MED SURG HESI V2_ 2025_2026 100% MARKING
SCHEME
After hospitalization for SIADH, a Reorient client to room
client develops pontine
myelinolysis. Which
intervention should the nurse implement
first?
A. Reorient client to room
B. Place a patch on one eye
C. Evaluate clients ability to swallow
D. Perform range of motion exercises
A male client with heart failure calls the Has his weight changed in the last several days?
clinic and reports that he cannot put
his shoes on because they are too tight.
Which additional information should
the nurse obtain?
A. What time did he take his medication?
B. Has his weight changed in the last
several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night?
An older adult woman with a long Assist her to an upright position
history of COPD is admitted with
progressive shortness of breath and a
persistent cough, is anxious, and is
complaining of dry mouth. which
intervention should the nurse implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high flow Venturi mask
D. Assist her to an upright position
, While caring for a client with Asymmetrical weakness
Amyotrophic lateral sclerosis (ALS) a
nurse performs a
neurological assessment every 4 hours.
Which assessment finding warrants
immediate
intervention by the nurse?
A. Inappropriate laughter
B. Increasing anxiety
C. Weakened cough effort
D. Asymmetrical weakness
The nurse is providing preoperative The xenograft is taken from a non-human source
education for a Jewish client scheduled
to receive a
xenograft to promote burn healing. Which
information should the provider this client?
A. Grafting increase the risk for
bacterial infections
B. The xenograft is taken from a non-
human source.
C. Grafts are later removed by a
debriding procedure
D. As the burns heals, the graft permanently
A male client who had colon surgery 3 Bring additional sterile dressing supplies to the room
days ago is anxious and requesting
assistance to reposition. While the nurse
is turning him, the wound dehiscences
and ulcerates. The nurse moistens an
available sterile dressing and
places it over the wound. Which intervention
should the nurse implement next.
A. Bring additional sterile dressing
supplies to the room.
B. Prepare the client to return to the OR
C. Obtain a sample of the drainage to
send to the lab
D. ausculate the abdomen for bowel sounds
SCHEME
After hospitalization for SIADH, a Reorient client to room
client develops pontine
myelinolysis. Which
intervention should the nurse implement
first?
A. Reorient client to room
B. Place a patch on one eye
C. Evaluate clients ability to swallow
D. Perform range of motion exercises
A male client with heart failure calls the Has his weight changed in the last several days?
clinic and reports that he cannot put
his shoes on because they are too tight.
Which additional information should
the nurse obtain?
A. What time did he take his medication?
B. Has his weight changed in the last
several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night?
An older adult woman with a long Assist her to an upright position
history of COPD is admitted with
progressive shortness of breath and a
persistent cough, is anxious, and is
complaining of dry mouth. which
intervention should the nurse implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high flow Venturi mask
D. Assist her to an upright position
, While caring for a client with Asymmetrical weakness
Amyotrophic lateral sclerosis (ALS) a
nurse performs a
neurological assessment every 4 hours.
Which assessment finding warrants
immediate
intervention by the nurse?
A. Inappropriate laughter
B. Increasing anxiety
C. Weakened cough effort
D. Asymmetrical weakness
The nurse is providing preoperative The xenograft is taken from a non-human source
education for a Jewish client scheduled
to receive a
xenograft to promote burn healing. Which
information should the provider this client?
A. Grafting increase the risk for
bacterial infections
B. The xenograft is taken from a non-
human source.
C. Grafts are later removed by a
debriding procedure
D. As the burns heals, the graft permanently
A male client who had colon surgery 3 Bring additional sterile dressing supplies to the room
days ago is anxious and requesting
assistance to reposition. While the nurse
is turning him, the wound dehiscences
and ulcerates. The nurse moistens an
available sterile dressing and
places it over the wound. Which intervention
should the nurse implement next.
A. Bring additional sterile dressing
supplies to the room.
B. Prepare the client to return to the OR
C. Obtain a sample of the drainage to
send to the lab
D. ausculate the abdomen for bowel sounds
