HESI RN MED SURG EXAM 2026
UPDATE QUESTIONS AND CORRECT
VERIFIED ANSWERS ALREADY
GRADED A+ (BRAND NEW VISION)
The client returns to the unit after abdominal surgery with a 5″ × 9″ absorbent dressing
in place to the mid abdomen. The nurse notes a spot of red staining centrally on the
dressing. What is the nurse's next action?
A.
Note the size of the stain in the chart.
B.
Circle the stain with an ink pen.
C.
Remove the dressing to assess the source of the bleeding.
D.
Place a pressure dressing on the existing dressing. - ANS-B
Rationale:By circling the existing stain upon admission to the unit, the nurse can
then assess any increase, though subtle, in the amount of drainage over time.
The size of the stain will need to be noted in the chart, but it is not the first action.
The nurse removes the dressing under the prescription of the health care
provider or in an emergency. Neither of those conditions exist in the question.
The dressing in place is an absorbent dressing. There is no need for a further
dressing until the existing dressing becomes saturated.
For the client undergoing hemodialysis, the nurse suspects the client has an air
embolism. What symptoms lead the nurse to this conclusion? (Select all that apply.)
A.
Dyspnea
B.
B/P 168/92 mm Hg
C.
Chest pain
D.
Anxiety
E.
O2 saturation of 98%
F.
Blue nail beds - ANS-A, C, D, F
,Rationale:For the client experiencing an air embolism, the nurse will see
hypotension and not hypertension. The O2 saturation will also fall with an air
embolism. The remaining are signs of an air embolism.
The nurse is preparing teaching for nursing students who are participating in a flu
vaccine clinic at a local school. Who should receive the vaccine? (Select all that apply.)
A.
Health care personnel
B.
Those who are allergic to eggs
C.
Individuals who are over 50 years old
D.
Individuals with chronic health conditions
E.
Those who live in nursing homes
F.
Infants under 6 months of age - ANS-A, C, D, E
Rationale:The current recommendation is those who are allergic to eggs can
receive the flu vaccine if it is administered in a healthcare environment that can
quickly deliver treatment for anaphylaxis. Infants over 6 months van receive the
flu shot, but not under 6 months. The remaining options are recommended to
receive the flu vaccine.
A practical nurse (PN) tells the charge nurse in a long-term facility that she does not
want to be assigned to one particular resident. She reports that the male client keeps
insisting that she is his daughter and begs her to stay in his room. What is the best
managerial decision?
A.
Notify the family that the resident will have to be discharged if his behavior does not
improve.
B.
Notify administration of the PN's insubordination and need for counseling about her
statements.
C.
Ask the PN what she has done to encourage the resident to believe that she is his
daughter.
D.
Reassign the PN until the resident can be assessed more completely for reality
orientation. - ANS-D
Rationale:Temporary reassignment is the best option until the resident can be
examined and his medications reviewed. He may have worsening cerebral
dysfunction from an infection or electrolyte imbalance. Option A is not the best
option because the family cannot control the resident's actions. The
administration may need to know about the situation, but not as a case of
,insubordination. Implying that the PN is somehow creating the situation is
inappropriate until a further evaluation has been conducted.
The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which
symptom of hyperglycemia is an older adult most likely to exhibit?
A.
Polyuria
B.
Polydipsia
C.
Weight loss
D.
Infection - ANS-D
ptoms of hyperglycemia in older adults may include fatigue, infection, and
evidence of neuropathy (e.g., sensory changes). The nurse needs to remember
that classic signs and symptoms of hyperglycemia, such as options A, B, and C
and polyphagia, may be absent in older adults.
A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8
on a 1 to 10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and
respirations of 20 breaths/min. The PACU recovery prescription is "Morphine, 2 to 4 mg
IV push, while in recovery for pain level over 5." Which action should the nurse take
first?
A.
Give the medication as prescribed to decrease the client's pain.
B.
Call the anesthesia provider for a different medication for pain.
C.
Use nonpharmacologic techniques before giving the medication.
D.
Reassess the pain level in 30 minutes and medicate if it remains elevated. - ANS-B
Rationale:The nurse should call the provider for a different medication because
morphine is a histamine-releasing opioid and should be avoided when the client
has asthma. Option A is unsafe because it puts the client at risk for an asthma
exacerbation. Even if the drug were safe for the client, options C and D both
disregard the prescription and the client's need for pain relief in the immediate
postoperative period.
The nurse is interviewing a client who is taking interferon-alfa-2a and ribavirin
combination therapy for hepatitis C. The client reports experiencing overwhelming
feelings of depression. Which action should the nurse take first?
A.
Recommend mental health counseling.
B.
Review the medication actions and interactions.
C.
, Assess for the client's daily activity level.
D.
Provide information regarding a support group. - ANS-B
Rationale:Interferon-alfa-2a and ribavirin combination therapy can cause severe
depression; therefore, it is most important for the nurse to review the medication
effects and report these to the health care provider. Options A, C, and D might be
implemented after the physiologic aspects of the situation have been assessed.
The nurse in the emergency room assesses a client with a head trauma and notes a
Glasgow Coma Scale (GCS) score of 5. What actions will the nurse take to ensure the
client's safety? (Select all that apply.)
A.
Place the client in the supine position.
B.
Assess airway and suction secretions as needed.
C.
Change the client's position every 2 hours.
D.
Avoid mouth care, to avoid stimulating a seizure.
E.
Monitor for drainage from the ears. - ANS-B, C, E
Rationale:The client should be at least sitting at a 45 degree angle to avoid
aspiration and increased intracranial pressure. Provide frequent mouth care as
the client is unable to do so at this time. The remaining actions are appropriate
for the client with a GCS score of 5.
A client is placed on a mechanical ventilator following a cerebral hemorrhage. What are
the priority nursing actions for this client? (Select all that apply.)
A.
Assess lung sounds.
B.
Look for equal and bilateral expansion of the chest.
C.
Monitor skin color.
D.
Evaluate the need for suctioning.
E.
Tell the family the client is expected to fully recover.
F.
Make sure the ventilator alarms are set. - ANS-A, B, C, D, F
Rationale:The outcome of the client is too early to relay to the family. The nurse must
not offer false reassurance. The remaining actions are correct for a client on a
ventilator.
UPDATE QUESTIONS AND CORRECT
VERIFIED ANSWERS ALREADY
GRADED A+ (BRAND NEW VISION)
The client returns to the unit after abdominal surgery with a 5″ × 9″ absorbent dressing
in place to the mid abdomen. The nurse notes a spot of red staining centrally on the
dressing. What is the nurse's next action?
A.
Note the size of the stain in the chart.
B.
Circle the stain with an ink pen.
C.
Remove the dressing to assess the source of the bleeding.
D.
Place a pressure dressing on the existing dressing. - ANS-B
Rationale:By circling the existing stain upon admission to the unit, the nurse can
then assess any increase, though subtle, in the amount of drainage over time.
The size of the stain will need to be noted in the chart, but it is not the first action.
The nurse removes the dressing under the prescription of the health care
provider or in an emergency. Neither of those conditions exist in the question.
The dressing in place is an absorbent dressing. There is no need for a further
dressing until the existing dressing becomes saturated.
For the client undergoing hemodialysis, the nurse suspects the client has an air
embolism. What symptoms lead the nurse to this conclusion? (Select all that apply.)
A.
Dyspnea
B.
B/P 168/92 mm Hg
C.
Chest pain
D.
Anxiety
E.
O2 saturation of 98%
F.
Blue nail beds - ANS-A, C, D, F
,Rationale:For the client experiencing an air embolism, the nurse will see
hypotension and not hypertension. The O2 saturation will also fall with an air
embolism. The remaining are signs of an air embolism.
The nurse is preparing teaching for nursing students who are participating in a flu
vaccine clinic at a local school. Who should receive the vaccine? (Select all that apply.)
A.
Health care personnel
B.
Those who are allergic to eggs
C.
Individuals who are over 50 years old
D.
Individuals with chronic health conditions
E.
Those who live in nursing homes
F.
Infants under 6 months of age - ANS-A, C, D, E
Rationale:The current recommendation is those who are allergic to eggs can
receive the flu vaccine if it is administered in a healthcare environment that can
quickly deliver treatment for anaphylaxis. Infants over 6 months van receive the
flu shot, but not under 6 months. The remaining options are recommended to
receive the flu vaccine.
A practical nurse (PN) tells the charge nurse in a long-term facility that she does not
want to be assigned to one particular resident. She reports that the male client keeps
insisting that she is his daughter and begs her to stay in his room. What is the best
managerial decision?
A.
Notify the family that the resident will have to be discharged if his behavior does not
improve.
B.
Notify administration of the PN's insubordination and need for counseling about her
statements.
C.
Ask the PN what she has done to encourage the resident to believe that she is his
daughter.
D.
Reassign the PN until the resident can be assessed more completely for reality
orientation. - ANS-D
Rationale:Temporary reassignment is the best option until the resident can be
examined and his medications reviewed. He may have worsening cerebral
dysfunction from an infection or electrolyte imbalance. Option A is not the best
option because the family cannot control the resident's actions. The
administration may need to know about the situation, but not as a case of
,insubordination. Implying that the PN is somehow creating the situation is
inappropriate until a further evaluation has been conducted.
The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which
symptom of hyperglycemia is an older adult most likely to exhibit?
A.
Polyuria
B.
Polydipsia
C.
Weight loss
D.
Infection - ANS-D
ptoms of hyperglycemia in older adults may include fatigue, infection, and
evidence of neuropathy (e.g., sensory changes). The nurse needs to remember
that classic signs and symptoms of hyperglycemia, such as options A, B, and C
and polyphagia, may be absent in older adults.
A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8
on a 1 to 10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and
respirations of 20 breaths/min. The PACU recovery prescription is "Morphine, 2 to 4 mg
IV push, while in recovery for pain level over 5." Which action should the nurse take
first?
A.
Give the medication as prescribed to decrease the client's pain.
B.
Call the anesthesia provider for a different medication for pain.
C.
Use nonpharmacologic techniques before giving the medication.
D.
Reassess the pain level in 30 minutes and medicate if it remains elevated. - ANS-B
Rationale:The nurse should call the provider for a different medication because
morphine is a histamine-releasing opioid and should be avoided when the client
has asthma. Option A is unsafe because it puts the client at risk for an asthma
exacerbation. Even if the drug were safe for the client, options C and D both
disregard the prescription and the client's need for pain relief in the immediate
postoperative period.
The nurse is interviewing a client who is taking interferon-alfa-2a and ribavirin
combination therapy for hepatitis C. The client reports experiencing overwhelming
feelings of depression. Which action should the nurse take first?
A.
Recommend mental health counseling.
B.
Review the medication actions and interactions.
C.
, Assess for the client's daily activity level.
D.
Provide information regarding a support group. - ANS-B
Rationale:Interferon-alfa-2a and ribavirin combination therapy can cause severe
depression; therefore, it is most important for the nurse to review the medication
effects and report these to the health care provider. Options A, C, and D might be
implemented after the physiologic aspects of the situation have been assessed.
The nurse in the emergency room assesses a client with a head trauma and notes a
Glasgow Coma Scale (GCS) score of 5. What actions will the nurse take to ensure the
client's safety? (Select all that apply.)
A.
Place the client in the supine position.
B.
Assess airway and suction secretions as needed.
C.
Change the client's position every 2 hours.
D.
Avoid mouth care, to avoid stimulating a seizure.
E.
Monitor for drainage from the ears. - ANS-B, C, E
Rationale:The client should be at least sitting at a 45 degree angle to avoid
aspiration and increased intracranial pressure. Provide frequent mouth care as
the client is unable to do so at this time. The remaining actions are appropriate
for the client with a GCS score of 5.
A client is placed on a mechanical ventilator following a cerebral hemorrhage. What are
the priority nursing actions for this client? (Select all that apply.)
A.
Assess lung sounds.
B.
Look for equal and bilateral expansion of the chest.
C.
Monitor skin color.
D.
Evaluate the need for suctioning.
E.
Tell the family the client is expected to fully recover.
F.
Make sure the ventilator alarms are set. - ANS-A, B, C, D, F
Rationale:The outcome of the client is too early to relay to the family. The nurse must
not offer false reassurance. The remaining actions are correct for a client on a
ventilator.
