HESI MED SURG Questions and Answers(Version-
2)(NEW-2020/2021, Answers)(50 Q/A)
1. A client is scheduled for an appendectomy and reports taking ibuprofen (Advil) daily for
arthritis. Which action should the nurse take first?
A. Document the medication and continue the preoperative checklist
B. Notify the surgeon of the NSAID use
C. Tell the client to hold the medication the morning of surgery
D. Reassure the client that NSAIDs do not affect surgery
Correct Answer: B — Notify the surgeon of the NSAID use
Rationale: NSAIDs inhibit platelet aggregation and increase bleeding risk; the surgeon must
decide whether to postpone surgery or adjust therapy. Documentation alone (A) delays
essential communication. Holding the morning dose (C) is insufficient because NSAID effects
persist. Reassurance (D) is inaccurate and unsafe.
2. A client in the PACU has a respiratory rate of 8/min, SpO₂ 88%, and is difficult to arouse after
general anesthesia. Which action should the nurse take first?
A. Administer oxygen via nasal cannula
B. Stimulate the client and reposition the head
C. Prepare to administer naloxone
D. Document the findings and reassess in 15 minutes
Correct Answer: B — Stimulate the client and reposition the head
Rationale: The priority is establishing a patent airway and arousing the client. Stimulation
and head repositioning (chin lift/jaw thrust) open the airway and are immediate nursing actions.
Oxygen (A) and naloxone (C) may be needed next but do not replace airway positioning.
Documentation (D) delays intervention.
3. Which finding in a client 12 hours after abdominal surgery requires immediate notification of
the surgeon?
A. Serosanguineous drainage on the dressing
B. Temperature of 99.8°F (37.7°C)
,C. Heart rate 120 bpm with blood pressure 88/50 mmHg
D. Report of incisional pain rated 5/10
Correct Answer: C — Heart rate 120 bpm with blood pressure 88/50 mmHg
Rationale: Tachycardia with hypotension indicates possible hemorrhage or hypovolemic
shock and requires immediate intervention. Serosanguineous drainage (A) is expected. Low-
grade fever (B) is common postoperatively. Moderate pain (D) is expected and managed with
analgesia.
4. A client scheduled for surgery asks why they must stop eating at midnight. Which response by
the nurse is best?
A. "It prevents you from being embarrassed during surgery."
B. "An empty stomach reduces the risk of vomiting and aspiration during anesthesia."
C. "It is hospital policy for all surgical clients."
D. "It makes the surgery go faster."
Correct Answer: B — "An empty stomach reduces the risk of vomiting and aspiration
during anesthesia."
Rationale: The primary rationale for NPO status is preventing aspiration of gastric contents
during induction of anesthesia. The other responses are not accurate or therapeutic.
5. A client is 2 days post–open cholecystectomy. Which assessment finding is most concerning?
A. Blood pressure 118/76 mmHg
B. Temperature 100.4°F (38°C)
C. Heart rate 96 bpm
D. Respiratory rate 20/min
Correct Answer: B — Temperature 100.4°F (38°C)
Rationale: Fever on postoperative day 2 may indicate atelectasis or infection and warrants
further assessment. The other vital signs are within acceptable limits.
6. Which client is at greatest risk for malignant hyperthermia during surgery?
A. Client with a history of asthma
B. Client with a family history of malignant hyperthermia
,C. Client taking beta-blockers
D. Client with type 2 diabetes
Correct Answer: B — Client with a family history of malignant hyperthermia
Rationale: Malignant hyperthermia is an autosomal dominant inherited disorder triggered
by volatile anesthetics and succinylcholine. Family history is the strongest risk factor.
7. A client returns from surgery with a Jackson-Pratt drain. Which action should the nurse take?
A. Empty and recompress the drain bulb
B. Irrigate the drain with sterile saline
C. Clamp the drain for 1 hour
D. Position the drain above the insertion site
Correct Answer: A — Empty and recompress the drain bulb
Rationale: JP drains require compression to maintain suction. Irrigation (B) is not routine,
clamping (C) prevents drainage, and positioning above the site (D) causes backflow.
8. A client who had spinal anesthesia reports a severe headache when sitting up. Which
intervention should the nurse anticipate?
A. Administer a stimulant laxative
B. Encourage caffeine intake and lying flat
C. Apply ice to the forehead
D. Restrict fluids
Correct Answer: B — Encourage caffeine intake and lying flat
Rationale: Post–dural puncture headache is treated with flat positioning, hydration,
caffeine, and sometimes an epidural blood patch. Ice and laxatives are not effective.
9. SATA: Which findings indicate the client is ready for discharge after outpatient
surgery? (Select all that apply)
A. Vital signs stable for 1 hour
B. Able to void
C. Pain controlled with oral analgesics
D. Drowsy but arousable
, E. No nausea or vomiting
F. Has a responsible adult to drive them home
Correct Answers: A, B, C, E, F
Rationale: Discharge criteria include stable vital signs, ability to void, controlled pain,
absence of nausea/vomiting, and a responsible escort. Drowsiness (D) indicates the client is not
fully recovered from anesthesia.
10. A client is scheduled for surgery and has an advance directive. Which action by the nurse
is most appropriate?
A. Place the advance directive in the chart and inform the surgical team
B. Ignore it because surgery overrides advance directives
C. Ask the family to decide about resuscitation
D. Have the client sign a new advance directive
Correct Answer: A — Place the advance directive in the chart and inform the surgical team
Rationale: Advance directives remain valid and must be communicated to the surgical team.
Surgery does not automatically override them.
11. A postoperative client has not voided 8 hours after surgery. Which action should the nurse
take first?
A. Insert an indwelling urinary catheter
B. Palpate the bladder and assist the client to the bathroom
C. Administer a diuretic
D. Restrict fluids
Correct Answer: B — Palpate the bladder and assist the client to the bathroom
Rationale: Noninvasive measures are attempted first. Catheterization (A) is reserved for
retention unrelieved by conservative measures. Diuretics (C) and fluid restriction (D) are
inappropriate.
12. A client is 1 day postoperative and has an order for incentive spirometry every hour while
awake. The client states, "This hurts too much to do." Which response by the nurse is best?
A. "You must do it or you will get pneumonia."
B. "I will medicate you for pain, then help you use the spirometer."
2)(NEW-2020/2021, Answers)(50 Q/A)
1. A client is scheduled for an appendectomy and reports taking ibuprofen (Advil) daily for
arthritis. Which action should the nurse take first?
A. Document the medication and continue the preoperative checklist
B. Notify the surgeon of the NSAID use
C. Tell the client to hold the medication the morning of surgery
D. Reassure the client that NSAIDs do not affect surgery
Correct Answer: B — Notify the surgeon of the NSAID use
Rationale: NSAIDs inhibit platelet aggregation and increase bleeding risk; the surgeon must
decide whether to postpone surgery or adjust therapy. Documentation alone (A) delays
essential communication. Holding the morning dose (C) is insufficient because NSAID effects
persist. Reassurance (D) is inaccurate and unsafe.
2. A client in the PACU has a respiratory rate of 8/min, SpO₂ 88%, and is difficult to arouse after
general anesthesia. Which action should the nurse take first?
A. Administer oxygen via nasal cannula
B. Stimulate the client and reposition the head
C. Prepare to administer naloxone
D. Document the findings and reassess in 15 minutes
Correct Answer: B — Stimulate the client and reposition the head
Rationale: The priority is establishing a patent airway and arousing the client. Stimulation
and head repositioning (chin lift/jaw thrust) open the airway and are immediate nursing actions.
Oxygen (A) and naloxone (C) may be needed next but do not replace airway positioning.
Documentation (D) delays intervention.
3. Which finding in a client 12 hours after abdominal surgery requires immediate notification of
the surgeon?
A. Serosanguineous drainage on the dressing
B. Temperature of 99.8°F (37.7°C)
,C. Heart rate 120 bpm with blood pressure 88/50 mmHg
D. Report of incisional pain rated 5/10
Correct Answer: C — Heart rate 120 bpm with blood pressure 88/50 mmHg
Rationale: Tachycardia with hypotension indicates possible hemorrhage or hypovolemic
shock and requires immediate intervention. Serosanguineous drainage (A) is expected. Low-
grade fever (B) is common postoperatively. Moderate pain (D) is expected and managed with
analgesia.
4. A client scheduled for surgery asks why they must stop eating at midnight. Which response by
the nurse is best?
A. "It prevents you from being embarrassed during surgery."
B. "An empty stomach reduces the risk of vomiting and aspiration during anesthesia."
C. "It is hospital policy for all surgical clients."
D. "It makes the surgery go faster."
Correct Answer: B — "An empty stomach reduces the risk of vomiting and aspiration
during anesthesia."
Rationale: The primary rationale for NPO status is preventing aspiration of gastric contents
during induction of anesthesia. The other responses are not accurate or therapeutic.
5. A client is 2 days post–open cholecystectomy. Which assessment finding is most concerning?
A. Blood pressure 118/76 mmHg
B. Temperature 100.4°F (38°C)
C. Heart rate 96 bpm
D. Respiratory rate 20/min
Correct Answer: B — Temperature 100.4°F (38°C)
Rationale: Fever on postoperative day 2 may indicate atelectasis or infection and warrants
further assessment. The other vital signs are within acceptable limits.
6. Which client is at greatest risk for malignant hyperthermia during surgery?
A. Client with a history of asthma
B. Client with a family history of malignant hyperthermia
,C. Client taking beta-blockers
D. Client with type 2 diabetes
Correct Answer: B — Client with a family history of malignant hyperthermia
Rationale: Malignant hyperthermia is an autosomal dominant inherited disorder triggered
by volatile anesthetics and succinylcholine. Family history is the strongest risk factor.
7. A client returns from surgery with a Jackson-Pratt drain. Which action should the nurse take?
A. Empty and recompress the drain bulb
B. Irrigate the drain with sterile saline
C. Clamp the drain for 1 hour
D. Position the drain above the insertion site
Correct Answer: A — Empty and recompress the drain bulb
Rationale: JP drains require compression to maintain suction. Irrigation (B) is not routine,
clamping (C) prevents drainage, and positioning above the site (D) causes backflow.
8. A client who had spinal anesthesia reports a severe headache when sitting up. Which
intervention should the nurse anticipate?
A. Administer a stimulant laxative
B. Encourage caffeine intake and lying flat
C. Apply ice to the forehead
D. Restrict fluids
Correct Answer: B — Encourage caffeine intake and lying flat
Rationale: Post–dural puncture headache is treated with flat positioning, hydration,
caffeine, and sometimes an epidural blood patch. Ice and laxatives are not effective.
9. SATA: Which findings indicate the client is ready for discharge after outpatient
surgery? (Select all that apply)
A. Vital signs stable for 1 hour
B. Able to void
C. Pain controlled with oral analgesics
D. Drowsy but arousable
, E. No nausea or vomiting
F. Has a responsible adult to drive them home
Correct Answers: A, B, C, E, F
Rationale: Discharge criteria include stable vital signs, ability to void, controlled pain,
absence of nausea/vomiting, and a responsible escort. Drowsiness (D) indicates the client is not
fully recovered from anesthesia.
10. A client is scheduled for surgery and has an advance directive. Which action by the nurse
is most appropriate?
A. Place the advance directive in the chart and inform the surgical team
B. Ignore it because surgery overrides advance directives
C. Ask the family to decide about resuscitation
D. Have the client sign a new advance directive
Correct Answer: A — Place the advance directive in the chart and inform the surgical team
Rationale: Advance directives remain valid and must be communicated to the surgical team.
Surgery does not automatically override them.
11. A postoperative client has not voided 8 hours after surgery. Which action should the nurse
take first?
A. Insert an indwelling urinary catheter
B. Palpate the bladder and assist the client to the bathroom
C. Administer a diuretic
D. Restrict fluids
Correct Answer: B — Palpate the bladder and assist the client to the bathroom
Rationale: Noninvasive measures are attempted first. Catheterization (A) is reserved for
retention unrelieved by conservative measures. Diuretics (C) and fluid restriction (D) are
inappropriate.
12. A client is 1 day postoperative and has an order for incentive spirometry every hour while
awake. The client states, "This hurts too much to do." Which response by the nurse is best?
A. "You must do it or you will get pneumonia."
B. "I will medicate you for pain, then help you use the spirometer."
