HESI: MEDICAL-SURGICAL ASSIGNMENT EXAM
AND RATIONALE WITH ALL CORRECT & VERIFIED
ANSWERS (UPDATED TO PASS)
1. Which assessment is most important for the nurse to perform on a client who is
hospitalized for Guillain-Barre syndrome that is rapidly progressing? A: Respiratory effort.
B: Unsteady gait.
C: Intensity of pain.
D: Ability to eat.: A: Respiratory Effort
(Guillain-Barre syndrome causes paralysis or weakness that typically starts at the
feet and progresses upwards. As the condition progresses, the nurse must ensure
that the client is able to breathe effectively.)
2. A male client comes into the clinic with a history of penile discharge with painful, burning
urination. Which action should the nurse implement?
A: Collect a culture of the penile discharge. B: Palpate
the inguinal lymph nodes gently. C: Observe for
scrotal swelling and redness.
D: Express the discharge to determine color.: A: Collect a culture of the penile
discharge.
(Penile discharge with painful urination is commonly associated with gonorrhea. Th
nurse should collect a culture of the penile discharge to determine the cause of the
symptoms. The cause must be determined or confirmed through culture to identify
the organism and ensure effective treatment.)
3. A client with history of atrial fibrillation is admitted to the telemetry unit with sudden onset of
shortness of breath. The nurse observes a new irregular heart rhythm and should perform
which assessment at this time?
A: Check for a pulse deficit. B:
Palpate the apical impulse. C:
Inspect jugular vein pulse.
D: Examine for a carotid bruit.: A: Check for a pulse deficit.
(A client with a past history of atrial fibrillation may return to that rhythm. Any
signs of atrial fibrillation, such as sudden onset shortness of breath, requires
further investigation. The nurse should assess this client for a pulse deficit
because this condition occurs with atrial fibrillation.)
4. Which client should be further assessed for an ectopic pregnancy? A: A 24-year-
old with shoulder and lower abdominal quadrant pain. B: A 33-year-old with
intermittent lower abdominal cramping.
C: A 20-year-old with fever and right lower abdominal colic.
D: A 40-year-old with jaundice and right lower abdominal pain.: A: A 24-year-old
, HESI: MEDICAL-SURGICAL ASSIGNMENT EXAM
AND RATIONALE WITH ALL CORRECT & VERIFIED
ANSWERS (UPDATED TO PASS)
with shoulder and lower abdominal quadrant pain.
(A 24-year-old with sudden onset of lower abdominal quadrant pain should be
assessed for an ectopic pregnancy. The pain can also be referred to the shoulder
and may be associated with vaginal bleeding.)
5. Which dietary assessment finding is most important for the nurse to ad- dress when
caring for a client with diabetic nephropathy?
A: Drinks a six pack of beer every day. B:
Enjoys a hamburger once a month. C: Eats
fortified breakfast cereal daily.
D: Consumes beans and rice every day.: A: Drinks a six pack of beer every day.
(Drinking six beers every day is the dietary assessment finding most important for
the nurse to address when caring for a client with diabetic nephropathy. The usual
can of beer is 12 ounces (355 mL). Clients with diabetes are recommended to drink
no more than 12 ounces of beer per day because beer contains carbohydrates that
can create unhealthy fluctuations in blood glucose and promote poorglucose contro
Nephropathy is exacerbated by poor blood glucose control.)
6. Which assessment finding is of greatest concern to the nurse who is caring for a client with
stomatitis?
A: Cough brought on by swallowing. B: Sore
throat caused by speaking.
C: Painful and dry oral cavity.
D: Unintended weight loss.: A: Cough brought on by swallowing.
A cough brought on by swallowing is a sign of dysphagia, which is a finding
of particular concern in a client with stomatitis. Dysphagia can cause numerous
problems, including airway obstruction, and should be reported to the healthcare
provider immediately.
7. The nurse is teaching a client diagnosed with peripheral arterial disease. Which
genitourinary system complication should the nurse include in the teaching?
A: Altered sexual response. B:
Sterility.
C: Urinary incontinence.
D: Decreased pelvic muscle tone.: A: Altered sexual response.
Peripheral arterial disease (PAD) is a cardiovascular condition characterized by
narrowing of the arteries and reduced blood flow to the extremities. PAD is known
, HESI: MEDICAL-SURGICAL ASSIGNMENT EXAM
AND RATIONALE WITH ALL CORRECT & VERIFIED
ANSWERS (UPDATED TO PASS)
alter the blood flow to the male's penis and is associated with erectile
dysfunction in men.
8. A 40-year-old female client has a history of smoking. Which finding should the nurse
identify as a risk factor for myocardia infarction?
A: Oral contraceptives. B:
Senile osteopenia.
C: Levothyroxine therapy.
D: Pernicious anemia.: A: Oral contraceptives.
Women older than 35 years old who smoke and take oral contraceptives have
an increased risk of myocardial infarction or stroke.
9. A client has been told that there is cataract formation over both eyes. Which finding should
the nurse expect when assessing the client?
A: Decreased color perception. B:
Presence of floaters.
C: Loss of central vision.
D: Reduced peripheral vision.: A: Decreased color perception.
Decreased color perception occurs with cataract formation. Cataract formation
is also associated with blurred vision and a global loss of vision so gradual that
the client may not be aware of it.
10.Which assessment finding should most concern the nurse who is monitor- ing a client two
hours after a thoracentesis?
A: New onset of coughing. B:
Low resting heart rate. C:
Distended neck veins.
D: Decreased shallow respirations.: A: New onset of coughing.
A pneumothorax (partial or complete lung collapse) is the potential complication
of a thoracentesis. Manifestations of a pneumothorax include new onset of a
nagging cough, tachycardia, and an increased shallow respiration rate.
11.While caring for a client who has esophageal varices, which nursing inter- vention is most
important for the registered nurse (RN) to implement?
A: Monitor infusing IV fluids and any replacement blood products. B: Prepare for
esophagogastroduodenoscopy (EGD).
C: Maintain the client on strict bedrest.
D: Insert a nasogastric tube (NGT) for intermittent suction.: A: Monitor infusing IV fluids
and any replacement blood products
, HESI: MEDICAL-SURGICAL ASSIGNMENT EXAM
AND RATIONALE WITH ALL CORRECT & VERIFIED
ANSWERS (UPDATED TO PASS)
(Maintaining hemodynamic stability in a client with esophageal varices can precip-
itate a life-threatening crisis if esophageal varies leak or rupture and can result in
hemorrhage. The priority is assessing and monitoring infusions of IV fluids and any
replacement blood products.)
12.The registered nurse (RN) is caring for a client who developed oliguria and was
diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to
the RN that the client is stabilizing?
A: Urine output of 40 mL/hour.
B: Apical pulse 100 and blood pressure 76/42. C: Urine
specific gravity 1.001.
D: Tented skin on dorsal surface of hands.: A: Urine output of 40 mL/hour.
A decrease in urinary output is a sign of dehydration. When the urine output
returns to a normal range, 40 mL/hour, the client's kidneys are perfusing
adequately and indicates the client's status is stablizing
13. After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned
the care of the client. Which nursing intervention is most important for the RN to implement?
A: Position client on left side with pillow placed under the costal margin. B: Assist the client
with voiding immediately after the procedure.
C: Evaluate vital signs q10 to 20 minutes for 2 hours after procedure. D: Ambulate
client 3 times in first hour with pillow held at abdomen.: C: Evaluate vital signs q10
to 20 minutes for 2 hours after procedure.
Vital signs should be checked every 10 to 20 minutes to assess for bleeding after
biopsy of the liver, which is highly vascular. The client should be positioned on the
right side with a pillow or sandbag under the costal margin and supporting the
biopsy site. The client should be maintained on bedrest for several hours to
decrease the risk of bleeding from the biopsy site.
14.The registered nurse (RN) is caring for a client with aplastic anemia who is hospitalized
for weight loss and generalized weakness. Laboratory values show a white blood count
(WBC) of 2,500/mm 3 and a platelet count of 160,000/mm 3. Which intervention is the
primary focus in the client's plan of care for the RN to implement?
A: Assist with frequent ambulation. B:
Encourage visitors to visit.
C: Maintain strict protective precautions.
D: Avoid peripheral injections.: C: Maintain strict protective precautions.
AND RATIONALE WITH ALL CORRECT & VERIFIED
ANSWERS (UPDATED TO PASS)
1. Which assessment is most important for the nurse to perform on a client who is
hospitalized for Guillain-Barre syndrome that is rapidly progressing? A: Respiratory effort.
B: Unsteady gait.
C: Intensity of pain.
D: Ability to eat.: A: Respiratory Effort
(Guillain-Barre syndrome causes paralysis or weakness that typically starts at the
feet and progresses upwards. As the condition progresses, the nurse must ensure
that the client is able to breathe effectively.)
2. A male client comes into the clinic with a history of penile discharge with painful, burning
urination. Which action should the nurse implement?
A: Collect a culture of the penile discharge. B: Palpate
the inguinal lymph nodes gently. C: Observe for
scrotal swelling and redness.
D: Express the discharge to determine color.: A: Collect a culture of the penile
discharge.
(Penile discharge with painful urination is commonly associated with gonorrhea. Th
nurse should collect a culture of the penile discharge to determine the cause of the
symptoms. The cause must be determined or confirmed through culture to identify
the organism and ensure effective treatment.)
3. A client with history of atrial fibrillation is admitted to the telemetry unit with sudden onset of
shortness of breath. The nurse observes a new irregular heart rhythm and should perform
which assessment at this time?
A: Check for a pulse deficit. B:
Palpate the apical impulse. C:
Inspect jugular vein pulse.
D: Examine for a carotid bruit.: A: Check for a pulse deficit.
(A client with a past history of atrial fibrillation may return to that rhythm. Any
signs of atrial fibrillation, such as sudden onset shortness of breath, requires
further investigation. The nurse should assess this client for a pulse deficit
because this condition occurs with atrial fibrillation.)
4. Which client should be further assessed for an ectopic pregnancy? A: A 24-year-
old with shoulder and lower abdominal quadrant pain. B: A 33-year-old with
intermittent lower abdominal cramping.
C: A 20-year-old with fever and right lower abdominal colic.
D: A 40-year-old with jaundice and right lower abdominal pain.: A: A 24-year-old
, HESI: MEDICAL-SURGICAL ASSIGNMENT EXAM
AND RATIONALE WITH ALL CORRECT & VERIFIED
ANSWERS (UPDATED TO PASS)
with shoulder and lower abdominal quadrant pain.
(A 24-year-old with sudden onset of lower abdominal quadrant pain should be
assessed for an ectopic pregnancy. The pain can also be referred to the shoulder
and may be associated with vaginal bleeding.)
5. Which dietary assessment finding is most important for the nurse to ad- dress when
caring for a client with diabetic nephropathy?
A: Drinks a six pack of beer every day. B:
Enjoys a hamburger once a month. C: Eats
fortified breakfast cereal daily.
D: Consumes beans and rice every day.: A: Drinks a six pack of beer every day.
(Drinking six beers every day is the dietary assessment finding most important for
the nurse to address when caring for a client with diabetic nephropathy. The usual
can of beer is 12 ounces (355 mL). Clients with diabetes are recommended to drink
no more than 12 ounces of beer per day because beer contains carbohydrates that
can create unhealthy fluctuations in blood glucose and promote poorglucose contro
Nephropathy is exacerbated by poor blood glucose control.)
6. Which assessment finding is of greatest concern to the nurse who is caring for a client with
stomatitis?
A: Cough brought on by swallowing. B: Sore
throat caused by speaking.
C: Painful and dry oral cavity.
D: Unintended weight loss.: A: Cough brought on by swallowing.
A cough brought on by swallowing is a sign of dysphagia, which is a finding
of particular concern in a client with stomatitis. Dysphagia can cause numerous
problems, including airway obstruction, and should be reported to the healthcare
provider immediately.
7. The nurse is teaching a client diagnosed with peripheral arterial disease. Which
genitourinary system complication should the nurse include in the teaching?
A: Altered sexual response. B:
Sterility.
C: Urinary incontinence.
D: Decreased pelvic muscle tone.: A: Altered sexual response.
Peripheral arterial disease (PAD) is a cardiovascular condition characterized by
narrowing of the arteries and reduced blood flow to the extremities. PAD is known
, HESI: MEDICAL-SURGICAL ASSIGNMENT EXAM
AND RATIONALE WITH ALL CORRECT & VERIFIED
ANSWERS (UPDATED TO PASS)
alter the blood flow to the male's penis and is associated with erectile
dysfunction in men.
8. A 40-year-old female client has a history of smoking. Which finding should the nurse
identify as a risk factor for myocardia infarction?
A: Oral contraceptives. B:
Senile osteopenia.
C: Levothyroxine therapy.
D: Pernicious anemia.: A: Oral contraceptives.
Women older than 35 years old who smoke and take oral contraceptives have
an increased risk of myocardial infarction or stroke.
9. A client has been told that there is cataract formation over both eyes. Which finding should
the nurse expect when assessing the client?
A: Decreased color perception. B:
Presence of floaters.
C: Loss of central vision.
D: Reduced peripheral vision.: A: Decreased color perception.
Decreased color perception occurs with cataract formation. Cataract formation
is also associated with blurred vision and a global loss of vision so gradual that
the client may not be aware of it.
10.Which assessment finding should most concern the nurse who is monitor- ing a client two
hours after a thoracentesis?
A: New onset of coughing. B:
Low resting heart rate. C:
Distended neck veins.
D: Decreased shallow respirations.: A: New onset of coughing.
A pneumothorax (partial or complete lung collapse) is the potential complication
of a thoracentesis. Manifestations of a pneumothorax include new onset of a
nagging cough, tachycardia, and an increased shallow respiration rate.
11.While caring for a client who has esophageal varices, which nursing inter- vention is most
important for the registered nurse (RN) to implement?
A: Monitor infusing IV fluids and any replacement blood products. B: Prepare for
esophagogastroduodenoscopy (EGD).
C: Maintain the client on strict bedrest.
D: Insert a nasogastric tube (NGT) for intermittent suction.: A: Monitor infusing IV fluids
and any replacement blood products
, HESI: MEDICAL-SURGICAL ASSIGNMENT EXAM
AND RATIONALE WITH ALL CORRECT & VERIFIED
ANSWERS (UPDATED TO PASS)
(Maintaining hemodynamic stability in a client with esophageal varices can precip-
itate a life-threatening crisis if esophageal varies leak or rupture and can result in
hemorrhage. The priority is assessing and monitoring infusions of IV fluids and any
replacement blood products.)
12.The registered nurse (RN) is caring for a client who developed oliguria and was
diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to
the RN that the client is stabilizing?
A: Urine output of 40 mL/hour.
B: Apical pulse 100 and blood pressure 76/42. C: Urine
specific gravity 1.001.
D: Tented skin on dorsal surface of hands.: A: Urine output of 40 mL/hour.
A decrease in urinary output is a sign of dehydration. When the urine output
returns to a normal range, 40 mL/hour, the client's kidneys are perfusing
adequately and indicates the client's status is stablizing
13. After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned
the care of the client. Which nursing intervention is most important for the RN to implement?
A: Position client on left side with pillow placed under the costal margin. B: Assist the client
with voiding immediately after the procedure.
C: Evaluate vital signs q10 to 20 minutes for 2 hours after procedure. D: Ambulate
client 3 times in first hour with pillow held at abdomen.: C: Evaluate vital signs q10
to 20 minutes for 2 hours after procedure.
Vital signs should be checked every 10 to 20 minutes to assess for bleeding after
biopsy of the liver, which is highly vascular. The client should be positioned on the
right side with a pillow or sandbag under the costal margin and supporting the
biopsy site. The client should be maintained on bedrest for several hours to
decrease the risk of bleeding from the biopsy site.
14.The registered nurse (RN) is caring for a client with aplastic anemia who is hospitalized
for weight loss and generalized weakness. Laboratory values show a white blood count
(WBC) of 2,500/mm 3 and a platelet count of 160,000/mm 3. Which intervention is the
primary focus in the client's plan of care for the RN to implement?
A: Assist with frequent ambulation. B:
Encourage visitors to visit.
C: Maintain strict protective precautions.
D: Avoid peripheral injections.: C: Maintain strict protective precautions.
