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HESI MEDICAL SURGICAL ACTUAL EXAM QUESTIONS WITH
DETAILED RATIONALE
When planning care for a client with right renal calculi, which nursing diagnosis has the
highest priority?
Acute pain related to movement of the stone
Impaired urinary elimination related to
Risk for infection related to urinary stasis.
Deficient knowledge related to need for
Rationale
The nursing diagnosis of the highest priority is "Acute pain related the the renal calculi's
movement".
The nurse is caring for a client with non-Hodgkin’s lymphoma who is receiving
chemotherapy.
Laboratory results reveal a platelet count of 10,000/ml. What action should the nurse
implement?
Encourage fluids to 3000 ml/day.
Check stools for occult blood.
Provide oral hygiene every 2 hours.
Check for fever every 4 hours.
Rationale
Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common side
effect of chemotherapy. A client with thrombocytopenia should be assessed frequently for
occult bleeding in the emesis, sputum, feces, urine, nasogastric secretions, or wounds.
A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and
asks the nurse how long will antibiotics have to be administered. Which information should the
nurse communicate?
Oral antibiotics for 2 to 4 months,
then for dental procedure
prophylaxis. Parenteral antibiotics
for 4 to 6 weeks, then oral
antibiotics for up to 1 year.
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Rationale
Treatment of acute osteomyelitis requires administration of high doses of parenteral antibiotics
for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks.
The unlicensed assistive personnel (UAP) reports that an 87-year-old female client who is sitting in
a chair at the bedside has an oral temperature of 97.2 F ( 36.4 C). Which intervention should the
nurse implement?
Document the temperature reading on the
vital sign graphic sheet.
Report the temperature to the
healthcare provider
immediately. Instruct the UAP to
Rationale
A subnormal temperature of 97.2 F (36.4 C) (orally) is a common finding in elderly clients, so the
nurse should document the findings and continue with the plan of care.
When teaching a client with breast cancer about the prescribed radiation therapy for
treatment, what information is important to include?
Dry, itchy skin changes may occur.
There is a possibility of long bone pain.
Permanent pigment changes to the breast
A low-residue diet may be ordered to reduce
Rationale
Side effects from radiation to the breast most often include temporary skin changes such as:
dryness, tenderness, redness, swelling, and pruritis.
The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which
finding should the nurse assess further?
Thinning hair and dry scalp.
Increase in appetite and taste-bud acuity.
Increase in muscle tone but decreased musc
Increase in abdominal fat deposits.
Rationale
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HESI MEDICAL SURGICAL ACTUAL EXAM QUESTIONS WITH
DETAILED RATIONALE
When planning care for a client with right renal calculi, which nursing diagnosis has the
highest priority?
Acute pain related to movement of the stone
Impaired urinary elimination related to
Risk for infection related to urinary stasis.
Deficient knowledge related to need for
Rationale
The nursing diagnosis of the highest priority is "Acute pain related the the renal calculi's
movement".
The nurse is caring for a client with non-Hodgkin’s lymphoma who is receiving
chemotherapy.
Laboratory results reveal a platelet count of 10,000/ml. What action should the nurse
implement?
Encourage fluids to 3000 ml/day.
Check stools for occult blood.
Provide oral hygiene every 2 hours.
Check for fever every 4 hours.
Rationale
Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common side
effect of chemotherapy. A client with thrombocytopenia should be assessed frequently for
occult bleeding in the emesis, sputum, feces, urine, nasogastric secretions, or wounds.
A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and
asks the nurse how long will antibiotics have to be administered. Which information should the
nurse communicate?
Oral antibiotics for 2 to 4 months,
then for dental procedure
prophylaxis. Parenteral antibiotics
for 4 to 6 weeks, then oral
antibiotics for up to 1 year.
Downloaded by Clinton Bundi ()
,
, lOMoARcPSD|5422489
Rationale
Treatment of acute osteomyelitis requires administration of high doses of parenteral antibiotics
for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks.
The unlicensed assistive personnel (UAP) reports that an 87-year-old female client who is sitting in
a chair at the bedside has an oral temperature of 97.2 F ( 36.4 C). Which intervention should the
nurse implement?
Document the temperature reading on the
vital sign graphic sheet.
Report the temperature to the
healthcare provider
immediately. Instruct the UAP to
Rationale
A subnormal temperature of 97.2 F (36.4 C) (orally) is a common finding in elderly clients, so the
nurse should document the findings and continue with the plan of care.
When teaching a client with breast cancer about the prescribed radiation therapy for
treatment, what information is important to include?
Dry, itchy skin changes may occur.
There is a possibility of long bone pain.
Permanent pigment changes to the breast
A low-residue diet may be ordered to reduce
Rationale
Side effects from radiation to the breast most often include temporary skin changes such as:
dryness, tenderness, redness, swelling, and pruritis.
The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which
finding should the nurse assess further?
Thinning hair and dry scalp.
Increase in appetite and taste-bud acuity.
Increase in muscle tone but decreased musc
Increase in abdominal fat deposits.
Rationale
Downloaded by
, ()
