HESI: Medical-Surgical Assignment Exam and Rationalg v g v g v g v g v
1. Which assessment is most important for the nurse to perform on a client wh
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o is hospitalized for Guillain-
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Barre syndrome that is rapidly progressing? A: Respiratory effort.
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B: Unsteady gait. C
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: Intensity of pain.
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D: Ability to eat.: A: Respiratory Ettort
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(Guillain-
Barre syndrome causes paralysis or weakness that typically starts at the feet and progresses upwards. As the condition
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progresses, the nurse must ensure that the client is able to breathe ettectively.)
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2. A male client comes into the clinic with a history of penile discharge with
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painful, burning urination. Which action should the nurse implement?
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g A: Collect a culture of the penile discharge.
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B: Palpate the inguinal lymph nodes gently.
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C: Observe for scrotal swelling and redness.
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D: Express the discharge to determine color.: A: Collect a culture of the penile discharge.
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(Penile discharge with painful urination is commonly associated with gonorrhea. The nurse should collect a culture of t
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he penile discharge to determine the cause of these symptoms. The cause must be determined or confirmed throug
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h culture to identify the organism and ensure ettective treatment.)
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3. A client with history of atrial fibrillation is admitted to the telemetry unit
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with sudden onset of shortness of breath. The nurse observes a new irregular
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heart rhythm and should perform which assessment at this time?
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A: Check for a pulse deficit. B
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: Palpate the apical impulse. C
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: Inspect jugular vein pulse.
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D: Examine for a carotid bruit.: A: Check for a pulse deficit.
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(A client with a past history of atrial fibrillation may return to that rhythm. Any signs of atrial fibrillation, such as sudden onse
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t shortness of breath, requires further investigation. The nurse should assess this client for a pulse deficit because this condi
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tion occurs with atrial fibrillation.)
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4. Which client should be further assessed for an ectopic pregnancy?
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A: A 24-year-old with shoulder and lower abdominal quadrant pain.
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1gv/gv75
, HESI: Medical-Surgical Assignment Exam and Rational
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B: A 33-year- g v g v
old with intermittent lower abdominal cramping. C: A 20-year-
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old with fever and right lower abdominal colic.
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D: A 40-year-old with jaundice and right lower abdominal pain.: A:A24-year-
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oldwith shoulder and lower abdominal quadrant pain.
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(A 24-year-
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old with sudden onset of lower abdominal quadrant pain should be assessed for an ectopic pregnancy. The pain can al
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so be referred to the shoulder and may be associated with vaginal bleeding.)
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5. Which dietary assessment finding is most important for the nurse to address
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when caring for a client with diabetic nephropathy? A
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: Drinks a six pack of beer every day.
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B: Enjoys a hamburger once a month. C
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: Eats fortified breakfast cereal daily.
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D: Consumes beans and rice every day.: A: Drinks a six pack of beer every day.
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(Drinking six beers every day is the dietary assessment finding most important for the nurse to address when caring for a
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client with diabetic nephropathy. The usual can of beer is 12 ounces (355 mL). Clients with diabetes are recommended
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to drink no more than 12 ounces of beer per day because beer contains carbohydrates that can create unhealthyfluctuatio
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nsinblood glucoseandpromotepoorglucosecontrol.Nephropathy isexacerbatedbypoorblood glucose control.)
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6. Which assessment finding is of greatest concern to the nurse who is carin
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g
for a client with stomatitis?
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A: Cough brought on by swallowing. B
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: Sore throat caused by speaking.
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C: Painful and dry oral cavity.
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D: Unintended weight loss.: A: Cough brought on by swallowing.
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A cough brought on by swallowing is a sign of dysphagia, which is a finding of particular concern in a client with stom
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atitis. Dysphagia can cause numerous problems, including airway obstruction, and should be reported to the healthcar
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e provider immediately.
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7. The nurse is teaching a client diagnosed with peripheral arterial disease.
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Which genitourinary system complication should the nurse include in the tea
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2gv/gv75
, HESI: Medical-Surgical Assignment Exam and Rational
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ching?
3gv/gv75
, HESI: Medical-Surgical Assignment Exam and Rational
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A: Altered sexual response. B
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: Sterility.
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C: Urinary incontinence.
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D: Decreased pelvic muscle tone.: A: Altered sexual response.
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Peripheral arterial disease (PAD) is a cardiovascular condition characterized by narrowing of the arteries and reduced blo
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od flow to the extremities. PAD is known to alter the blood flow to the male's penis and is associated with erectile dysfunct
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ion in men. gv gv
8. A 40-year-old female client has a history of smoking. Which finding should
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the nurse identify as a risk factor for myocardia infarction? A
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: Oral contraceptives.
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B: Senile osteopenia.gv gv
C: Levothyroxine therapy.
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D: Pernicious anemia.: A: Oral contraceptives.
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Women older than 35 years old who smoke and take oral contraceptives have an increased risk of myocardial infarction or str
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oke.
9. A client has been told that there is cataract formation over both eyes. Which
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finding should the nurse expect when assessing the client?
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A: Decreased color perception.
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B: Presence of floaters.
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C: Loss of central vision.
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D: Reduced peripheral vision.: A: Decreased color perception.
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Decreased color perception occurs with cataract formation. Cataract formation is also associated with blurred vision an
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d a global loss of vision so gradual that the client may not be aware of it.
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10. Which assessment finding should most concern the nurse who is monitor
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-
ing a client two hours after a thoracentesis?
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A: New onset of coughing.
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B: Low resting heart rate. C
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: Distended neck veins.
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D: Decreased shallow respirations.: A: New onset of coughing.
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4gv/gv75
1. Which assessment is most important for the nurse to perform on a client wh
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o is hospitalized for Guillain-
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Barre syndrome that is rapidly progressing? A: Respiratory effort.
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B: Unsteady gait. C
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: Intensity of pain.
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D: Ability to eat.: A: Respiratory Ettort
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(Guillain-
Barre syndrome causes paralysis or weakness that typically starts at the feet and progresses upwards. As the condition
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progresses, the nurse must ensure that the client is able to breathe ettectively.)
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2. A male client comes into the clinic with a history of penile discharge with
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painful, burning urination. Which action should the nurse implement?
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g A: Collect a culture of the penile discharge.
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B: Palpate the inguinal lymph nodes gently.
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C: Observe for scrotal swelling and redness.
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D: Express the discharge to determine color.: A: Collect a culture of the penile discharge.
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(Penile discharge with painful urination is commonly associated with gonorrhea. The nurse should collect a culture of t
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he penile discharge to determine the cause of these symptoms. The cause must be determined or confirmed throug
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h culture to identify the organism and ensure ettective treatment.)
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3. A client with history of atrial fibrillation is admitted to the telemetry unit
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with sudden onset of shortness of breath. The nurse observes a new irregular
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heart rhythm and should perform which assessment at this time?
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A: Check for a pulse deficit. B
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: Palpate the apical impulse. C
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: Inspect jugular vein pulse.
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D: Examine for a carotid bruit.: A: Check for a pulse deficit.
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(A client with a past history of atrial fibrillation may return to that rhythm. Any signs of atrial fibrillation, such as sudden onse
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t shortness of breath, requires further investigation. The nurse should assess this client for a pulse deficit because this condi
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tion occurs with atrial fibrillation.)
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4. Which client should be further assessed for an ectopic pregnancy?
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A: A 24-year-old with shoulder and lower abdominal quadrant pain.
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1gv/gv75
, HESI: Medical-Surgical Assignment Exam and Rational
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B: A 33-year- g v g v
old with intermittent lower abdominal cramping. C: A 20-year-
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old with fever and right lower abdominal colic.
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D: A 40-year-old with jaundice and right lower abdominal pain.: A:A24-year-
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oldwith shoulder and lower abdominal quadrant pain.
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(A 24-year-
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old with sudden onset of lower abdominal quadrant pain should be assessed for an ectopic pregnancy. The pain can al
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so be referred to the shoulder and may be associated with vaginal bleeding.)
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5. Which dietary assessment finding is most important for the nurse to address
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when caring for a client with diabetic nephropathy? A
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: Drinks a six pack of beer every day.
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B: Enjoys a hamburger once a month. C
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: Eats fortified breakfast cereal daily.
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D: Consumes beans and rice every day.: A: Drinks a six pack of beer every day.
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(Drinking six beers every day is the dietary assessment finding most important for the nurse to address when caring for a
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client with diabetic nephropathy. The usual can of beer is 12 ounces (355 mL). Clients with diabetes are recommended
v gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv
to drink no more than 12 ounces of beer per day because beer contains carbohydrates that can create unhealthyfluctuatio
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nsinblood glucoseandpromotepoorglucosecontrol.Nephropathy isexacerbatedbypoorblood glucose control.)
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6. Which assessment finding is of greatest concern to the nurse who is carin
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for a client with stomatitis?
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A: Cough brought on by swallowing. B
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: Sore throat caused by speaking.
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C: Painful and dry oral cavity.
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D: Unintended weight loss.: A: Cough brought on by swallowing.
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A cough brought on by swallowing is a sign of dysphagia, which is a finding of particular concern in a client with stom
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atitis. Dysphagia can cause numerous problems, including airway obstruction, and should be reported to the healthcar
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e provider immediately.
gv gv
7. The nurse is teaching a client diagnosed with peripheral arterial disease.
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Which genitourinary system complication should the nurse include in the tea
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2gv/gv75
, HESI: Medical-Surgical Assignment Exam and Rational
g v g v g v g v g v
ching?
3gv/gv75
, HESI: Medical-Surgical Assignment Exam and Rational
g v g v g v g v g v
A: Altered sexual response. B
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: Sterility.
gv
C: Urinary incontinence.
gv gv
D: Decreased pelvic muscle tone.: A: Altered sexual response.
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Peripheral arterial disease (PAD) is a cardiovascular condition characterized by narrowing of the arteries and reduced blo
gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv
od flow to the extremities. PAD is known to alter the blood flow to the male's penis and is associated with erectile dysfunct
gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv
ion in men. gv gv
8. A 40-year-old female client has a history of smoking. Which finding should
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the nurse identify as a risk factor for myocardia infarction? A
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: Oral contraceptives.
gv gv
B: Senile osteopenia.gv gv
C: Levothyroxine therapy.
gv gv
D: Pernicious anemia.: A: Oral contraceptives.
gv gv gv gv gv
Women older than 35 years old who smoke and take oral contraceptives have an increased risk of myocardial infarction or str
gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv
oke.
9. A client has been told that there is cataract formation over both eyes. Which
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finding should the nurse expect when assessing the client?
g v g v g v g v g v g v g v g v
A: Decreased color perception.
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B: Presence of floaters.
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C: Loss of central vision.
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D: Reduced peripheral vision.: A: Decreased color perception.
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Decreased color perception occurs with cataract formation. Cataract formation is also associated with blurred vision an
gv gv gv gv gv gv gv gv gv gv gv gv gv gv gv
d a global loss of vision so gradual that the client may not be aware of it.
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10. Which assessment finding should most concern the nurse who is monitor
g v g v g v g v g v g v g v g v g v g v
-
ing a client two hours after a thoracentesis?
gv gv gv gv gv gv gv gv
A: New onset of coughing.
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B: Low resting heart rate. C
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: Distended neck veins.
gv gv gv
D: Decreased shallow respirations.: A: New onset of coughing.
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4gv/gv75
