HESI PN MEDICAL-SURGICAL (NGN) EXAM
QUESTIONS AND CORRECT VERIFIED
ANSWERS WITH RATIONALES ||
100% GUARANTEED PASS!!
<LATEST VERSION>
1.
A 68-year-old client with a history of heart failure reports increasing shortness of
breath over the past two days. Assessment reveals crackles in both lung bases,
jugular venous distention, bilateral ankle edema, respiratory rate 28/min, and
oxygen saturation of 89% on room air. Which action should the nurse take first?
A. Administer the prescribed IV furosemide.
B. Encourage oral fluid intake.
C. Elevate the client's legs.
D. Obtain a daily weight.
Answer: A
Rationale: Pulmonary congestion and hypoxemia indicate acute fluid overload.
Administering the prescribed loop diuretic addresses the immediate cause of
respiratory compromise. The remaining interventions are appropriate but do not
correct the urgent problem.
,2.
A client admitted with bacterial pneumonia suddenly becomes confused and
restless. Vital signs are BP 130/76 mm Hg, HR 118/min, RR 30/min, temperature
38.8°C (101.8°F), and oxygen saturation 84% on room air. Which nursing
intervention has the highest priority?
A. Apply supplemental oxygen.
B. Administer acetaminophen.
C. Encourage oral fluids.
D. Collect a sputum specimen.
Answer: A
Rationale: Hypoxemia is the most immediate threat. Oxygen therapy improves
tissue oxygenation while additional assessments and treatments are completed.
3.
A client with type 2 diabetes is receiving regular insulin before meals. Before
administering the scheduled dose, the nurse notes the client is diaphoretic, shaky,
and confused. Which action is appropriate first?
A. Check the blood glucose level.
B. Administer the scheduled insulin.
C. Notify the healthcare provider.
D. Encourage ambulation.
Answer: A
Rationale: The symptoms suggest hypoglycemia. Blood glucose should be
verified immediately before additional insulin is administered.
,4.
The nurse is caring for a client 24 hours after a thyroidectomy. Which finding
requires immediate intervention?
A. Hoarseness and inspiratory stridor
B. Mild incisional discomfort
C. Blood pressure 138/82 mm Hg
D. Small amount of serosanguineous drainage
Answer: A
Rationale: Stridor may indicate airway obstruction caused by swelling or
hemorrhage and requires immediate intervention.
5.
A client with chronic kidney disease has the following laboratory results:
Potassium: 6.4 mEq/L
Creatinine: 5.7 mg/dL
BUN: 74 mg/dL
Which assessment finding is most concerning?
A. Peaked T waves on ECG
B. Blood pressure 148/88 mm Hg
C. Mild ankle edema
D. Fatigue
Answer: A
Rationale: Hyperkalemia places the client at high risk for lethal cardiac
dysrhythmias.
, 6.
A client is receiving a transfusion of packed red blood cells. Fifteen minutes after
initiation, the client develops chills, fever, flank pain, and dyspnea. What should
the nurse do first?
A. Stop the transfusion.
B. Increase the infusion rate.
C. Administer acetaminophen.
D. Notify the laboratory after the transfusion is complete.
Answer: A
Rationale: These findings suggest an acute transfusion reaction. The transfusion
must be stopped immediately while maintaining IV access with normal saline.
7.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen
at 2 L/min via nasal cannula. Oxygen saturation improves from 86% to 91%.
Which action is most appropriate?
A. Continue the prescribed oxygen therapy.
B. Increase oxygen to 8 L/min.
C. Discontinue oxygen therapy.
D. Place the client in Trendelenburg position.
Answer: A
Rationale: Oxygen saturation has improved to an acceptable level for many clients
with COPD while minimizing the risk of oxygen-induced hypoventilation.
QUESTIONS AND CORRECT VERIFIED
ANSWERS WITH RATIONALES ||
100% GUARANTEED PASS!!
<LATEST VERSION>
1.
A 68-year-old client with a history of heart failure reports increasing shortness of
breath over the past two days. Assessment reveals crackles in both lung bases,
jugular venous distention, bilateral ankle edema, respiratory rate 28/min, and
oxygen saturation of 89% on room air. Which action should the nurse take first?
A. Administer the prescribed IV furosemide.
B. Encourage oral fluid intake.
C. Elevate the client's legs.
D. Obtain a daily weight.
Answer: A
Rationale: Pulmonary congestion and hypoxemia indicate acute fluid overload.
Administering the prescribed loop diuretic addresses the immediate cause of
respiratory compromise. The remaining interventions are appropriate but do not
correct the urgent problem.
,2.
A client admitted with bacterial pneumonia suddenly becomes confused and
restless. Vital signs are BP 130/76 mm Hg, HR 118/min, RR 30/min, temperature
38.8°C (101.8°F), and oxygen saturation 84% on room air. Which nursing
intervention has the highest priority?
A. Apply supplemental oxygen.
B. Administer acetaminophen.
C. Encourage oral fluids.
D. Collect a sputum specimen.
Answer: A
Rationale: Hypoxemia is the most immediate threat. Oxygen therapy improves
tissue oxygenation while additional assessments and treatments are completed.
3.
A client with type 2 diabetes is receiving regular insulin before meals. Before
administering the scheduled dose, the nurse notes the client is diaphoretic, shaky,
and confused. Which action is appropriate first?
A. Check the blood glucose level.
B. Administer the scheduled insulin.
C. Notify the healthcare provider.
D. Encourage ambulation.
Answer: A
Rationale: The symptoms suggest hypoglycemia. Blood glucose should be
verified immediately before additional insulin is administered.
,4.
The nurse is caring for a client 24 hours after a thyroidectomy. Which finding
requires immediate intervention?
A. Hoarseness and inspiratory stridor
B. Mild incisional discomfort
C. Blood pressure 138/82 mm Hg
D. Small amount of serosanguineous drainage
Answer: A
Rationale: Stridor may indicate airway obstruction caused by swelling or
hemorrhage and requires immediate intervention.
5.
A client with chronic kidney disease has the following laboratory results:
Potassium: 6.4 mEq/L
Creatinine: 5.7 mg/dL
BUN: 74 mg/dL
Which assessment finding is most concerning?
A. Peaked T waves on ECG
B. Blood pressure 148/88 mm Hg
C. Mild ankle edema
D. Fatigue
Answer: A
Rationale: Hyperkalemia places the client at high risk for lethal cardiac
dysrhythmias.
, 6.
A client is receiving a transfusion of packed red blood cells. Fifteen minutes after
initiation, the client develops chills, fever, flank pain, and dyspnea. What should
the nurse do first?
A. Stop the transfusion.
B. Increase the infusion rate.
C. Administer acetaminophen.
D. Notify the laboratory after the transfusion is complete.
Answer: A
Rationale: These findings suggest an acute transfusion reaction. The transfusion
must be stopped immediately while maintaining IV access with normal saline.
7.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen
at 2 L/min via nasal cannula. Oxygen saturation improves from 86% to 91%.
Which action is most appropriate?
A. Continue the prescribed oxygen therapy.
B. Increase oxygen to 8 L/min.
C. Discontinue oxygen therapy.
D. Place the client in Trendelenburg position.
Answer: A
Rationale: Oxygen saturation has improved to an acceptable level for many clients
with COPD while minimizing the risk of oxygen-induced hypoventilation.
