HESI MED SURG ACTUAL EXAM QUESTIONS AND
CORRECT ANSWERS WITH WELL-ELABORATED
RATIONALES
Which foods will the nurse recommend for the client with tuberculosis being
discharged to home? (Select all that apply.)
A.Bean soup
B.Spinach
C.Apples
D.Bananas
E.Dark chocolate
F.Shellfish -Answer:-A.Bean soup
B.Spinach
E.Dark chocolate
F.Shellfish
Rationale: Apples and bananas are good sources of fiber but are low in
protein and iron. The remaining foods are high in iron along with organ meats,
all legumes, red meat, pumpkin seeds, quinoa, turkey, broccoli, and tofu.
After attending a class on reducing cancer risk factors, a client selects bran
flakes with 2% milk and orange slices from a breakfast menu. In evaluating
the client's learning, the nurse affirms that the client has made good choices
and makes what additional recommendation?
A.Switch to skim milk.
B.Switch to orange juice.
C.Add a source of protein.
,D.Add herbal tea. -Answer:-A.Switch to skim milk.
Rationale:
Dietary recommendations to reduce cancer risk include reduced consumption
of fats, with increased consumption of fruits, vegetables, and fiber. Option A
promotes reduced fat consumption. Orange slices provide more fiber than
orange juice. Options B, C, and D are not standard recommendations for
reducing cancer risk.
An older client comes to the outpatient clinic complaining of left calf pain. The
nurse notices a reddened area on the calf of the right leg that is warm to the
touch, and the nurse suspects that the client may have thrombophlebitis.
Which additional assessment is most important for the nurse to perform?
A.Measure the client's calf circumference.
B.Auscultate the client's breath sounds.
C.Observe for ecchymosis and petechiae.
D.Obtain the client's blood pressure. -Answer:-B.Auscultate the client's breath
sounds.
Rationale:
All these techniques provide useful assessment data. The most important is to
auscultate the client's breath sounds because the client may have a pulmonary
embolus secondary to the thrombophlebitis. Option A may provide data that
support the nurse's suspicion of thrombophlebitis. Option C is the least
helpful assessment because bruising is not a typical finding associated with
thrombophlebitis. Option D is always useful in evaluating the client's response
to a problem but is of less immediate priority than breath sound auscultation.
,The nurse is completing an admission interview for a client with Parkinson
disease. Which question will provide additional information about
manifestations that the client is likely to experience?
A."Have you ever experienced any paralysis of your arms or legs?"
B."Do you have frequent blackout spells?"
C."Have you ever been frozen in one spot, unable to move?"
D."Do you have headaches, especially ones with throbbing pain?" -Answer:-
C."Have you ever been frozen in one spot, unable to move?"
Rationale:Clients with Parkinson disease frequently experience difficulty in
initiating, maintaining, and performing motor activities. They may even
experience being rooted to the spot and unable to move. Parkinson disease
does not typically cause option A, B, or D
The nurse is preparing a 45-year-old client for discharge from a cancer center
following ileostomy surgery for colon cancer. Which discharge goal should the
nurse include in this client's discharge plan?
A.Reduce the daily intake of animal fat to 10% of the diet within 6 weeks.
B.Exhibit regular, soft-formed stool within 1 month.
C.Demonstrate the irrigation procedure correctly within 1 week.
D.Attend an ostomy support group within 2 weeks -Answer:-D.Attend an
ostomy support group within 2 weeks
Rationale:Attending a support group will be beneficial to the client and
should be encouraged because adaptation to the ostomy can be difficult. This
goal is attainable and is measurable. Option A is not specifically related to
ileostomy care. The client with an ileostomy will not be able to accomplish
option B. Option C is not necessary
, The nurse receives the client's next scheduled bag of TPN labeled with the
additive NPH insulin. Which action should the nurse implement?
A.Hang the solution at the current rate.
B.Refrigerate the solution until needed.
C.Prepare the solution with new tubing.
D.Return the solution to the pharmacy -Answer:-D.Return the solution to the
pharmacy
Rationale:Only regular insulin is administered by the IV route, so the TPN
solution containing NPH insulin should be returned to the pharmacy. Options
A, B, and C are not indicated because the solution should not be administered
The nurse observes ventricular fibrillation on telemetry and, on entering the
client's bathroom, finds the client unconscious on the floor. Which action
should the nurse take first?
A.Administer an antidysrhythmic medication.
B.Start cardiopulmonary resuscitation.
C.Prepare for mechanical ventilation.
D.Assess the client's pulse oximetry. -Answer:-B.Start cardiopulmonary
resuscitation.
Rationale:Ventricular fibrillation is a life-threatening dysrhythmia, and CPR
should be started immediately until the crash cart arrives. Options A and C are
appropriate, but CPR is the priority action until a defibrillator is available,
which is the most effective treatment for ventricular fibrillation. The client is
dying, and option D does not address the seriousness of this situation.
CORRECT ANSWERS WITH WELL-ELABORATED
RATIONALES
Which foods will the nurse recommend for the client with tuberculosis being
discharged to home? (Select all that apply.)
A.Bean soup
B.Spinach
C.Apples
D.Bananas
E.Dark chocolate
F.Shellfish -Answer:-A.Bean soup
B.Spinach
E.Dark chocolate
F.Shellfish
Rationale: Apples and bananas are good sources of fiber but are low in
protein and iron. The remaining foods are high in iron along with organ meats,
all legumes, red meat, pumpkin seeds, quinoa, turkey, broccoli, and tofu.
After attending a class on reducing cancer risk factors, a client selects bran
flakes with 2% milk and orange slices from a breakfast menu. In evaluating
the client's learning, the nurse affirms that the client has made good choices
and makes what additional recommendation?
A.Switch to skim milk.
B.Switch to orange juice.
C.Add a source of protein.
,D.Add herbal tea. -Answer:-A.Switch to skim milk.
Rationale:
Dietary recommendations to reduce cancer risk include reduced consumption
of fats, with increased consumption of fruits, vegetables, and fiber. Option A
promotes reduced fat consumption. Orange slices provide more fiber than
orange juice. Options B, C, and D are not standard recommendations for
reducing cancer risk.
An older client comes to the outpatient clinic complaining of left calf pain. The
nurse notices a reddened area on the calf of the right leg that is warm to the
touch, and the nurse suspects that the client may have thrombophlebitis.
Which additional assessment is most important for the nurse to perform?
A.Measure the client's calf circumference.
B.Auscultate the client's breath sounds.
C.Observe for ecchymosis and petechiae.
D.Obtain the client's blood pressure. -Answer:-B.Auscultate the client's breath
sounds.
Rationale:
All these techniques provide useful assessment data. The most important is to
auscultate the client's breath sounds because the client may have a pulmonary
embolus secondary to the thrombophlebitis. Option A may provide data that
support the nurse's suspicion of thrombophlebitis. Option C is the least
helpful assessment because bruising is not a typical finding associated with
thrombophlebitis. Option D is always useful in evaluating the client's response
to a problem but is of less immediate priority than breath sound auscultation.
,The nurse is completing an admission interview for a client with Parkinson
disease. Which question will provide additional information about
manifestations that the client is likely to experience?
A."Have you ever experienced any paralysis of your arms or legs?"
B."Do you have frequent blackout spells?"
C."Have you ever been frozen in one spot, unable to move?"
D."Do you have headaches, especially ones with throbbing pain?" -Answer:-
C."Have you ever been frozen in one spot, unable to move?"
Rationale:Clients with Parkinson disease frequently experience difficulty in
initiating, maintaining, and performing motor activities. They may even
experience being rooted to the spot and unable to move. Parkinson disease
does not typically cause option A, B, or D
The nurse is preparing a 45-year-old client for discharge from a cancer center
following ileostomy surgery for colon cancer. Which discharge goal should the
nurse include in this client's discharge plan?
A.Reduce the daily intake of animal fat to 10% of the diet within 6 weeks.
B.Exhibit regular, soft-formed stool within 1 month.
C.Demonstrate the irrigation procedure correctly within 1 week.
D.Attend an ostomy support group within 2 weeks -Answer:-D.Attend an
ostomy support group within 2 weeks
Rationale:Attending a support group will be beneficial to the client and
should be encouraged because adaptation to the ostomy can be difficult. This
goal is attainable and is measurable. Option A is not specifically related to
ileostomy care. The client with an ileostomy will not be able to accomplish
option B. Option C is not necessary
, The nurse receives the client's next scheduled bag of TPN labeled with the
additive NPH insulin. Which action should the nurse implement?
A.Hang the solution at the current rate.
B.Refrigerate the solution until needed.
C.Prepare the solution with new tubing.
D.Return the solution to the pharmacy -Answer:-D.Return the solution to the
pharmacy
Rationale:Only regular insulin is administered by the IV route, so the TPN
solution containing NPH insulin should be returned to the pharmacy. Options
A, B, and C are not indicated because the solution should not be administered
The nurse observes ventricular fibrillation on telemetry and, on entering the
client's bathroom, finds the client unconscious on the floor. Which action
should the nurse take first?
A.Administer an antidysrhythmic medication.
B.Start cardiopulmonary resuscitation.
C.Prepare for mechanical ventilation.
D.Assess the client's pulse oximetry. -Answer:-B.Start cardiopulmonary
resuscitation.
Rationale:Ventricular fibrillation is a life-threatening dysrhythmia, and CPR
should be started immediately until the crash cart arrives. Options A and C are
appropriate, but CPR is the priority action until a defibrillator is available,
which is the most effective treatment for ventricular fibrillation. The client is
dying, and option D does not address the seriousness of this situation.
