HESI: Medical-Surgical Assignment Exam and
Rationale Questions and Verified Answers
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. Correct Answer: 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.)
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. Correct Answer: A: Collect a culture of the penile discharge.
(Penile discharge with painful urination is commonly associated with gonorrhea. The nurse should
collect a culture of the penile discharge to determine the cause of these symptoms. The cause must be
determined or confirmed through culture to identify the organism and ensure effective treatment.)
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. Correct Answer: 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.)
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. Correct Answer: 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
pregnancy. The pain can also be referred to the shoulder and may be associated with vaginal bleeding.)
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. Correct Answer: 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 exacerbated by poor blood glucose control.)
,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. Correct Answer: 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.
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. Correct Answer: 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 to alter the blood flow to the male's penis and
is associated with erectile dysfunction in men.
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. Correct Answer: A: Oral contraceptives.
, Women older than 35 years old who smoke and take oral contraceptives have an increased risk of
myocardial infarction or stroke.
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. Correct Answer: 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.
Which assessment finding should most concern the nurse who is monitoring 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. Correct Answer: 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.
While caring for a client who has esophageal varices, which nursing intervention 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.
Rationale Questions and Verified Answers
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. Correct Answer: 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.)
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. Correct Answer: A: Collect a culture of the penile discharge.
(Penile discharge with painful urination is commonly associated with gonorrhea. The nurse should
collect a culture of the penile discharge to determine the cause of these symptoms. The cause must be
determined or confirmed through culture to identify the organism and ensure effective treatment.)
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. Correct Answer: 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.)
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. Correct Answer: 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
pregnancy. The pain can also be referred to the shoulder and may be associated with vaginal bleeding.)
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. Correct Answer: 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 exacerbated by poor blood glucose control.)
,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. Correct Answer: 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.
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. Correct Answer: 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 to alter the blood flow to the male's penis and
is associated with erectile dysfunction in men.
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. Correct Answer: A: Oral contraceptives.
, Women older than 35 years old who smoke and take oral contraceptives have an increased risk of
myocardial infarction or stroke.
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. Correct Answer: 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.
Which assessment finding should most concern the nurse who is monitoring 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. Correct Answer: 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.
While caring for a client who has esophageal varices, which nursing intervention 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.
