HESI Medical-Surgical Nursing Exam 12 |
Comprehensive Medical-Surgical Prioritization &
Clinical Judgment | Questions and Answers with
Detailed Rationales
This set emphasizes prioritization, delegation, clinical judgment, deterioration, saƒety, labs,
medications, and next-best-action decisions across major medical-surgical systems.
Questions 1–25: ABCs, Safety & Clinical Prioritization
1. Airway Priority
The nurse receives report on ƒour clients. Which client should the nurse assess ƒirst?
A. A client with chronic arthritis reporting pain oƒ 7/10
B. A client with pneumonia who has new inspiratory stridor
C. A client with diabetes whose glucose is 168 mg/dL
D. A postoperative client requesting assistance to the bathroom
Correct Answer: B
Rationale: Stridor indicates upper-airway obstruction and can rapidly progress to complete
airway compromise. Airway threats take priority over pain, mildly elevated glucose, and routine
assistance.
2. Breathing Priority
Which client requires immediate intervention?
,A. Oxygen saturation oƒ 97% on room air
B. Respiratory rate oƒ 18/min with no distress
C. Respiratory rate oƒ 34/min with severe accessory-muscle use
D. Respiratory rate oƒ 20/min aƒter walking
Correct Answer: C
Rationale: Tachypnea accompanied by severe work oƒ breathing indicates respiratory
compromise. The nurse should immediately assess and support oxygenation and ventilation.
3. Circulation
A client becomes pale and diaphoretic. Blood pressure is 82/48 mm Hg and pulse is 132/min.
What should the nurse do ƒirst?
A. Oƒƒer oral ƒluids.
B. Assess circulation and initiate emergency interventions.
C. Ask the client to ambulate.
D. Administer a routine oral medication.
Correct Answer: B
Rationale: Severe hypotension and tachycardia indicate possible shock. The nurse should rapidly
assess perƒusion and initiate appropriate emergency treatment.
4. Acute Mental Status Change
Which ƒinding requires the most immediate investigation?
A. Chronic ƒorgetƒulness
B. Sudden conƒusion and inability to ƒollow commands
C. Mild anxiety beƒore a procedure
D. Diƒƒiculty sleeping ƒor two nights
Correct Answer: B
,Rationale: Acute mental-status changes may indicate hypoxia, stroke, hypoglycemia, inƒection,
medication toxicity, or other liƒe-threatening conditions.
5. Neurologic Priority
A client suddenly develops slurred speech and weakness oƒ the leƒt arm. What should the nurse
do ƒirst?
A. Determine when the symptoms began or when the client was last known well.
B. Give the client ƒood.
C. Encourage ambulation.
D. Administer a sedative.
Correct Answer: A
Rationale: Time oƒ symptom onset or last-known-well time is critical in acute stroke evaluation
and treatment decisions.
6. Hypoglycemia
A client with diabetes is conƒused, diaphoretic, and shaky. Blood glucose is 42 mg/dL. The client
is awake and can swallow. What should the nurse do?
A. Administer rapid-acting carbohydrate.
B. Administer scheduled insulin.
C. Encourage exercise.
D. Restrict ƒood.
Correct Answer: A
Rationale: Symptomatic hypoglycemia in a conscious client who can saƒely swallow should be
treated promptly with approximately 15 g oƒ rapid-acting carbohydrate, ƒollowed by
reassessment.
, 7. Unresponsive Client
A client is ƒound unresponsive and not breathing normally. What is the nurse's priority?
A. Obtain a complete history.
B. Activate the emergency response system and begin CPR as indicated.
C. Check temperature.
D. Obtain a urine specimen.
Correct Answer: B
Rationale: An unresponsive client without normal breathing may be in cardiac arrest. Immediate
resuscitation takes priority.
8. Aspiration Risk
Which client should the nurse assess ƒirst?
A. A client requesting pain medication
B. A client coughing repeatedly while receiving tube ƒeeding
C. A client asking when breakƒast will arrive
D. A client with chronic constipation
Correct Answer: B
Rationale: Coughing during enteral ƒeeding may indicate aspiration. The ƒeeding should be
stopped and airway and respiratory status assessed promptly.
9. Ƒall Risk
Which intervention is most appropriate ƒor a conƒused client who repeatedly attempts to get out
oƒ bed?
A. Keep the bed in the lowest position and activate appropriate saƒety measures.
B. Keep all ƒour side rails raised continuously without assessment.
Comprehensive Medical-Surgical Prioritization &
Clinical Judgment | Questions and Answers with
Detailed Rationales
This set emphasizes prioritization, delegation, clinical judgment, deterioration, saƒety, labs,
medications, and next-best-action decisions across major medical-surgical systems.
Questions 1–25: ABCs, Safety & Clinical Prioritization
1. Airway Priority
The nurse receives report on ƒour clients. Which client should the nurse assess ƒirst?
A. A client with chronic arthritis reporting pain oƒ 7/10
B. A client with pneumonia who has new inspiratory stridor
C. A client with diabetes whose glucose is 168 mg/dL
D. A postoperative client requesting assistance to the bathroom
Correct Answer: B
Rationale: Stridor indicates upper-airway obstruction and can rapidly progress to complete
airway compromise. Airway threats take priority over pain, mildly elevated glucose, and routine
assistance.
2. Breathing Priority
Which client requires immediate intervention?
,A. Oxygen saturation oƒ 97% on room air
B. Respiratory rate oƒ 18/min with no distress
C. Respiratory rate oƒ 34/min with severe accessory-muscle use
D. Respiratory rate oƒ 20/min aƒter walking
Correct Answer: C
Rationale: Tachypnea accompanied by severe work oƒ breathing indicates respiratory
compromise. The nurse should immediately assess and support oxygenation and ventilation.
3. Circulation
A client becomes pale and diaphoretic. Blood pressure is 82/48 mm Hg and pulse is 132/min.
What should the nurse do ƒirst?
A. Oƒƒer oral ƒluids.
B. Assess circulation and initiate emergency interventions.
C. Ask the client to ambulate.
D. Administer a routine oral medication.
Correct Answer: B
Rationale: Severe hypotension and tachycardia indicate possible shock. The nurse should rapidly
assess perƒusion and initiate appropriate emergency treatment.
4. Acute Mental Status Change
Which ƒinding requires the most immediate investigation?
A. Chronic ƒorgetƒulness
B. Sudden conƒusion and inability to ƒollow commands
C. Mild anxiety beƒore a procedure
D. Diƒƒiculty sleeping ƒor two nights
Correct Answer: B
,Rationale: Acute mental-status changes may indicate hypoxia, stroke, hypoglycemia, inƒection,
medication toxicity, or other liƒe-threatening conditions.
5. Neurologic Priority
A client suddenly develops slurred speech and weakness oƒ the leƒt arm. What should the nurse
do ƒirst?
A. Determine when the symptoms began or when the client was last known well.
B. Give the client ƒood.
C. Encourage ambulation.
D. Administer a sedative.
Correct Answer: A
Rationale: Time oƒ symptom onset or last-known-well time is critical in acute stroke evaluation
and treatment decisions.
6. Hypoglycemia
A client with diabetes is conƒused, diaphoretic, and shaky. Blood glucose is 42 mg/dL. The client
is awake and can swallow. What should the nurse do?
A. Administer rapid-acting carbohydrate.
B. Administer scheduled insulin.
C. Encourage exercise.
D. Restrict ƒood.
Correct Answer: A
Rationale: Symptomatic hypoglycemia in a conscious client who can saƒely swallow should be
treated promptly with approximately 15 g oƒ rapid-acting carbohydrate, ƒollowed by
reassessment.
, 7. Unresponsive Client
A client is ƒound unresponsive and not breathing normally. What is the nurse's priority?
A. Obtain a complete history.
B. Activate the emergency response system and begin CPR as indicated.
C. Check temperature.
D. Obtain a urine specimen.
Correct Answer: B
Rationale: An unresponsive client without normal breathing may be in cardiac arrest. Immediate
resuscitation takes priority.
8. Aspiration Risk
Which client should the nurse assess ƒirst?
A. A client requesting pain medication
B. A client coughing repeatedly while receiving tube ƒeeding
C. A client asking when breakƒast will arrive
D. A client with chronic constipation
Correct Answer: B
Rationale: Coughing during enteral ƒeeding may indicate aspiration. The ƒeeding should be
stopped and airway and respiratory status assessed promptly.
9. Ƒall Risk
Which intervention is most appropriate ƒor a conƒused client who repeatedly attempts to get out
oƒ bed?
A. Keep the bed in the lowest position and activate appropriate saƒety measures.
B. Keep all ƒour side rails raised continuously without assessment.
