HESI: MEDICAL-SURGICAL ASSIGNMENT EXAM AND
RATIONALE
1. Which assessment is most A: Respiratory Ettort
impor- tant for the nurse to
perform on a client who is (Guillain-Barre syndrome causes paralysis or
hospitalized for Guil- weakness
lain-Barre syndrome that is rapidly that typically starts at the feet and
progresses upwards.
progressing? As the condition progresses, the nurse must
A: Respiratory ensure that the client is able to breathe
effort. B: Unsteady ettectively.)
gait.
C: Intensity of
pain. D: Ability to
eat.
A: Collect a culture of the penile discharge.
2. A male client comes into the
clin- ic with a history of
(Penile discharge with painful urination is
penile dis- charge with
commonly associated with gonorrhea. The
painful, burning uri- nation.
nurse should collect a culture of the penile
Which action should the
discharge to determine the cause of these
nurse implement?
symptoms. The cause must be determined or
A: Collect a culture of the
confirmed through culture to identify the
penile discharge.
organism and ensure ettective treatment.)
B: Palpate the inguinal
lymph nodes gently.
C: Observe for scrotal swelling
and redness.
D: Express the discharge to
deter- mine color.
3. A client with history of atrial A: Check for a pulse deficit.
fibril- lation is admitted to the
telemetry unit with sudden (A client with a past history of atrial fibrillation
onset of short- may re-
, HESI: MEDICAL-SURGICAL ASSIGNMENT EXAM AND
RATIONALE
ness of breath. The nurse observes turn to that rhythm. Any signs of atrial
fibrillation, such
a new irregular heart rhythm as sudden onset shortness of breath, requires
and should perform which further investigation. The nurse should assess
assessment at this time? this client for a pulse deficit because this
A: Check for a pulse deficit. condition occurs with atrial fibrillation.)
, HESI: MEDICAL-SURGICAL ASSIGNMENT EXAM AND
RATIONALE
B: Palpate the apical 6. Which assessment finding
impulse. C: Inspect jugular is of greatest concern to the
vein pulse. D: Examine for nurse who is caring for a
a carotid bruit. client with stomati- tis?
4. Which client should be
further as- sessed 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.
5. Which dietary assessment
finding is most important for
the nurse to address 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.
, HESI: MEDICAL-SURGICAL ASSIGNMENT EXAM AND
RATIONALE
dys- phagia, which is a finding of particular
concern in a client with stomatitis. Dysphagia
can cause numerous
A: A 24-year-old 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 preg- nancy. The pain can also be
referred to the shoulder and may be associated
with vaginal bleeding.)
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 control. Nephropathy is
exacer- bated by poor blood glucose control.)
A: Cough brought on by swallowing.
A cough brought on by swallowing is a sign of
RATIONALE
1. Which assessment is most A: Respiratory Ettort
impor- tant for the nurse to
perform on a client who is (Guillain-Barre syndrome causes paralysis or
hospitalized for Guil- weakness
lain-Barre syndrome that is rapidly that typically starts at the feet and
progresses upwards.
progressing? As the condition progresses, the nurse must
A: Respiratory ensure that the client is able to breathe
effort. B: Unsteady ettectively.)
gait.
C: Intensity of
pain. D: Ability to
eat.
A: Collect a culture of the penile discharge.
2. A male client comes into the
clin- ic with a history of
(Penile discharge with painful urination is
penile dis- charge with
commonly associated with gonorrhea. The
painful, burning uri- nation.
nurse should collect a culture of the penile
Which action should the
discharge to determine the cause of these
nurse implement?
symptoms. The cause must be determined or
A: Collect a culture of the
confirmed through culture to identify the
penile discharge.
organism and ensure ettective treatment.)
B: Palpate the inguinal
lymph nodes gently.
C: Observe for scrotal swelling
and redness.
D: Express the discharge to
deter- mine color.
3. A client with history of atrial A: Check for a pulse deficit.
fibril- lation is admitted to the
telemetry unit with sudden (A client with a past history of atrial fibrillation
onset of short- may re-
, HESI: MEDICAL-SURGICAL ASSIGNMENT EXAM AND
RATIONALE
ness of breath. The nurse observes turn to that rhythm. Any signs of atrial
fibrillation, such
a new irregular heart rhythm as sudden onset shortness of breath, requires
and should perform which further investigation. The nurse should assess
assessment at this time? this client for a pulse deficit because this
A: Check for a pulse deficit. condition occurs with atrial fibrillation.)
, HESI: MEDICAL-SURGICAL ASSIGNMENT EXAM AND
RATIONALE
B: Palpate the apical 6. Which assessment finding
impulse. C: Inspect jugular is of greatest concern to the
vein pulse. D: Examine for nurse who is caring for a
a carotid bruit. client with stomati- tis?
4. Which client should be
further as- sessed 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.
5. Which dietary assessment
finding is most important for
the nurse to address 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.
, HESI: MEDICAL-SURGICAL ASSIGNMENT EXAM AND
RATIONALE
dys- phagia, which is a finding of particular
concern in a client with stomatitis. Dysphagia
can cause numerous
A: A 24-year-old 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 preg- nancy. The pain can also be
referred to the shoulder and may be associated
with vaginal bleeding.)
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 control. Nephropathy is
exacer- bated by poor blood glucose control.)
A: Cough brought on by swallowing.
A cough brought on by swallowing is a sign of
