pressure of 160/102 mm Hg. Which intervention is most
important for the nurse to implement?: C) Implement seizure
precautions and pad the bedrails.
NSG223
NSG223
NSG233/ NSG 233 HESI FINAL (NEW 2025/
2026 UPDATE) MEDICAL-SURGICAL NURSING II
REVIEW| QUESTIONS & ANSWERS| GRADE A| 100%
CORRECT (VERIFIED SOLUTIONS)
1. A client with end stage liver disease is scheduled to receive a
liver transplant tomorrow. While completing preoperative
teaching with the client and the client's spouse, the nurse
determines that the client is becoming increasingly confused.
Which action should the nurse implement first?: C) Review the
client's most recent serum laboratory values.
2. A client is admitted to the emergency department (ED) with
slurred speech and severe lethargy after being found semi-
conscious by a roommate. The roommate voices concern about
the client's involvement in using drugs.
Which approach is best for the nurse to take when the client is
alert to answer questions about substance use?: D) Begin with
questions that are less sensitive in nature.
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3. Following a motor vehicle accident, an unconscious client is
admitted to the emergency department via ambulance. Vital signs
on arrival are a heart rate of 100 beats/minute, respirations of 16
breaths/minute, and a blood pressure of 130/76 mm Hg. The nurse
plans to monitor the client for complications associated with a
basilar skull fracture. Which finding confirms this complication?:
C) Halo around blood dropped on gauze.
4. The nurse plans to assess urine in the Cather bag of a client
who is receiving bladder irrigation of fluid following a
transuthethral resection of the prostate (TURP). Which
observation indicates a possible postoperative complication and
should be reported to the healthcare provider immediately?: D)
Thick, amber colored fluid in the urinary drainage bag 24 hours
postoperative.
5. The nurse performs a postoperative assessment of a client
following an abdominal gunshot wound repair and finds the
dressing saturated with blood and petechiae is observed on the
extensor surfaces of the extremities. The client's current blood
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pressure is 80/40 mm Hg and the heart rate is 130 beats/minute.
Which laboratory result should the nurse expect to find
confirming the presence of disseminated intravascular
coagulopathy (DIC)?: D) Positive D-dimer.
6. A client involved in a motor vehicle collision is admitted to
the trauma intensive care unit. Which assessment finding
warrants immediate intervention by the nurse?: D) Diminished
peripheral capillary refill.
7. The nurse is developing a plan of care for a client with
dementia caused by AIDS. Which nursing problem has the
highest priority?: B) Risk for injury
8. 1. A client is admitted to the psychiatric unit for alcohol
detoxification. On the second day of hospitalization, the client is
nauseated, confused, incontinent, has visible hand tremors, and a
blood pressure of 160/102 mm Hg. Which intervention is most
important for the nurse to implement?: C) Implement seizure
precautions and pad the bedrails.
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