MED SURG2 HESI GUIDE MEDICAL-SURGICAL
NURSING FORTIS COLLEGE 2026 UPDATE
1.Penicillin G procaine 240,000 units intramuscularly is prescribed for a 4-year-old child who
has a streptococcal respiratory infection. The medication vial is labeled 1,200,000 units/2 mL.
How many mL should the nurse administer? (Enter numeric value only. If rounding is required,
round to the nearest tenth.) 0.4 mL
2. A 4-year-old is admitted with a group and receives a prescription for a single dose of
dexamethasone 0.6 mg/kg IM. The child weighs 35 pounds. How many mg should the nurse
administer? (Enter numerical value only. If rounding is required, round to the nearest whole
number.) 10
3. Following a motor vehicle accident, a client with chest trauma receives a chest tube to
relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water
level in the water-seal chamber is rising during inspiration and falling during expiration. Which
action should the nurse implement? Continue to monitor the drainage system.
4. A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The
nurse should first assess the client for which precipitating factor?
An acutely distended bladder.
5.A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse
should first assess the client for which precipitating factor? An acutely distended bladder.
6.The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private
room with airborne precautions pending diagnostic test results. Which diagnostic test should the
nurse review to confirm the diagnosis of TB?
Sputum culture positive for Mycobacterium tuberculosis.
, lOMoAR cPSD| 67928686
7.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)] Continue the prescribed dose of lactulose.
8. The nurse is obtaining the admission history for a client with suspected peptic ulcer disease
(PUD). Which subjective data reported by the client supports this disease process? Upper mid
abdominal pain described as gnawing and burning.
9.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? Monitor urinary
stream for decrease in output.
10. The nurse is caring for a client receiving thrombolytic therapy following an acute
myocardial infarction (MI). Which nursing problem should the nurse identify as a priority for
this client? Risk for injury related to effects of thrombolysis.
11. The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding
requires immediate action by the nurse? High-pitched sound heard upon inspiration.
12. 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? Fatigue.
13.A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which
action should the nurse take next? Assess right radial pulse volume.
14.A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and
palpitations. Which finding is most important for the nurse to monitor? Excessive perspiration.
15.A client asks the nurse for information about how to reduce risk factors for benign prostatic
hyperplasia (BPH). Which information should the nurse provide? Increase physical activity.
,16. In assessing a client with skin ulcers on the lower extremity, which findings indicate that
the ulcers are likely to be of venous, rather than arterial origin? Irregular ulcer shapes and severe
edema.
17. A family suspects that AIDS dementia is occurring in their adult child who is HIV
positive. Which symptom confirms the suspicion? A change has recently occurred in
handwriting.
18. Five months following treatment for herpes zoster, an older adult client tells the home
health nurse to continue to experience pain where the rash occurred. Which action should the
nurse implement? Complete an assessment of the client's pain.
19.A client who reports feeling chronically fatigued has a hemoglobin of 10 g/dL (110 mmol/L).
hematocrit of 34% (0.34 volume fraction), and microcytic and hypochromic red blood cells
(RBCs). Based on these findings, which dinner selection should the nurse suggest to the client?
Reference Range.
Hemoglobin (Hgb) [16 to 18 g/dL (160 to 180 g/L)]
Hematocrit (Hct) [42% to 52% (0.42 to 0.52 volume fraction)]
9000
Beef steak with steamed broccoli and orange slices.
20. A postoperative client reports incisional pain. The client has two prescriptions for PRN
analgesia that accompanied the client from the post anesthesia unit. Before selecting which
medication to administer, which action should the nurse implement? Compare the client's pain
scale rating with the prescribed dosing.
21.A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with
severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
Occult positive emesis.
22.A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which
interpretation of this finding should the nurse make? Confirmation of the autoimmune disease
process.
, lOMoAR cPSD| 67928686
23.A client with metastatic cancer reports a pain level of 10 on a scale of 0 to 10. Twenty
minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which
intervention is most important for the nurse to include in this client's plan of care? Monitor client
for break through pain.
24. In providing discharge teaching to a client with chronic obstructive pulmonary disease
(COPD), which instruction is most important for the nurse to emphasize?
Notify the healthcare provider of any change in sputum color.
25.While completing a health assessment for a young adult female with acute appendicitis, the
client informs the nurse that there is a chance that she may be pregnant. The operating team is
preparing to take the client to surgery. Which intervention should the nurse implement
immediately? Perform a bedside pregnancy test.
26. The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary
Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is
adhering to the eating plan?
Enjoys fat free yogurt as an occasional snack food.
27.A client has an absolute neutrophil count (ANC) of 500/mm3 (0.5 x 10/L) after completing
chemotherapy. Which intervention is most important for the nurse to implement? Reference
Range:
Neutrophils (ANC) [2.500 to 5,800/mm (2.5 to 5.8 x 10/L)] Place the client in protective
isolation.
28. A patient is receiving a secondary infusion of vancomycin 1,500 mg in 250 mL to be
infused over two hours. The IV administration set delivers 10 gtt/mL. How many gtt/min should
the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the
nearest whole number.) 21
29. A patient receives a prescription for warfarin 2 mg IM daily. The pharmacy delivers a
vial labeled, warfarin 5 mg/single-use vial. The instructions read, reconstitute with 2.7 mL of
NURSING FORTIS COLLEGE 2026 UPDATE
1.Penicillin G procaine 240,000 units intramuscularly is prescribed for a 4-year-old child who
has a streptococcal respiratory infection. The medication vial is labeled 1,200,000 units/2 mL.
How many mL should the nurse administer? (Enter numeric value only. If rounding is required,
round to the nearest tenth.) 0.4 mL
2. A 4-year-old is admitted with a group and receives a prescription for a single dose of
dexamethasone 0.6 mg/kg IM. The child weighs 35 pounds. How many mg should the nurse
administer? (Enter numerical value only. If rounding is required, round to the nearest whole
number.) 10
3. Following a motor vehicle accident, a client with chest trauma receives a chest tube to
relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water
level in the water-seal chamber is rising during inspiration and falling during expiration. Which
action should the nurse implement? Continue to monitor the drainage system.
4. A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The
nurse should first assess the client for which precipitating factor?
An acutely distended bladder.
5.A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse
should first assess the client for which precipitating factor? An acutely distended bladder.
6.The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private
room with airborne precautions pending diagnostic test results. Which diagnostic test should the
nurse review to confirm the diagnosis of TB?
Sputum culture positive for Mycobacterium tuberculosis.
, lOMoAR cPSD| 67928686
7.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)] Continue the prescribed dose of lactulose.
8. The nurse is obtaining the admission history for a client with suspected peptic ulcer disease
(PUD). Which subjective data reported by the client supports this disease process? Upper mid
abdominal pain described as gnawing and burning.
9.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? Monitor urinary
stream for decrease in output.
10. The nurse is caring for a client receiving thrombolytic therapy following an acute
myocardial infarction (MI). Which nursing problem should the nurse identify as a priority for
this client? Risk for injury related to effects of thrombolysis.
11. The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding
requires immediate action by the nurse? High-pitched sound heard upon inspiration.
12. 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? Fatigue.
13.A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which
action should the nurse take next? Assess right radial pulse volume.
14.A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and
palpitations. Which finding is most important for the nurse to monitor? Excessive perspiration.
15.A client asks the nurse for information about how to reduce risk factors for benign prostatic
hyperplasia (BPH). Which information should the nurse provide? Increase physical activity.
,16. In assessing a client with skin ulcers on the lower extremity, which findings indicate that
the ulcers are likely to be of venous, rather than arterial origin? Irregular ulcer shapes and severe
edema.
17. A family suspects that AIDS dementia is occurring in their adult child who is HIV
positive. Which symptom confirms the suspicion? A change has recently occurred in
handwriting.
18. Five months following treatment for herpes zoster, an older adult client tells the home
health nurse to continue to experience pain where the rash occurred. Which action should the
nurse implement? Complete an assessment of the client's pain.
19.A client who reports feeling chronically fatigued has a hemoglobin of 10 g/dL (110 mmol/L).
hematocrit of 34% (0.34 volume fraction), and microcytic and hypochromic red blood cells
(RBCs). Based on these findings, which dinner selection should the nurse suggest to the client?
Reference Range.
Hemoglobin (Hgb) [16 to 18 g/dL (160 to 180 g/L)]
Hematocrit (Hct) [42% to 52% (0.42 to 0.52 volume fraction)]
9000
Beef steak with steamed broccoli and orange slices.
20. A postoperative client reports incisional pain. The client has two prescriptions for PRN
analgesia that accompanied the client from the post anesthesia unit. Before selecting which
medication to administer, which action should the nurse implement? Compare the client's pain
scale rating with the prescribed dosing.
21.A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with
severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
Occult positive emesis.
22.A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which
interpretation of this finding should the nurse make? Confirmation of the autoimmune disease
process.
, lOMoAR cPSD| 67928686
23.A client with metastatic cancer reports a pain level of 10 on a scale of 0 to 10. Twenty
minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which
intervention is most important for the nurse to include in this client's plan of care? Monitor client
for break through pain.
24. In providing discharge teaching to a client with chronic obstructive pulmonary disease
(COPD), which instruction is most important for the nurse to emphasize?
Notify the healthcare provider of any change in sputum color.
25.While completing a health assessment for a young adult female with acute appendicitis, the
client informs the nurse that there is a chance that she may be pregnant. The operating team is
preparing to take the client to surgery. Which intervention should the nurse implement
immediately? Perform a bedside pregnancy test.
26. The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary
Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is
adhering to the eating plan?
Enjoys fat free yogurt as an occasional snack food.
27.A client has an absolute neutrophil count (ANC) of 500/mm3 (0.5 x 10/L) after completing
chemotherapy. Which intervention is most important for the nurse to implement? Reference
Range:
Neutrophils (ANC) [2.500 to 5,800/mm (2.5 to 5.8 x 10/L)] Place the client in protective
isolation.
28. A patient is receiving a secondary infusion of vancomycin 1,500 mg in 250 mL to be
infused over two hours. The IV administration set delivers 10 gtt/mL. How many gtt/min should
the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the
nearest whole number.) 21
29. A patient receives a prescription for warfarin 2 mg IM daily. The pharmacy delivers a
vial labeled, warfarin 5 mg/single-use vial. The instructions read, reconstitute with 2.7 mL of
