MED SURG II HESI EXAM EXAM SCRIPT 2026
TEST PAPER QUESTIONS AND SOLUTIONS
GRADED A+
◉ The nurse is concerned about infection for a client after an
esophagogastrostomy for esophageal cancer. Which actions should
the nurse include in the client's plan of care? (Select all that apply.)
A.
Frequent oral care every 2 hours while awake.
B.
Use incentive spirometer every 2 hours.
C.
Empty contents from NG tube every 8 hours.
D.
Ambulate within 1 hour of return from the PACU.
E.
Limit visitors until postoperative day 2. Answer: A, B, C
Rationale:One hour post op is too soon to ambulate for this client.
Visitors help support the patient and are encouraged to visit. Oral
care is necessary as the client will be NPO. To decrease the risk of
infection post operatively, implement routine pulmonary exercises.
The client will have an NG tube in place, likely to intermittent
suction, to decompress the stomach post surgery.
,◉ The nurse is observing an unlicensed assistive personnel (UAP)
performing care for a bedridden client with advanced Huntington
disease. Which care measures are most important for the nurse to
supervise? (Select all that apply.)
A.
Oral care
B.
Bathing
C.
Foot care
D.
Catheter care
E.
Enteral feeding Answer: A, E
Rationale:The client with Huntington disease experiences problems
with motor skills such as swallowing and is at high risk for
aspiration, so the highest priority for the nurse to observe is the
UAP's ability to perform oral care and feeding safely. Options B, C,
and D do not necessarily require registered nurse (RN) supervision
because they do not ordinarily pose life-threatening consequences.
,◉ A tornado warning alarm has been activated at the local hospital.
Which action should the charge nurse working on a surgical unit
take first?
A.
Instruct the nursing staff to close all window blinds and curtains in
clients' rooms.
B.
Move clients and visitors into the hallways and close all doors to
clients' rooms.
C.
Visually confirm the location of the tornado by checking the
windows on the unit.
D.
Assist all visitors with evacuation down the stairs in a calm and
orderly manner. Answer: B
Rationale:In the event of a tornado, all persons should be moved into
the hallways, away from windows, to prevent flying debris from
causing injury. Although option A may help decrease the amount of
flying debris, it is not safe to leave clients in rooms with closed
blinds; option B is a higher priority at this time. Hospital staff should
stay away from windows to avoid injury and should focus on client
evacuation into hallways rather than option C. Option D is not the
first action that should be taken.
, ◉ The nurse is teaching a group of elders at a senior center. Which is
the most significant safety implication for this group that the nurse
will include in the teaching plan?
A.
Change in height
B.
Hair loss
C.
Stooped posture
D.
Age spots Answer: C
Rationale:Stooped posture results in the upper torso becoming the
center of gravity for older persons. The center of gravity for adults is
the hips. However, as a person grows older, a stooped posture is
common because of changes caused by osteoporosis and normal
bone degeneration. Furthermore, the knees, hips, and elbows flex.
This age-related change can put the older adult at risk for falls.
Options A, B, and D are age-related changes but are not high safety
concerns.
◉ An emaciated homeless client presents to the emergency
department complaining of a productive cough, with blood-tinged
sputum and night sweats. Which action is most important for the
emergency department triage nurse to take for this client?
A.
TEST PAPER QUESTIONS AND SOLUTIONS
GRADED A+
◉ The nurse is concerned about infection for a client after an
esophagogastrostomy for esophageal cancer. Which actions should
the nurse include in the client's plan of care? (Select all that apply.)
A.
Frequent oral care every 2 hours while awake.
B.
Use incentive spirometer every 2 hours.
C.
Empty contents from NG tube every 8 hours.
D.
Ambulate within 1 hour of return from the PACU.
E.
Limit visitors until postoperative day 2. Answer: A, B, C
Rationale:One hour post op is too soon to ambulate for this client.
Visitors help support the patient and are encouraged to visit. Oral
care is necessary as the client will be NPO. To decrease the risk of
infection post operatively, implement routine pulmonary exercises.
The client will have an NG tube in place, likely to intermittent
suction, to decompress the stomach post surgery.
,◉ The nurse is observing an unlicensed assistive personnel (UAP)
performing care for a bedridden client with advanced Huntington
disease. Which care measures are most important for the nurse to
supervise? (Select all that apply.)
A.
Oral care
B.
Bathing
C.
Foot care
D.
Catheter care
E.
Enteral feeding Answer: A, E
Rationale:The client with Huntington disease experiences problems
with motor skills such as swallowing and is at high risk for
aspiration, so the highest priority for the nurse to observe is the
UAP's ability to perform oral care and feeding safely. Options B, C,
and D do not necessarily require registered nurse (RN) supervision
because they do not ordinarily pose life-threatening consequences.
,◉ A tornado warning alarm has been activated at the local hospital.
Which action should the charge nurse working on a surgical unit
take first?
A.
Instruct the nursing staff to close all window blinds and curtains in
clients' rooms.
B.
Move clients and visitors into the hallways and close all doors to
clients' rooms.
C.
Visually confirm the location of the tornado by checking the
windows on the unit.
D.
Assist all visitors with evacuation down the stairs in a calm and
orderly manner. Answer: B
Rationale:In the event of a tornado, all persons should be moved into
the hallways, away from windows, to prevent flying debris from
causing injury. Although option A may help decrease the amount of
flying debris, it is not safe to leave clients in rooms with closed
blinds; option B is a higher priority at this time. Hospital staff should
stay away from windows to avoid injury and should focus on client
evacuation into hallways rather than option C. Option D is not the
first action that should be taken.
, ◉ The nurse is teaching a group of elders at a senior center. Which is
the most significant safety implication for this group that the nurse
will include in the teaching plan?
A.
Change in height
B.
Hair loss
C.
Stooped posture
D.
Age spots Answer: C
Rationale:Stooped posture results in the upper torso becoming the
center of gravity for older persons. The center of gravity for adults is
the hips. However, as a person grows older, a stooped posture is
common because of changes caused by osteoporosis and normal
bone degeneration. Furthermore, the knees, hips, and elbows flex.
This age-related change can put the older adult at risk for falls.
Options A, B, and D are age-related changes but are not high safety
concerns.
◉ An emaciated homeless client presents to the emergency
department complaining of a productive cough, with blood-tinged
sputum and night sweats. Which action is most important for the
emergency department triage nurse to take for this client?
A.
