HESI PN Med Surg Exit Exam 2025/2026
– Actual 75 Questions with 100% Verified
Answers and Expert Rationales
Question 1
A client with pneumonia is experiencing dyspnea. What is the priority nursing action?
A. Administer antibiotics as prescribed
B. Place the client in a supine position
C. Assess oxygen saturation and apply oxygen if needed
D. Encourage fluid restriction
C. Assess oxygen saturation and apply oxygen if needed
Rationale: Dyspnea indicates impaired gas exchange, a priority in pneumonia. Assessing
oxygen saturation (SpO2) and providing supplemental oxygen address airway, breathing, and
circulation (ABCs), per Maslow’s hierarchy. Antibiotics treat infection but are secondary to
immediate oxygenation needs.
Question 2
A client with a new colostomy reports leakage around the appliance. What should the nurse do
first?
A. Change the appliance immediately
B. Assess the stoma and skin for proper fit and irritation
C. Administer an antidiarrheal medication
D. Refer the client to a surgeon
B. Assess the stoma and skin for proper fit and irritation
Rationale: Leakage may indicate an ill-fitting appliance or skin breakdown. Assessment
determines the cause (e.g., improper sizing, peristomal irritation), guiding interventions.
Changing without assessment may worsen the issue, and antidiarrheals or surgery are premature.
Question 3
A client with type 1 diabetes has a blood glucose of 50 mg/dL. What is the nurse’s first action?
A. Administer insulin as prescribed
B. Provide 15 grams of fast-acting carbohydrate
C. Encourage the client to rest
D. Notify the healthcare provider
B. Provide 15 grams of fast-acting carbohydrate
Rationale: A blood glucose of 50 mg/dL indicates hypoglycemia. Per ADA guidelines, 15
,grams of fast-acting carbohydrate (e.g., juice, glucose tabs) is the first-line treatment, followed
by rechecking in 15 minutes. Insulin worsens hypoglycemia, and rest or notification delays
treatment.
Question 4
A client post-appendectomy reports severe abdominal pain and rigidity. What should the nurse
suspect?
A. Normal postoperative pain
B. Peritonitis
C. Constipation
D. Gas pain
B. Peritonitis
Rationale: Severe pain and abdominal rigidity post-appendectomy suggest peritonitis, a surgical
emergency due to possible perforation or infection. Normal pain is less intense, and constipation
or gas do not typically cause rigidity.
Question 5
A client with heart failure is prescribed furosemide. What should the nurse monitor?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypocalcemia
B. Hypokalemia
Rationale: Furosemide, a loop diuretic, increases potassium excretion, risking hypokalemia
(e.g., muscle weakness, arrhythmias). Monitoring electrolytes is critical. Hyperkalemia is
associated with potassium-sparing diuretics.
Question 6
A client with a fracture has a cast applied. What should the nurse teach the client to report?
A. Warmth in the casted area
B. Numbness or tingling in the extremity
C. Mild swelling around the cast
D. Itching under the cast
B. Numbness or tingling in the extremity
Rationale: Numbness or tingling may indicate compartment syndrome or nerve compression,
requiring immediate evaluation. Warmth and itching are common, and mild swelling may be
monitored, but neurovascular changes are urgent.
Question 7
, A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via
nasal cannula. What is the priority nursing assessment?
A. Blood pressure
B. Respiratory rate and oxygen saturation
C. Temperature
D. Heart rate
B. Respiratory rate and oxygen saturation
Rationale: In COPD, oxygen therapy aims to maintain SpO2 at 88–92% to avoid suppressing
respiratory drive. Monitoring respiratory rate and SpO2 ensures effective oxygenation and
safety, per GOLD guidelines.
Question 8
A client post-myocardial infarction reports chest pain. What is the nurse’s first action?
A. Administer aspirin
B. Notify the healthcare provider
C. Administer nitroglycerin as prescribed
D. Perform a 12-lead ECG
C. Administer nitroglycerin as prescribed
Rationale: Nitroglycerin relieves angina by dilating coronary arteries. Per AHA guidelines,
administer sublingual nitroglycerin first, then notify the provider if pain persists after three doses
(5 minutes apart). ECG and aspirin are secondary.
Question 9
A client with a urinary tract infection (UTI) is prescribed nitrofurantoin. What should the nurse
teach?
A. Take on an empty stomach
B. Report yellowing of the skin
C. Expect photosensitivity
D. Avoid fluids
B. Report yellowing of the skin
Rationale: Nitrofurantoin can cause hepatotoxicity; jaundice indicates liver dysfunction and
requires immediate reporting. It is taken with food, photosensitivity is rare, and fluids are
encouraged for UTIs.
Question 10
A client with a deep vein thrombosis (DVT) is receiving heparin. Which lab value should the
nurse monitor?
A. International Normalized Ratio (INR)
B. Activated Partial Thromboplastin Time (aPTT)
– Actual 75 Questions with 100% Verified
Answers and Expert Rationales
Question 1
A client with pneumonia is experiencing dyspnea. What is the priority nursing action?
A. Administer antibiotics as prescribed
B. Place the client in a supine position
C. Assess oxygen saturation and apply oxygen if needed
D. Encourage fluid restriction
C. Assess oxygen saturation and apply oxygen if needed
Rationale: Dyspnea indicates impaired gas exchange, a priority in pneumonia. Assessing
oxygen saturation (SpO2) and providing supplemental oxygen address airway, breathing, and
circulation (ABCs), per Maslow’s hierarchy. Antibiotics treat infection but are secondary to
immediate oxygenation needs.
Question 2
A client with a new colostomy reports leakage around the appliance. What should the nurse do
first?
A. Change the appliance immediately
B. Assess the stoma and skin for proper fit and irritation
C. Administer an antidiarrheal medication
D. Refer the client to a surgeon
B. Assess the stoma and skin for proper fit and irritation
Rationale: Leakage may indicate an ill-fitting appliance or skin breakdown. Assessment
determines the cause (e.g., improper sizing, peristomal irritation), guiding interventions.
Changing without assessment may worsen the issue, and antidiarrheals or surgery are premature.
Question 3
A client with type 1 diabetes has a blood glucose of 50 mg/dL. What is the nurse’s first action?
A. Administer insulin as prescribed
B. Provide 15 grams of fast-acting carbohydrate
C. Encourage the client to rest
D. Notify the healthcare provider
B. Provide 15 grams of fast-acting carbohydrate
Rationale: A blood glucose of 50 mg/dL indicates hypoglycemia. Per ADA guidelines, 15
,grams of fast-acting carbohydrate (e.g., juice, glucose tabs) is the first-line treatment, followed
by rechecking in 15 minutes. Insulin worsens hypoglycemia, and rest or notification delays
treatment.
Question 4
A client post-appendectomy reports severe abdominal pain and rigidity. What should the nurse
suspect?
A. Normal postoperative pain
B. Peritonitis
C. Constipation
D. Gas pain
B. Peritonitis
Rationale: Severe pain and abdominal rigidity post-appendectomy suggest peritonitis, a surgical
emergency due to possible perforation or infection. Normal pain is less intense, and constipation
or gas do not typically cause rigidity.
Question 5
A client with heart failure is prescribed furosemide. What should the nurse monitor?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypocalcemia
B. Hypokalemia
Rationale: Furosemide, a loop diuretic, increases potassium excretion, risking hypokalemia
(e.g., muscle weakness, arrhythmias). Monitoring electrolytes is critical. Hyperkalemia is
associated with potassium-sparing diuretics.
Question 6
A client with a fracture has a cast applied. What should the nurse teach the client to report?
A. Warmth in the casted area
B. Numbness or tingling in the extremity
C. Mild swelling around the cast
D. Itching under the cast
B. Numbness or tingling in the extremity
Rationale: Numbness or tingling may indicate compartment syndrome or nerve compression,
requiring immediate evaluation. Warmth and itching are common, and mild swelling may be
monitored, but neurovascular changes are urgent.
Question 7
, A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via
nasal cannula. What is the priority nursing assessment?
A. Blood pressure
B. Respiratory rate and oxygen saturation
C. Temperature
D. Heart rate
B. Respiratory rate and oxygen saturation
Rationale: In COPD, oxygen therapy aims to maintain SpO2 at 88–92% to avoid suppressing
respiratory drive. Monitoring respiratory rate and SpO2 ensures effective oxygenation and
safety, per GOLD guidelines.
Question 8
A client post-myocardial infarction reports chest pain. What is the nurse’s first action?
A. Administer aspirin
B. Notify the healthcare provider
C. Administer nitroglycerin as prescribed
D. Perform a 12-lead ECG
C. Administer nitroglycerin as prescribed
Rationale: Nitroglycerin relieves angina by dilating coronary arteries. Per AHA guidelines,
administer sublingual nitroglycerin first, then notify the provider if pain persists after three doses
(5 minutes apart). ECG and aspirin are secondary.
Question 9
A client with a urinary tract infection (UTI) is prescribed nitrofurantoin. What should the nurse
teach?
A. Take on an empty stomach
B. Report yellowing of the skin
C. Expect photosensitivity
D. Avoid fluids
B. Report yellowing of the skin
Rationale: Nitrofurantoin can cause hepatotoxicity; jaundice indicates liver dysfunction and
requires immediate reporting. It is taken with food, photosensitivity is rare, and fluids are
encouraged for UTIs.
Question 10
A client with a deep vein thrombosis (DVT) is receiving heparin. Which lab value should the
nurse monitor?
A. International Normalized Ratio (INR)
B. Activated Partial Thromboplastin Time (aPTT)
