MED SURG 203 Medical-Surgical Nursing HESI-Style Assessment Fortis College
Actual Exam 2026/2027 – Complete Exam-Style Questions with Detailed
Rationales | 100% Verified | Pass Guaranteed – A+ Graded
Section A: Perioperative Care & Surgical Nursing (Q1–Q10)
Q1: A patient scheduled for surgery at 10:00 AM tells the nurse he ate a full breakfast at
7:00 AM despite being NPO after midnight. What is the nurse's priority action?
A. Document the finding and proceed with pre-op prep as scheduled
B. Offer an antacid to neutralize gastric contents
C. Notify the surgeon and anesthesia provider that the surgery may be delayed or
canceled [CORRECT]
D. Encourage the patient to ambulate to speed gastric emptying
Correct Answer: C
Rationale: Food intake violates NPO status and creates a serious aspiration risk under
anesthesia, requiring immediate notification of the surgeon and anesthesia provider.
Proceeding, masking the risk, or ambulating does not remove the aspiration hazard.
Q2: A patient about to sign the surgical consent states, "I'm not really sure what they're
going to do to me." What is the nurse's best response?
A. Have the patient sign anyway, since the consent form explains everything
B. Contact the surgeon to return and explain the procedure before signing [CORRECT]
C. Explain the surgical procedure to the patient herself so signing can proceed
D. Ask a family member to sign the consent in place of the patient
Correct Answer: B
Rationale: The surgeon is responsible for explaining the procedure, risks, and
alternatives; the nurse must stop the process and notify the surgeon when
understanding is lacking. The nurse cannot clarify informed consent, and the consent is
invalid without patient understanding.
Q3: During preoperative assessment, the nurse reviews the medication list for a patient
scheduled for surgery in the morning. Which medication finding requires priority
notification of the surgical team?
A. Daily multivitamin
B. Warfarin taken daily [CORRECT]
C. Acetaminophen as needed for headache
,D. Diphenhydramine as needed for sleep
Correct Answer: B
Rationale: Warfarin is an anticoagulant that markedly increases surgical bleeding risk
and is typically held days before surgery per provider order. A multivitamin,
acetaminophen, and diphenhydramine do not create the same intraoperative bleeding
hazard.
Q4: A postoperative patient is transferred to the surgical unit from the PACU. What is the
nurse's first action upon arrival?
A. Check the surgical dressing for drainage
B. Assess pain level using the numeric scale
C. Review the surgeon's postoperative orders
D. Assess airway patency, respiratory rate, and oxygen saturation [CORRECT]
Correct Answer: D
Rationale: Assessment follows the ABC priority framework, making airway and
breathing the first actions after transfer. Dressing checks, pain assessment, and order
review follow once oxygenation is confirmed adequate.
Q5: During surgery, a patient receiving general anesthesia with succinylcholine develops
tachycardia, muscle rigidity, and a rapidly rising temperature of 39.8°C (103.6°F). Which
medication should be immediately available?
A. Protamine sulfate
B. Naloxone
C. Dantrolene [CORRECT]
D. Flumazenil
Correct Answer: C
Rationale: The presentation is malignant hyperthermia, a life-threatening
hypermetabolic crisis treated with dantrolene plus cooling and discontinuation of
triggering agents. Protamine reverses heparin, naloxone reverses opioids, and
flumazenil reverses benzodiazepines.
Q6: Which statement by a postoperative patient demonstrates correct understanding of
incentive spirometer use?
A. "I will blow into it forcefully several times in a row."
B. "I will use it only when I feel short of breath."
C. "I will take a slow, deep breath in, hold it briefly, then exhale, repeating about 10 times
each hour while awake." [CORRECT]
D. "I will breathe normally through it while watching television."
Correct Answer: C
,Rationale: Effective incentive spirometry requires slow deep inspiration with a
breath-hold, performed frequently (about 10 times hourly) to promote alveolar inflation
and prevent atelectasis. Forceful blowing, sporadic use, or passive breathing does not
expand collapsed alveoli.
Q7: A patient on the surgical unit experiences sudden wound evisceration with
protrusion of abdominal contents. What is the nurse's priority action?
A. Attempt to reinsert the organs into the abdomen
B. Place the patient in low-Fowler's with knees flexed and cover the contents with sterile
gauze moistened with sterile saline [CORRECT]
C. Apply firm direct pressure over the exposed organs
D. Have the patient cough deeply to reposition the organs
Correct Answer: B
Rationale: Evisceration is treated by flexing the knees to reduce tension, covering
contents with sterile saline-moistened gauze to prevent drying, and notifying the
surgeon urgently. Reinsertion, pressure, or coughing can damage organs and worsen
the exposure.
Q8: A postoperative patient refuses to ambulate, stating, "It hurts too much to walk."
What is the nurse's best response?
A. Document the refusal and try again the next day
B. Tell the patient that walking is optional after surgery
C. Explain the DVT risk of immobility and administer ordered analgesia before assisting
with ambulation [CORRECT]
D. Contact the provider to cancel ambulation orders
Correct Answer: C
Rationale: Early ambulation prevents venous stasis and DVT, and pre-medication
addresses the pain barrier preventing participation. Accepting refusal or canceling
orders increases thromboembolic risk, while forcing ambulation without pain control is
ineffective and unkind.
Q9: On postoperative day 1, a patient has absent bowel sounds, abdominal distention,
nausea, and no passage of flatus. Which intervention does the nurse anticipate?
A. Advance to a regular diet to stimulate peristalsis
B. Encourage frequent gum chewing and carbonated beverages
C. Administer a bulk-forming laxative immediately
D. Keep the patient NPO and anticipate insertion of a nasogastric tube to
decompression [CORRECT]
Correct Answer: D
, Rationale: The findings indicate paralytic ileus, managed with bowel rest, NPO status,
and NG decompression until peristalsis returns. Feeding, gum, carbonation, or laxatives
would distend the bowel further and are contraindicated.
Q10: Which preoperative teaching intervention is most effective in reducing
postoperative pulmonary and thromboembolic complications?
A. Teaching coughing, deep breathing, incentive spirometry, and early ambulation
expectations [CORRECT]
B. Instructing the patient to remain on strict bed rest for 48 hours after surgery
C. Advising the patient that postoperative pain should be endured without medication
D. Explaining that visitors should perform leg exercises for the patient
Correct Answer: A
Rationale: Preoperative instruction in pulmonary toilet and early ambulation prepares
the patient to actively prevent atelectasis, pneumonia, and DVT. Bed rest, unmanaged
pain, and passive exercise by others contradict evidence-based prevention.
Section B: Cardiovascular & Hematologic Disorders (Q11–Q22)
Q11: A patient with left-sided heart failure has bilateral crackles, dyspnea, and
orthopnea. In which position should the nurse place the patient?
A. Trendelenburg
B. Flat, supine with legs elevated
C. Left lateral recumbent
D. High-Fowler's with legs dependent [CORRECT]
Correct Answer: D
Rationale: High-Fowler's with legs dependent maximizes lung expansion and promotes
venous pooling in the lower extremities, decreasing pulmonary congestion. Supine,
Trendelenburg, and legs-elevated positions worsen venous return and pulmonary
edema.
Q12: Before administering digoxin, the nurse counts the apical pulse for one full minute
and obtains a rate of 58 beats/min. What is the correct action?
A. Administer the dose as prescribed
B. Withhold the dose and notify the healthcare provider [CORRECT]
C. Administer a double dose at the next scheduled time
D. Crush the tablet and administer via feeding tube
Correct Answer: B
Actual Exam 2026/2027 – Complete Exam-Style Questions with Detailed
Rationales | 100% Verified | Pass Guaranteed – A+ Graded
Section A: Perioperative Care & Surgical Nursing (Q1–Q10)
Q1: A patient scheduled for surgery at 10:00 AM tells the nurse he ate a full breakfast at
7:00 AM despite being NPO after midnight. What is the nurse's priority action?
A. Document the finding and proceed with pre-op prep as scheduled
B. Offer an antacid to neutralize gastric contents
C. Notify the surgeon and anesthesia provider that the surgery may be delayed or
canceled [CORRECT]
D. Encourage the patient to ambulate to speed gastric emptying
Correct Answer: C
Rationale: Food intake violates NPO status and creates a serious aspiration risk under
anesthesia, requiring immediate notification of the surgeon and anesthesia provider.
Proceeding, masking the risk, or ambulating does not remove the aspiration hazard.
Q2: A patient about to sign the surgical consent states, "I'm not really sure what they're
going to do to me." What is the nurse's best response?
A. Have the patient sign anyway, since the consent form explains everything
B. Contact the surgeon to return and explain the procedure before signing [CORRECT]
C. Explain the surgical procedure to the patient herself so signing can proceed
D. Ask a family member to sign the consent in place of the patient
Correct Answer: B
Rationale: The surgeon is responsible for explaining the procedure, risks, and
alternatives; the nurse must stop the process and notify the surgeon when
understanding is lacking. The nurse cannot clarify informed consent, and the consent is
invalid without patient understanding.
Q3: During preoperative assessment, the nurse reviews the medication list for a patient
scheduled for surgery in the morning. Which medication finding requires priority
notification of the surgical team?
A. Daily multivitamin
B. Warfarin taken daily [CORRECT]
C. Acetaminophen as needed for headache
,D. Diphenhydramine as needed for sleep
Correct Answer: B
Rationale: Warfarin is an anticoagulant that markedly increases surgical bleeding risk
and is typically held days before surgery per provider order. A multivitamin,
acetaminophen, and diphenhydramine do not create the same intraoperative bleeding
hazard.
Q4: A postoperative patient is transferred to the surgical unit from the PACU. What is the
nurse's first action upon arrival?
A. Check the surgical dressing for drainage
B. Assess pain level using the numeric scale
C. Review the surgeon's postoperative orders
D. Assess airway patency, respiratory rate, and oxygen saturation [CORRECT]
Correct Answer: D
Rationale: Assessment follows the ABC priority framework, making airway and
breathing the first actions after transfer. Dressing checks, pain assessment, and order
review follow once oxygenation is confirmed adequate.
Q5: During surgery, a patient receiving general anesthesia with succinylcholine develops
tachycardia, muscle rigidity, and a rapidly rising temperature of 39.8°C (103.6°F). Which
medication should be immediately available?
A. Protamine sulfate
B. Naloxone
C. Dantrolene [CORRECT]
D. Flumazenil
Correct Answer: C
Rationale: The presentation is malignant hyperthermia, a life-threatening
hypermetabolic crisis treated with dantrolene plus cooling and discontinuation of
triggering agents. Protamine reverses heparin, naloxone reverses opioids, and
flumazenil reverses benzodiazepines.
Q6: Which statement by a postoperative patient demonstrates correct understanding of
incentive spirometer use?
A. "I will blow into it forcefully several times in a row."
B. "I will use it only when I feel short of breath."
C. "I will take a slow, deep breath in, hold it briefly, then exhale, repeating about 10 times
each hour while awake." [CORRECT]
D. "I will breathe normally through it while watching television."
Correct Answer: C
,Rationale: Effective incentive spirometry requires slow deep inspiration with a
breath-hold, performed frequently (about 10 times hourly) to promote alveolar inflation
and prevent atelectasis. Forceful blowing, sporadic use, or passive breathing does not
expand collapsed alveoli.
Q7: A patient on the surgical unit experiences sudden wound evisceration with
protrusion of abdominal contents. What is the nurse's priority action?
A. Attempt to reinsert the organs into the abdomen
B. Place the patient in low-Fowler's with knees flexed and cover the contents with sterile
gauze moistened with sterile saline [CORRECT]
C. Apply firm direct pressure over the exposed organs
D. Have the patient cough deeply to reposition the organs
Correct Answer: B
Rationale: Evisceration is treated by flexing the knees to reduce tension, covering
contents with sterile saline-moistened gauze to prevent drying, and notifying the
surgeon urgently. Reinsertion, pressure, or coughing can damage organs and worsen
the exposure.
Q8: A postoperative patient refuses to ambulate, stating, "It hurts too much to walk."
What is the nurse's best response?
A. Document the refusal and try again the next day
B. Tell the patient that walking is optional after surgery
C. Explain the DVT risk of immobility and administer ordered analgesia before assisting
with ambulation [CORRECT]
D. Contact the provider to cancel ambulation orders
Correct Answer: C
Rationale: Early ambulation prevents venous stasis and DVT, and pre-medication
addresses the pain barrier preventing participation. Accepting refusal or canceling
orders increases thromboembolic risk, while forcing ambulation without pain control is
ineffective and unkind.
Q9: On postoperative day 1, a patient has absent bowel sounds, abdominal distention,
nausea, and no passage of flatus. Which intervention does the nurse anticipate?
A. Advance to a regular diet to stimulate peristalsis
B. Encourage frequent gum chewing and carbonated beverages
C. Administer a bulk-forming laxative immediately
D. Keep the patient NPO and anticipate insertion of a nasogastric tube to
decompression [CORRECT]
Correct Answer: D
, Rationale: The findings indicate paralytic ileus, managed with bowel rest, NPO status,
and NG decompression until peristalsis returns. Feeding, gum, carbonation, or laxatives
would distend the bowel further and are contraindicated.
Q10: Which preoperative teaching intervention is most effective in reducing
postoperative pulmonary and thromboembolic complications?
A. Teaching coughing, deep breathing, incentive spirometry, and early ambulation
expectations [CORRECT]
B. Instructing the patient to remain on strict bed rest for 48 hours after surgery
C. Advising the patient that postoperative pain should be endured without medication
D. Explaining that visitors should perform leg exercises for the patient
Correct Answer: A
Rationale: Preoperative instruction in pulmonary toilet and early ambulation prepares
the patient to actively prevent atelectasis, pneumonia, and DVT. Bed rest, unmanaged
pain, and passive exercise by others contradict evidence-based prevention.
Section B: Cardiovascular & Hematologic Disorders (Q11–Q22)
Q11: A patient with left-sided heart failure has bilateral crackles, dyspnea, and
orthopnea. In which position should the nurse place the patient?
A. Trendelenburg
B. Flat, supine with legs elevated
C. Left lateral recumbent
D. High-Fowler's with legs dependent [CORRECT]
Correct Answer: D
Rationale: High-Fowler's with legs dependent maximizes lung expansion and promotes
venous pooling in the lower extremities, decreasing pulmonary congestion. Supine,
Trendelenburg, and legs-elevated positions worsen venous return and pulmonary
edema.
Q12: Before administering digoxin, the nurse counts the apical pulse for one full minute
and obtains a rate of 58 beats/min. What is the correct action?
A. Administer the dose as prescribed
B. Withhold the dose and notify the healthcare provider [CORRECT]
C. Administer a double dose at the next scheduled time
D. Crush the tablet and administer via feeding tube
Correct Answer: B
