MEDICAL SURGICAL HESI /HESI MED SURG ACTUAL
EXAM LATEST VERSION 2026-2027 ACTUAL 120
QUESTION AND CORRECT DETAILED ANSWERS RATED
AGRADE.
QUESTION
A nurse is assisting an 82-year-old client with ambulation and is concerned that the
client may fall due to age-related changes in posture and balance. The nurse
understands that the location of the center of gravity shifts with aging, increasing the
risk of falls. In an older adult, which anatomical area contains the person's center of
gravity?
CORRECT ANSWER: Upper torso
Expert Rationale
As individuals age, there are significant changes in posture and body mechanics that
affect their center of gravity. In younger adults, the center of gravity is typically located
in the pelvic region. However, with aging, there is a progressive forward shift of the
center of gravity to the upper torso. This shift is due to a combination of factors,
including kyphosis (an increased forward curvature of the thoracic spine), loss of muscle
mass and tone, and decreased flexibility of the spine and joints. This anterior
displacement of the center of gravity makes older adults more prone to forward falls,
particularly when walking or changing positions. Understanding this physiological
change is crucial for nurses when implementing fall prevention strategies, such as
ensuring the client uses assistive devices, maintaining a clear pathway, and providing
appropriate gait training and supervision during ambulation.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
WITHOUT MULTICHOICES
QUESTION
One day after undergoing a Billroth II surgical procedure (a partial gastrectomy with
gastrojejunostomy), a male client suddenly grabs his right chest and becomes pale and
,diaphoretic. His vital signs are assessed as blood pressure 100/80 mmHg, pulse 110
beats per minute, and respirations 36 breaths per minute. The nurse recognizes these
findings as indicative of a potentially life-threatening postoperative complication. What
is the most important immediate action for the nurse to take?
CORRECT ANSWER: Apply oxygen at 2 L per nasal cannula.
Expert Rationale
The client's sudden onset of pleuritic chest pain, pallor, diaphoresis, tachycardia, and
tachypnea following abdominal surgery is highly suggestive of a pulmonary embolism
(PE). Postoperative patients are at an increased risk for venous thromboembolism due to
venous stasis, hypercoagulability, and endothelial injury. A PE occurs when a thrombus,
typically from the deep veins of the lower extremities, dislodges and lodges in the
pulmonary vasculature, causing a ventilation-perfusion mismatch. The priority nursing
intervention is to immediately administer supplemental oxygen to correct the
hypoxemia and prevent further tissue hypoxia. Applying oxygen at 2 L per nasal cannula
is the most immediate and life-sustaining action. While notifying the healthcare provider
is also essential, it should occur after the initiation of oxygen therapy. The nurse should
also prepare for further diagnostic testing and potential interventions such as
anticoagulation therapy.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
WITHOUT MULTICHOICES
QUESTION
During assessment of a client in the intensive care unit, the nurse notes that the client's
breath sounds are clear upon auscultation, but jugular vein distention and muffled heart
sounds are present. The nurse recognizes this triad of signs as indicative of a specific
cardiac emergency that requires immediate intervention. Which intervention should the
nurse prepare to implement?
CORRECT ANSWER: Prepare the client for a pericardial tap.
Expert Rationale
The combination of clear breath sounds, jugular venous distention (JVD), and muffled
heart sounds is a classic triad of signs known as Beck's triad, which is highly indicative of
,cardiac tamponade. Cardiac tamponade is a life-threatening condition caused by the
accumulation of fluid (blood, pus, or other fluid) in the pericardial sac, which compresses
the heart and impairs its ability to fill and pump effectively. The clear breath sounds help
differentiate tamponade from other causes of JVD, such as heart failure or pulmonary
edema. The muffled heart sounds (often described as distant or faint) occur because the
fluid acts as a barrier to sound transmission. The definitive treatment for cardiac
tamponade is an emergency pericardiocentesis (pericardial tap), which involves inserting
a needle into the pericardial space to aspirate the fluid and relieve the pressure on the
heart. The nurse should prepare the client and the necessary equipment for this
procedure immediately.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
WITHOUT MULTICHOICES
QUESTION
The nurse is receiving report from the post-anesthesia care unit (PACU) about a client
with a Penrose drain who is to be admitted to the surgical nursing unit. Before choosing
a room for this client, which information is most important for the nurse to obtain to
ensure appropriate placement and prevent the spread of infection?
CORRECT ANSWER: If the client's wound is infected
Expert Rationale
A Penrose drain is a soft, pliable, open tube used to provide drainage from a surgical
site. It is typically used to drain fluid from a wound that is at high risk for infection. The
most critical information the receiving nurse must obtain before assigning a room is
whether the client's wound is infected. If the wound is infected, the client will require
contact isolation precautions to prevent the transmission of infectious organisms to
other patients, visitors, and staff. This will determine whether the client should be placed
in a private room or in a room with another client who does not have a contagious
condition. While other information such as the type of surgery, the location of the drain,
and the amount of drainage is important for ongoing care, the infection status of the
wound is the highest priority for ensuring patient safety and infection control.
, DIF: Cognitive Level: Apply (Application)
TOP: Safety and Infection Control
MSC: NCLEX: Safe and Effective Care Environment
WITHOUT MULTICHOICES
QUESTION
An antacid (Maalox) is prescribed for a client with peptic ulcer disease. The nurse is
educating the client about the therapeutic action of this medication. What is the primary
mechanism by which this medication is effective in treating the client's ulcer?
CORRECT ANSWER: Maintenance of a gastric pH of 3.5 or above
Expert Rationale
Peptic ulcer disease (PUD) involves the erosion of the mucosal lining of the stomach or
duodenum, which can be exacerbated by the corrosive effects of gastric acid. Antacids,
such as Maalox (which contains aluminum hydroxide and magnesium hydroxide), are
alkaline compounds that work by directly neutralizing gastric acid. The therapeutic goal
of antacid therapy is to maintain the gastric pH at 3.5 or above. At this pH level, pepsin
(a digestive enzyme that can further damage the ulcer) is inactivated. By raising the pH
and inactivating pepsin, antacids reduce the irritation of the ulcer site, promote mucosal
healing, and provide symptomatic relief of pain. Antacids do not prevent the secretion
of acid; they neutralize acid that is already present in the stomach. They are typically
used for symptomatic relief and as an adjunct to other medications that reduce acid
production.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Implementation
MSC: NCLEX: Pharmacological and Parenteral Therapies
WITHOUT MULTICHOICES
QUESTION
When preparing a male client who has had a total laryngectomy for discharge, what
EXAM LATEST VERSION 2026-2027 ACTUAL 120
QUESTION AND CORRECT DETAILED ANSWERS RATED
AGRADE.
QUESTION
A nurse is assisting an 82-year-old client with ambulation and is concerned that the
client may fall due to age-related changes in posture and balance. The nurse
understands that the location of the center of gravity shifts with aging, increasing the
risk of falls. In an older adult, which anatomical area contains the person's center of
gravity?
CORRECT ANSWER: Upper torso
Expert Rationale
As individuals age, there are significant changes in posture and body mechanics that
affect their center of gravity. In younger adults, the center of gravity is typically located
in the pelvic region. However, with aging, there is a progressive forward shift of the
center of gravity to the upper torso. This shift is due to a combination of factors,
including kyphosis (an increased forward curvature of the thoracic spine), loss of muscle
mass and tone, and decreased flexibility of the spine and joints. This anterior
displacement of the center of gravity makes older adults more prone to forward falls,
particularly when walking or changing positions. Understanding this physiological
change is crucial for nurses when implementing fall prevention strategies, such as
ensuring the client uses assistive devices, maintaining a clear pathway, and providing
appropriate gait training and supervision during ambulation.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
WITHOUT MULTICHOICES
QUESTION
One day after undergoing a Billroth II surgical procedure (a partial gastrectomy with
gastrojejunostomy), a male client suddenly grabs his right chest and becomes pale and
,diaphoretic. His vital signs are assessed as blood pressure 100/80 mmHg, pulse 110
beats per minute, and respirations 36 breaths per minute. The nurse recognizes these
findings as indicative of a potentially life-threatening postoperative complication. What
is the most important immediate action for the nurse to take?
CORRECT ANSWER: Apply oxygen at 2 L per nasal cannula.
Expert Rationale
The client's sudden onset of pleuritic chest pain, pallor, diaphoresis, tachycardia, and
tachypnea following abdominal surgery is highly suggestive of a pulmonary embolism
(PE). Postoperative patients are at an increased risk for venous thromboembolism due to
venous stasis, hypercoagulability, and endothelial injury. A PE occurs when a thrombus,
typically from the deep veins of the lower extremities, dislodges and lodges in the
pulmonary vasculature, causing a ventilation-perfusion mismatch. The priority nursing
intervention is to immediately administer supplemental oxygen to correct the
hypoxemia and prevent further tissue hypoxia. Applying oxygen at 2 L per nasal cannula
is the most immediate and life-sustaining action. While notifying the healthcare provider
is also essential, it should occur after the initiation of oxygen therapy. The nurse should
also prepare for further diagnostic testing and potential interventions such as
anticoagulation therapy.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
WITHOUT MULTICHOICES
QUESTION
During assessment of a client in the intensive care unit, the nurse notes that the client's
breath sounds are clear upon auscultation, but jugular vein distention and muffled heart
sounds are present. The nurse recognizes this triad of signs as indicative of a specific
cardiac emergency that requires immediate intervention. Which intervention should the
nurse prepare to implement?
CORRECT ANSWER: Prepare the client for a pericardial tap.
Expert Rationale
The combination of clear breath sounds, jugular venous distention (JVD), and muffled
heart sounds is a classic triad of signs known as Beck's triad, which is highly indicative of
,cardiac tamponade. Cardiac tamponade is a life-threatening condition caused by the
accumulation of fluid (blood, pus, or other fluid) in the pericardial sac, which compresses
the heart and impairs its ability to fill and pump effectively. The clear breath sounds help
differentiate tamponade from other causes of JVD, such as heart failure or pulmonary
edema. The muffled heart sounds (often described as distant or faint) occur because the
fluid acts as a barrier to sound transmission. The definitive treatment for cardiac
tamponade is an emergency pericardiocentesis (pericardial tap), which involves inserting
a needle into the pericardial space to aspirate the fluid and relieve the pressure on the
heart. The nurse should prepare the client and the necessary equipment for this
procedure immediately.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
WITHOUT MULTICHOICES
QUESTION
The nurse is receiving report from the post-anesthesia care unit (PACU) about a client
with a Penrose drain who is to be admitted to the surgical nursing unit. Before choosing
a room for this client, which information is most important for the nurse to obtain to
ensure appropriate placement and prevent the spread of infection?
CORRECT ANSWER: If the client's wound is infected
Expert Rationale
A Penrose drain is a soft, pliable, open tube used to provide drainage from a surgical
site. It is typically used to drain fluid from a wound that is at high risk for infection. The
most critical information the receiving nurse must obtain before assigning a room is
whether the client's wound is infected. If the wound is infected, the client will require
contact isolation precautions to prevent the transmission of infectious organisms to
other patients, visitors, and staff. This will determine whether the client should be placed
in a private room or in a room with another client who does not have a contagious
condition. While other information such as the type of surgery, the location of the drain,
and the amount of drainage is important for ongoing care, the infection status of the
wound is the highest priority for ensuring patient safety and infection control.
, DIF: Cognitive Level: Apply (Application)
TOP: Safety and Infection Control
MSC: NCLEX: Safe and Effective Care Environment
WITHOUT MULTICHOICES
QUESTION
An antacid (Maalox) is prescribed for a client with peptic ulcer disease. The nurse is
educating the client about the therapeutic action of this medication. What is the primary
mechanism by which this medication is effective in treating the client's ulcer?
CORRECT ANSWER: Maintenance of a gastric pH of 3.5 or above
Expert Rationale
Peptic ulcer disease (PUD) involves the erosion of the mucosal lining of the stomach or
duodenum, which can be exacerbated by the corrosive effects of gastric acid. Antacids,
such as Maalox (which contains aluminum hydroxide and magnesium hydroxide), are
alkaline compounds that work by directly neutralizing gastric acid. The therapeutic goal
of antacid therapy is to maintain the gastric pH at 3.5 or above. At this pH level, pepsin
(a digestive enzyme that can further damage the ulcer) is inactivated. By raising the pH
and inactivating pepsin, antacids reduce the irritation of the ulcer site, promote mucosal
healing, and provide symptomatic relief of pain. Antacids do not prevent the secretion
of acid; they neutralize acid that is already present in the stomach. They are typically
used for symptomatic relief and as an adjunct to other medications that reduce acid
production.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Implementation
MSC: NCLEX: Pharmacological and Parenteral Therapies
WITHOUT MULTICHOICES
QUESTION
When preparing a male client who has had a total laryngectomy for discharge, what
