HESI Medical-Surgical Nursing
Q1. The nurse is caring for four patients on a medical-surgical unit. Which patient should the
nurse assess first?
A) A 45-year-old with diabetes and a blood glucose of 180 mg/dL
B) A 68-year-old with pneumonia and an oxygen saturation of 89% on room air
C) A 72-year-old with heart failure and 2+ pitting edema in the lower extremities
D) A 55-year-old with a hip fracture who is requesting pain medication
E) A 60-year-old with a urinary tract infection and a temperature of 38.2°C (100.8°F)
Detailed Answer:
Correct Answer: B
The patient with pneumonia and an oxygen saturation of 89% is hypoxemic and requires
immediate intervention to prevent respiratory failure. Airway and breathing are always the top
priorities. The other patients have urgent but not immediately life-threatening issues:
hyperglycemia (A) can be managed, edema (C) is chronic, pain (D) is important but not
emergent, and a low-grade fever (E) is expected.
Q2. The nurse is delegating tasks to a licensed practical nurse (LPN) and a nursing assistant
(UAP). Which task is most appropriate for the nurse to delegate to the LPN?
A) Assisting a patient with ambulation
B) Administering a tube feeding to a patient with a gastrostomy tube
C) Teaching a patient about insulin administration
D) Performing a comprehensive admission assessment
E) Changing a sterile dressing on a postoperative wound
Detailed Answer:
Correct Answer: B
LPNs can administer enteral feedings (via gastrostomy or nasogastric tube) and perform many
technical skills. Assisting with ambulation (A) is appropriate for a UAP. Teaching (C) and
comprehensive assessment (D) must be performed by the RN. Changing a sterile dressing (E)
may be within the LPN's scope depending on state regulations, but tube feeding is a more
standard LPN task.
Q3. A patient is prescribed warfarin (Coumadin) for atrial fibrillation. The nurse notes an INR
of 4.5. The patient is asymptomatic. Which of the following is the nurse's priority action?
A) Administer vitamin K 10 mg IM
B) Hold the next dose of warfarin and notify the healthcare provider
,C) Increase the warfarin dose
D) Administer fresh frozen plasma
E) Continue the warfarin as prescribed
Detailed Answer:
Correct Answer: B
An INR of 4.5 is above the therapeutic range (2-3 for atrial fibrillation). The patient is
asymptomatic, so the first action is to hold the dose and notify the provider. Vitamin K (A) is
used for life-threatening bleeding. FFP (D) is for emergent reversal. Increasing the dose (C) is
contraindicated. Continuing (E) would increase bleeding risk.
Q4. The nurse is caring for a patient who is 24 hours post-total hip arthroplasty. Which finding
requires immediate notification of the surgeon?
A) Pain rated 4 out of 10
B) Slight erythema at the incision site
C) Sudden onset of shortness of breath and chest pain
D) Blood pressure of 142/88 mmHg
E) Urinary output of 30 mL/hr
Detailed Answer:
Correct Answer: C
Sudden dyspnea and chest pain in a postoperative patient are classic signs of a pulmonary
embolism (PE), a life-threatening complication of hip surgery. This requires immediate
notification and intervention. The other findings are expected or manageable: pain (A), mild
erythema (B), mild hypertension (D), and urine output 30 mL/hr (E) are within acceptable limits
or expected.
Q5. The nurse is caring for a patient with a nasogastric (NG) tube set to low intermittent
suction. The patient reports nausea and abdominal distension. The nurse should first:
A) Irrigate the NG tube with 50 mL of normal saline
B) Check the placement of the NG tube
C) Increase the suction pressure
D) Administer an antiemetic
E) Remove the NG tube
Detailed Answer:
Correct Answer: B
Nausea and distension with an NG tube suggest that the tube may be dislodged or clogged. The
,first action is to check placement (by auscultating the air bolus or checking pH of aspirate) to
ensure the tube is in the stomach. Irrigating (A) is done if the tube is patent but clogged.
Increasing suction (C) is not the first step. Antiemetics (D) may be given later. Removing the tube
(E) is not indicated.
Q6. A patient with a history of heart failure is receiving furosemide (Lasix) IV. The nurse
should monitor for which of the following adverse effects?
A) Hyperkalemia
B) Hypokalemia
C) Hyponatremia
D) Hypercalcemia
E) Both B and C
Detailed Answer:
Correct Answer: E
Furosemide is a loop diuretic that causes loss of potassium (hypokalemia) and sodium
(hyponatremia). It also causes hypocalcemia and hypomagnesemia. Hyperkalemia (A) is not an
effect of furosemide (it's a side effect of potassium-sparing diuretics). Hypercalcemia (D) is not
an effect.
Q7. The nurse is preparing to administer a blood transfusion to a patient. Which of the
following actions is most important before starting the transfusion?
A) Check the patient's vital signs
B) Obtain informed consent
C) Verify the blood product with another licensed professional
D) Administer premedication with diphenhydramine
E) Ensure the patient has a patent IV line
Detailed Answer:
Correct Answer: C
Verifying the blood product with another licensed professional (RN or provider) is the most
critical safety measure to prevent transfusion errors. It involves checking the patient's identity,
blood type, Rh factor, and the unit number. Vital signs (A) and consent (B) are also important
but verification is the priority. Premedication (D) is not routine. A patent IV (E) is needed but not
the most important safety step.
, Q8. A patient with cirrhosis is admitted with ascites. Which of the following nursing
interventions is the highest priority?
A) Measure abdominal girth daily
B) Monitor serum albumin levels
C) Assess respiratory status daily
D) Provide a low-sodium diet
E) Prepare for paracentesis
Detailed Answer:
Correct Answer: C
Ascites can lead to respiratory compromise due to pressure on the diaphragm. While all options
are appropriate, assessing respiratory status (especially for dyspnea and orthopnea) is the
highest priority because it addresses a potential life-threatening complication. Daily girth (A)
and sodium restriction (D) are important but not the top priority.
Q9. The nurse is caring for a patient with an order for a 24-hour urine collection. Which of the
following actions is correct?
A) Start the collection at 0600 and end at 0600 the next day
B) Discard the first void and start the collection with the second void
C) Collect all urine in a container without preservatives
D) Label the container with the patient's name and date only
E) Keep the container at room temperature
Detailed Answer:
Correct Answer: B
For a 24-hour urine collection, the first void of the day is discarded, and the collection begins
with the second void. All subsequent urine is collected for 24 hours, and the final void at the
end of the period is included. Option A is incorrect because you don't start with the first void.
Preservatives (C) may be required depending on the test. The container should be labeled with
name, date, time, and type of collection (D). It should be refrigerated or kept on ice (E).
Q10. The nurse is caring for a patient with an indwelling urinary catheter. Which of the
following interventions is most important to prevent catheter-associated urinary tract
infection (CAUTI)?
A) Empty the drainage bag every 8 hours
B) Maintain a closed drainage system
C) Clean the perineal area with soap and water twice daily
Q1. The nurse is caring for four patients on a medical-surgical unit. Which patient should the
nurse assess first?
A) A 45-year-old with diabetes and a blood glucose of 180 mg/dL
B) A 68-year-old with pneumonia and an oxygen saturation of 89% on room air
C) A 72-year-old with heart failure and 2+ pitting edema in the lower extremities
D) A 55-year-old with a hip fracture who is requesting pain medication
E) A 60-year-old with a urinary tract infection and a temperature of 38.2°C (100.8°F)
Detailed Answer:
Correct Answer: B
The patient with pneumonia and an oxygen saturation of 89% is hypoxemic and requires
immediate intervention to prevent respiratory failure. Airway and breathing are always the top
priorities. The other patients have urgent but not immediately life-threatening issues:
hyperglycemia (A) can be managed, edema (C) is chronic, pain (D) is important but not
emergent, and a low-grade fever (E) is expected.
Q2. The nurse is delegating tasks to a licensed practical nurse (LPN) and a nursing assistant
(UAP). Which task is most appropriate for the nurse to delegate to the LPN?
A) Assisting a patient with ambulation
B) Administering a tube feeding to a patient with a gastrostomy tube
C) Teaching a patient about insulin administration
D) Performing a comprehensive admission assessment
E) Changing a sterile dressing on a postoperative wound
Detailed Answer:
Correct Answer: B
LPNs can administer enteral feedings (via gastrostomy or nasogastric tube) and perform many
technical skills. Assisting with ambulation (A) is appropriate for a UAP. Teaching (C) and
comprehensive assessment (D) must be performed by the RN. Changing a sterile dressing (E)
may be within the LPN's scope depending on state regulations, but tube feeding is a more
standard LPN task.
Q3. A patient is prescribed warfarin (Coumadin) for atrial fibrillation. The nurse notes an INR
of 4.5. The patient is asymptomatic. Which of the following is the nurse's priority action?
A) Administer vitamin K 10 mg IM
B) Hold the next dose of warfarin and notify the healthcare provider
,C) Increase the warfarin dose
D) Administer fresh frozen plasma
E) Continue the warfarin as prescribed
Detailed Answer:
Correct Answer: B
An INR of 4.5 is above the therapeutic range (2-3 for atrial fibrillation). The patient is
asymptomatic, so the first action is to hold the dose and notify the provider. Vitamin K (A) is
used for life-threatening bleeding. FFP (D) is for emergent reversal. Increasing the dose (C) is
contraindicated. Continuing (E) would increase bleeding risk.
Q4. The nurse is caring for a patient who is 24 hours post-total hip arthroplasty. Which finding
requires immediate notification of the surgeon?
A) Pain rated 4 out of 10
B) Slight erythema at the incision site
C) Sudden onset of shortness of breath and chest pain
D) Blood pressure of 142/88 mmHg
E) Urinary output of 30 mL/hr
Detailed Answer:
Correct Answer: C
Sudden dyspnea and chest pain in a postoperative patient are classic signs of a pulmonary
embolism (PE), a life-threatening complication of hip surgery. This requires immediate
notification and intervention. The other findings are expected or manageable: pain (A), mild
erythema (B), mild hypertension (D), and urine output 30 mL/hr (E) are within acceptable limits
or expected.
Q5. The nurse is caring for a patient with a nasogastric (NG) tube set to low intermittent
suction. The patient reports nausea and abdominal distension. The nurse should first:
A) Irrigate the NG tube with 50 mL of normal saline
B) Check the placement of the NG tube
C) Increase the suction pressure
D) Administer an antiemetic
E) Remove the NG tube
Detailed Answer:
Correct Answer: B
Nausea and distension with an NG tube suggest that the tube may be dislodged or clogged. The
,first action is to check placement (by auscultating the air bolus or checking pH of aspirate) to
ensure the tube is in the stomach. Irrigating (A) is done if the tube is patent but clogged.
Increasing suction (C) is not the first step. Antiemetics (D) may be given later. Removing the tube
(E) is not indicated.
Q6. A patient with a history of heart failure is receiving furosemide (Lasix) IV. The nurse
should monitor for which of the following adverse effects?
A) Hyperkalemia
B) Hypokalemia
C) Hyponatremia
D) Hypercalcemia
E) Both B and C
Detailed Answer:
Correct Answer: E
Furosemide is a loop diuretic that causes loss of potassium (hypokalemia) and sodium
(hyponatremia). It also causes hypocalcemia and hypomagnesemia. Hyperkalemia (A) is not an
effect of furosemide (it's a side effect of potassium-sparing diuretics). Hypercalcemia (D) is not
an effect.
Q7. The nurse is preparing to administer a blood transfusion to a patient. Which of the
following actions is most important before starting the transfusion?
A) Check the patient's vital signs
B) Obtain informed consent
C) Verify the blood product with another licensed professional
D) Administer premedication with diphenhydramine
E) Ensure the patient has a patent IV line
Detailed Answer:
Correct Answer: C
Verifying the blood product with another licensed professional (RN or provider) is the most
critical safety measure to prevent transfusion errors. It involves checking the patient's identity,
blood type, Rh factor, and the unit number. Vital signs (A) and consent (B) are also important
but verification is the priority. Premedication (D) is not routine. A patent IV (E) is needed but not
the most important safety step.
, Q8. A patient with cirrhosis is admitted with ascites. Which of the following nursing
interventions is the highest priority?
A) Measure abdominal girth daily
B) Monitor serum albumin levels
C) Assess respiratory status daily
D) Provide a low-sodium diet
E) Prepare for paracentesis
Detailed Answer:
Correct Answer: C
Ascites can lead to respiratory compromise due to pressure on the diaphragm. While all options
are appropriate, assessing respiratory status (especially for dyspnea and orthopnea) is the
highest priority because it addresses a potential life-threatening complication. Daily girth (A)
and sodium restriction (D) are important but not the top priority.
Q9. The nurse is caring for a patient with an order for a 24-hour urine collection. Which of the
following actions is correct?
A) Start the collection at 0600 and end at 0600 the next day
B) Discard the first void and start the collection with the second void
C) Collect all urine in a container without preservatives
D) Label the container with the patient's name and date only
E) Keep the container at room temperature
Detailed Answer:
Correct Answer: B
For a 24-hour urine collection, the first void of the day is discarded, and the collection begins
with the second void. All subsequent urine is collected for 24 hours, and the final void at the
end of the period is included. Option A is incorrect because you don't start with the first void.
Preservatives (C) may be required depending on the test. The container should be labeled with
name, date, time, and type of collection (D). It should be refrigerated or kept on ice (E).
Q10. The nurse is caring for a patient with an indwelling urinary catheter. Which of the
following interventions is most important to prevent catheter-associated urinary tract
infection (CAUTI)?
A) Empty the drainage bag every 8 hours
B) Maintain a closed drainage system
C) Clean the perineal area with soap and water twice daily
