NSG 223 MEDICAL-SURGICAL NURSING
I HESI FINAL PREPARATION
1. A patient with chronic kidney disease (CKD) reports severe itching. Which laboratory value
should the nurse check first?
A. Serum creatinine
B. Serum phosphate
C. Hemoglobin
D. Serum potassium
Answer: B
Conceptual Explanation: Uremic pruritus is common in CKD and is often associated with
high serum phosphate levels and calcium-phosphate deposits in the skin.
2. A nurse is caring for a patient who is 24 hours post-thyroidectomy. The patient reports
tingling in the fingers and around the mouth. What is the priority nursing action?
A. Check the patient’s blood pressure
B. Assess for Chvostek’s sign
C. Administer a sedative as prescribed
D. Encourage the patient to cough and deep breathe
,Answer: B
Conceptual Explanation: Tingling (paresthesia) after thyroidectomy suggests
hypocalcemia due to accidental parathyroid gland removal. Assessing for Chvostek’s sign
helps confirm tetany.
3. Which clinical manifestation should the nurse expect to find in a patient with a suspected
tension pneumothorax?
A. Tracheal deviation to the unaffected side
B. Bradypnea
C. Increased breath sounds on the affected side
D. Tracheal deviation to the affected side
Answer: A
Conceptual Explanation: In a tension pneumothorax, air buildup causes a mediastinal
shift, pushing the trachea toward the opposite (unaffected) side.
4. A patient is receiving a continuous intravenous infusion of heparin for a pulmonary
embolism. The nurse notes a PTT of 110 seconds (Control: 25-35 seconds). What is the nurse’s
first action?
A. Increase the infusion rate
B. Administer Vitamin K intramuscularly
C. Stop the infusion and notify the provider
, D. Document the finding as therapeutic
Answer: C
Conceptual Explanation: A PTT of 110 is significantly above the therapeutic range
(usually 1.5 to 2.5 times the control). The infusion must be stopped to prevent bleeding.
5. A patient with Type 1 Diabetes Mellitus is found unconscious and diaphoretic. The nurse is
unable to obtain a blood glucose reading. What should be the nurse’s immediate action?
A. Call the family to determine the last meal
B. Administer regular insulin subcutaneously
C. Wait for the laboratory to perform a venous draw
D. Administer 50% Dextrose (D50) IV
Answer: D
Conceptual Explanation: In an unconscious diabetic patient where hypoglycemia is
suspected, immediate administration of glucose (D50) is life-saving and safer than delaying
treatment.
6. The nurse is assessing a patient with a deep vein thrombosis (DVT) in the right leg. Which
assessment finding requires immediate intervention?
A. Right calf circumference 2 cm larger than the left
B. Patient reporting sudden onset shortness of breath
C. Pain in the right calf on dorsiflexion
I HESI FINAL PREPARATION
1. A patient with chronic kidney disease (CKD) reports severe itching. Which laboratory value
should the nurse check first?
A. Serum creatinine
B. Serum phosphate
C. Hemoglobin
D. Serum potassium
Answer: B
Conceptual Explanation: Uremic pruritus is common in CKD and is often associated with
high serum phosphate levels and calcium-phosphate deposits in the skin.
2. A nurse is caring for a patient who is 24 hours post-thyroidectomy. The patient reports
tingling in the fingers and around the mouth. What is the priority nursing action?
A. Check the patient’s blood pressure
B. Assess for Chvostek’s sign
C. Administer a sedative as prescribed
D. Encourage the patient to cough and deep breathe
,Answer: B
Conceptual Explanation: Tingling (paresthesia) after thyroidectomy suggests
hypocalcemia due to accidental parathyroid gland removal. Assessing for Chvostek’s sign
helps confirm tetany.
3. Which clinical manifestation should the nurse expect to find in a patient with a suspected
tension pneumothorax?
A. Tracheal deviation to the unaffected side
B. Bradypnea
C. Increased breath sounds on the affected side
D. Tracheal deviation to the affected side
Answer: A
Conceptual Explanation: In a tension pneumothorax, air buildup causes a mediastinal
shift, pushing the trachea toward the opposite (unaffected) side.
4. A patient is receiving a continuous intravenous infusion of heparin for a pulmonary
embolism. The nurse notes a PTT of 110 seconds (Control: 25-35 seconds). What is the nurse’s
first action?
A. Increase the infusion rate
B. Administer Vitamin K intramuscularly
C. Stop the infusion and notify the provider
, D. Document the finding as therapeutic
Answer: C
Conceptual Explanation: A PTT of 110 is significantly above the therapeutic range
(usually 1.5 to 2.5 times the control). The infusion must be stopped to prevent bleeding.
5. A patient with Type 1 Diabetes Mellitus is found unconscious and diaphoretic. The nurse is
unable to obtain a blood glucose reading. What should be the nurse’s immediate action?
A. Call the family to determine the last meal
B. Administer regular insulin subcutaneously
C. Wait for the laboratory to perform a venous draw
D. Administer 50% Dextrose (D50) IV
Answer: D
Conceptual Explanation: In an unconscious diabetic patient where hypoglycemia is
suspected, immediate administration of glucose (D50) is life-saving and safer than delaying
treatment.
6. The nurse is assessing a patient with a deep vein thrombosis (DVT) in the right leg. Which
assessment finding requires immediate intervention?
A. Right calf circumference 2 cm larger than the left
B. Patient reporting sudden onset shortness of breath
C. Pain in the right calf on dorsiflexion
