HESI MEDICAL-SURGICAL NURSING FINAL EXAM
QUESTIONS AND CORRECT VERIFIED ANSWERS
WITH RATIONALES GRADED A+ |
(LATEST VERSION)
Question 1
A 72-year-old client with a history of chronic heart failure arrives at the emergency
department reporting severe shortness of breath. The client is sitting upright,
coughing pink, frothy sputum, and has bilateral crackles extending halfway up the
lung fields. The oxygen saturation is 82% on room air, and the respiratory rate is
34 breaths/min. Which action should the nurse prioritize?
A. Obtain the client's daily weight and compare it with the previous measurement.
B. Position the client upright and initiate supplemental oxygen while summoning
emergency assistance.
C. Encourage the client to drink warm fluids to loosen respiratory secretions.
D. Administer the prescribed oral diuretic and reassess the client in 30 minutes.
Answer: B
Rationale: The findings indicate acute pulmonary edema associated with
decompensated heart failure. Severe hypoxemia requires immediate respiratory
support, an upright position to improve ventilation, and urgent assistance.
Additional treatment may include prescribed intravenous diuretics and
vasodilators, depending on the client's hemodynamic status. Daily weights and oral
medications do not address the immediate threat to oxygenation.
,Question 2
A 64-year-old woman with type 2 diabetes mellitus reports unusual fatigue,
nausea, diaphoresis, and pressure in the upper abdomen. She denies sharp chest
pain. Her blood pressure is 148/88 mmHg, and her heart rate is 104 beats/min.
Which action is most appropriate?
A. Administer an antacid and evaluate whether the discomfort resolves.
B. Encourage the client to rest and repeat the assessment in one hour.
C. Obtain a 12-lead electrocardiogram promptly and activate the facility's acute
coronary syndrome protocol.
D. Assist the client to walk briefly to determine whether the symptoms are activity-
related.
Answer: C
Rationale: Myocardial ischemia may present with atypical symptoms, particularly
in women and people with diabetes. Epigastric pressure, unexplained fatigue,
nausea, and diaphoresis should prompt urgent evaluation for acute coronary
syndrome. A prompt 12-lead ECG, cardiac biomarkers, and appropriate emergency
interventions help identify myocardial infarction. Delaying evaluation to assess the
effects of antacids, rest, or exercise could worsen the outcome.
Question 3
A client with advanced chronic kidney disease has a serum potassium
concentration of 6.6 mEq/L. The cardiac monitor displays tall, peaked T waves,
and the client reports new muscle weakness. Which prescribed intervention should
the nurse anticipate administering first to reduce the immediate risk of a lethal
dysrhythmia?
A. Intravenous calcium gluconate.
B. Oral potassium chloride.
C. Intravenous furosemide as the sole emergency intervention.
D. Dietary potassium supplementation.
Answer: A
,Rationale: Severe hyperkalemia accompanied by ECG changes is a medical
emergency. Intravenous calcium gluconate stabilizes the cardiac membrane and
reduces the immediate risk of dangerous dysrhythmias, although it does not lower
the serum potassium concentration. Additional treatment, such as insulin with
dextrose, may shift potassium into cells, while other therapies remove potassium
from the body. Potassium supplementation is contraindicated, and furosemide
alone is not adequate for immediate cardiac stabilization.
Question 4
A client with advanced chronic obstructive pulmonary disease (COPD) becomes
increasingly dyspneic while walking to the bathroom. The client is anxious, using
accessory muscles, and has an oxygen saturation of 86% on the prescribed oxygen
regimen. Which nursing intervention is most appropriate initially?
A. Place the client flat in bed to decrease energy expenditure.
B. Encourage rapid, deep breathing to increase the respiratory rate.
C. Discontinue oxygen because supplemental oxygen is contraindicated in COPD.
D. Assist the client into an upright position, assess respiratory status, and promptly
titrate oxygen according to the prescribed target and protocol.
Answer: D
Rationale: An upright or high-Fowler's position facilitates diaphragmatic
movement and lung expansion. The nurse should assess for acute deterioration and
provide appropriately titrated oxygen, commonly targeting an SpO₂ of 88%–92%
in clients at risk of hypercapnic respiratory failure unless another individualized
target is prescribed. Oxygen must not be withheld from a hypoxemic client.
Pursed-lip breathing can also help reduce air trapping and ease dyspnea once
immediate stabilization is addressed.
, Question 5
Fifteen minutes after a packed red blood cell transfusion begins, a client develops
chills, severe lower back pain, dyspnea, and a blood pressure decrease from 126/76
to 86/50 mmHg. The nurse suspects an acute hemolytic transfusion reaction. What
should the nurse do first?
A. Slow the transfusion and administer an antipyretic.
B. Stop the transfusion immediately.
C. Flush the blood tubing with dextrose solution.
D. Obtain a urine specimen before changing the infusion rate.
Answer: B
Rationale: Sudden lower back pain, chills, dyspnea, and hypotension during
transfusion suggest a potentially life-threatening transfusion reaction. The nurse
must immediately stop the transfusion. The nurse should then maintain IV access
with normal saline using new tubing, assess and support the airway and circulation,
notify the provider and blood bank, and follow the facility's transfusion-reaction
protocol. The blood product must not be restarted or flushed into the client.
Question 6
A 69-year-old client suddenly develops right-sided facial drooping, right arm
weakness, and difficulty speaking. The symptoms began 40 minutes ago. The
point-of-care blood glucose is 104 mg/dL. Which action should the nurse
prioritize?
A. Administer oral aspirin before obtaining imaging.
B. Give water to determine whether swallowing is impaired.
C. Activate the stroke response protocol and facilitate urgent brain imaging.
D. Lower the head of the bed completely and encourage the client to sleep.
Answer: C
QUESTIONS AND CORRECT VERIFIED ANSWERS
WITH RATIONALES GRADED A+ |
(LATEST VERSION)
Question 1
A 72-year-old client with a history of chronic heart failure arrives at the emergency
department reporting severe shortness of breath. The client is sitting upright,
coughing pink, frothy sputum, and has bilateral crackles extending halfway up the
lung fields. The oxygen saturation is 82% on room air, and the respiratory rate is
34 breaths/min. Which action should the nurse prioritize?
A. Obtain the client's daily weight and compare it with the previous measurement.
B. Position the client upright and initiate supplemental oxygen while summoning
emergency assistance.
C. Encourage the client to drink warm fluids to loosen respiratory secretions.
D. Administer the prescribed oral diuretic and reassess the client in 30 minutes.
Answer: B
Rationale: The findings indicate acute pulmonary edema associated with
decompensated heart failure. Severe hypoxemia requires immediate respiratory
support, an upright position to improve ventilation, and urgent assistance.
Additional treatment may include prescribed intravenous diuretics and
vasodilators, depending on the client's hemodynamic status. Daily weights and oral
medications do not address the immediate threat to oxygenation.
,Question 2
A 64-year-old woman with type 2 diabetes mellitus reports unusual fatigue,
nausea, diaphoresis, and pressure in the upper abdomen. She denies sharp chest
pain. Her blood pressure is 148/88 mmHg, and her heart rate is 104 beats/min.
Which action is most appropriate?
A. Administer an antacid and evaluate whether the discomfort resolves.
B. Encourage the client to rest and repeat the assessment in one hour.
C. Obtain a 12-lead electrocardiogram promptly and activate the facility's acute
coronary syndrome protocol.
D. Assist the client to walk briefly to determine whether the symptoms are activity-
related.
Answer: C
Rationale: Myocardial ischemia may present with atypical symptoms, particularly
in women and people with diabetes. Epigastric pressure, unexplained fatigue,
nausea, and diaphoresis should prompt urgent evaluation for acute coronary
syndrome. A prompt 12-lead ECG, cardiac biomarkers, and appropriate emergency
interventions help identify myocardial infarction. Delaying evaluation to assess the
effects of antacids, rest, or exercise could worsen the outcome.
Question 3
A client with advanced chronic kidney disease has a serum potassium
concentration of 6.6 mEq/L. The cardiac monitor displays tall, peaked T waves,
and the client reports new muscle weakness. Which prescribed intervention should
the nurse anticipate administering first to reduce the immediate risk of a lethal
dysrhythmia?
A. Intravenous calcium gluconate.
B. Oral potassium chloride.
C. Intravenous furosemide as the sole emergency intervention.
D. Dietary potassium supplementation.
Answer: A
,Rationale: Severe hyperkalemia accompanied by ECG changes is a medical
emergency. Intravenous calcium gluconate stabilizes the cardiac membrane and
reduces the immediate risk of dangerous dysrhythmias, although it does not lower
the serum potassium concentration. Additional treatment, such as insulin with
dextrose, may shift potassium into cells, while other therapies remove potassium
from the body. Potassium supplementation is contraindicated, and furosemide
alone is not adequate for immediate cardiac stabilization.
Question 4
A client with advanced chronic obstructive pulmonary disease (COPD) becomes
increasingly dyspneic while walking to the bathroom. The client is anxious, using
accessory muscles, and has an oxygen saturation of 86% on the prescribed oxygen
regimen. Which nursing intervention is most appropriate initially?
A. Place the client flat in bed to decrease energy expenditure.
B. Encourage rapid, deep breathing to increase the respiratory rate.
C. Discontinue oxygen because supplemental oxygen is contraindicated in COPD.
D. Assist the client into an upright position, assess respiratory status, and promptly
titrate oxygen according to the prescribed target and protocol.
Answer: D
Rationale: An upright or high-Fowler's position facilitates diaphragmatic
movement and lung expansion. The nurse should assess for acute deterioration and
provide appropriately titrated oxygen, commonly targeting an SpO₂ of 88%–92%
in clients at risk of hypercapnic respiratory failure unless another individualized
target is prescribed. Oxygen must not be withheld from a hypoxemic client.
Pursed-lip breathing can also help reduce air trapping and ease dyspnea once
immediate stabilization is addressed.
, Question 5
Fifteen minutes after a packed red blood cell transfusion begins, a client develops
chills, severe lower back pain, dyspnea, and a blood pressure decrease from 126/76
to 86/50 mmHg. The nurse suspects an acute hemolytic transfusion reaction. What
should the nurse do first?
A. Slow the transfusion and administer an antipyretic.
B. Stop the transfusion immediately.
C. Flush the blood tubing with dextrose solution.
D. Obtain a urine specimen before changing the infusion rate.
Answer: B
Rationale: Sudden lower back pain, chills, dyspnea, and hypotension during
transfusion suggest a potentially life-threatening transfusion reaction. The nurse
must immediately stop the transfusion. The nurse should then maintain IV access
with normal saline using new tubing, assess and support the airway and circulation,
notify the provider and blood bank, and follow the facility's transfusion-reaction
protocol. The blood product must not be restarted or flushed into the client.
Question 6
A 69-year-old client suddenly develops right-sided facial drooping, right arm
weakness, and difficulty speaking. The symptoms began 40 minutes ago. The
point-of-care blood glucose is 104 mg/dL. Which action should the nurse
prioritize?
A. Administer oral aspirin before obtaining imaging.
B. Give water to determine whether swallowing is impaired.
C. Activate the stroke response protocol and facilitate urgent brain imaging.
D. Lower the head of the bed completely and encourage the client to sleep.
Answer: C
