NSG 223 Med Surg 2 HESI Final
Answers | 2026 New Update with
complete solutions.
Course
NSG 223
1. A client with heart failure is receiving IV furosemide. Which laboratory result requires the
nurse's immediate attention?
A. Sodium 138 mEq/L
B. Potassium 2.9 mEq/L
C. Calcium 9.2 mg/dL
D. Magnesium 2.0 mg/dL
Answer: B. Potassium 2.9 mEq/L
Rationale: Furosemide can cause significant potassium loss. Severe hypokalemia increases the
risk of ventricular dysrhythmias and requires prompt intervention.
2. A client with COPD reports severe dyspnea. Which position should the nurse implement
first?
A. Supine
B. Trendelenburg
C. High-Fowler's with arms supported
D. Side-lying with legs elevated
Answer: C. High-Fowler's with arms supported
Rationale: Upright positioning maximizes lung expansion and decreases diaphragmatic
compression. Supporting the arms can also reduce the work of accessory respiratory muscles.
3. A client suddenly develops facial drooping, right-sided weakness, and difficulty speaking.
What is the nurse's priority action?
A. Give oral aspirin
B. Determine the time the client was last known well
C. Place the client in Trendelenburg position
D. Encourage ambulation
,Answer: B. Determine the time the client was last known well
Rationale: Time of symptom onset or last-known-well time is critical in determining eligibility
for time-sensitive stroke interventions.
4. A client with suspected ischemic stroke has difficulty swallowing. Which intervention is
most appropriate?
A. Give water to test swallowing
B. Keep the client NPO until swallowing is evaluated
C. Administer medications with thin liquids
D. Place food on the affected side of the mouth
Answer: B. Keep the client NPO until swallowing is evaluated
Rationale: Dysphagia is common after stroke and creates a significant aspiration risk. Oral intake
should be withheld until swallowing ability is assessed.
5. A client with a spinal cord injury develops severe hypertension, headache, flushing, and
diaphoresis above the level of injury. What should the nurse do first?
A. Place the client flat
B. Sit the client upright
C. Administer a sedative
D. Restrict fluids
Answer: B. Sit the client upright
Rationale: These findings suggest autonomic dysreflexia. Sitting the client upright helps reduce
blood pressure while the nurse searches for and removes the triggering stimulus, commonly
bladder or bowel distention.
6. Which finding is most concerning in a client with increased intracranial pressure?
A. Mild headache
B. Increased appetite
C. Decreasing level of consciousness
D. Warm hands
Answer: C. Decreasing level of consciousness
, Rationale: A change in level of consciousness is an important early indicator of neurological
deterioration and increased intracranial pressure.
7. A client is experiencing status epilepticus. Which intervention has the highest priority?
A. Insert an oral airway
B. Maintain airway and provide oxygen as indicated
C. Restrain all extremities
D. Give oral fluids
Answer: B. Maintain airway and provide oxygen as indicated
Rationale: Status epilepticus is a medical emergency. Airway, breathing, and circulation take
priority while prescribed emergency antiseizure medication is administered.
8. A client with asthma develops severe respiratory distress and suddenly has very diminished
breath sounds. How should the nurse interpret this finding?
A. The asthma attack is resolving
B. Airflow obstruction may be critically severe
C. The client has improved ventilation
D. Bronchodilator therapy is unnecessary
Answer: B. Airflow obstruction may be critically severe
Rationale: A markedly diminished or "silent" chest can indicate minimal air movement and
severe bronchospasm. It is an emergency finding.
9. Which assessment finding is most consistent with acute pulmonary edema?
A. Dry skin and bradycardia
B. Pink frothy sputum and severe dyspnea
C. Increased appetite
D. Absent bowel sounds
Answer: B. Pink frothy sputum and severe dyspnea
Rationale: Pulmonary edema can cause severe respiratory distress, crackles, hypoxemia, and
pink or frothy sputum due to fluid entering the alveoli.
Answers | 2026 New Update with
complete solutions.
Course
NSG 223
1. A client with heart failure is receiving IV furosemide. Which laboratory result requires the
nurse's immediate attention?
A. Sodium 138 mEq/L
B. Potassium 2.9 mEq/L
C. Calcium 9.2 mg/dL
D. Magnesium 2.0 mg/dL
Answer: B. Potassium 2.9 mEq/L
Rationale: Furosemide can cause significant potassium loss. Severe hypokalemia increases the
risk of ventricular dysrhythmias and requires prompt intervention.
2. A client with COPD reports severe dyspnea. Which position should the nurse implement
first?
A. Supine
B. Trendelenburg
C. High-Fowler's with arms supported
D. Side-lying with legs elevated
Answer: C. High-Fowler's with arms supported
Rationale: Upright positioning maximizes lung expansion and decreases diaphragmatic
compression. Supporting the arms can also reduce the work of accessory respiratory muscles.
3. A client suddenly develops facial drooping, right-sided weakness, and difficulty speaking.
What is the nurse's priority action?
A. Give oral aspirin
B. Determine the time the client was last known well
C. Place the client in Trendelenburg position
D. Encourage ambulation
,Answer: B. Determine the time the client was last known well
Rationale: Time of symptom onset or last-known-well time is critical in determining eligibility
for time-sensitive stroke interventions.
4. A client with suspected ischemic stroke has difficulty swallowing. Which intervention is
most appropriate?
A. Give water to test swallowing
B. Keep the client NPO until swallowing is evaluated
C. Administer medications with thin liquids
D. Place food on the affected side of the mouth
Answer: B. Keep the client NPO until swallowing is evaluated
Rationale: Dysphagia is common after stroke and creates a significant aspiration risk. Oral intake
should be withheld until swallowing ability is assessed.
5. A client with a spinal cord injury develops severe hypertension, headache, flushing, and
diaphoresis above the level of injury. What should the nurse do first?
A. Place the client flat
B. Sit the client upright
C. Administer a sedative
D. Restrict fluids
Answer: B. Sit the client upright
Rationale: These findings suggest autonomic dysreflexia. Sitting the client upright helps reduce
blood pressure while the nurse searches for and removes the triggering stimulus, commonly
bladder or bowel distention.
6. Which finding is most concerning in a client with increased intracranial pressure?
A. Mild headache
B. Increased appetite
C. Decreasing level of consciousness
D. Warm hands
Answer: C. Decreasing level of consciousness
, Rationale: A change in level of consciousness is an important early indicator of neurological
deterioration and increased intracranial pressure.
7. A client is experiencing status epilepticus. Which intervention has the highest priority?
A. Insert an oral airway
B. Maintain airway and provide oxygen as indicated
C. Restrain all extremities
D. Give oral fluids
Answer: B. Maintain airway and provide oxygen as indicated
Rationale: Status epilepticus is a medical emergency. Airway, breathing, and circulation take
priority while prescribed emergency antiseizure medication is administered.
8. A client with asthma develops severe respiratory distress and suddenly has very diminished
breath sounds. How should the nurse interpret this finding?
A. The asthma attack is resolving
B. Airflow obstruction may be critically severe
C. The client has improved ventilation
D. Bronchodilator therapy is unnecessary
Answer: B. Airflow obstruction may be critically severe
Rationale: A markedly diminished or "silent" chest can indicate minimal air movement and
severe bronchospasm. It is an emergency finding.
9. Which assessment finding is most consistent with acute pulmonary edema?
A. Dry skin and bradycardia
B. Pink frothy sputum and severe dyspnea
C. Increased appetite
D. Absent bowel sounds
Answer: B. Pink frothy sputum and severe dyspnea
Rationale: Pulmonary edema can cause severe respiratory distress, crackles, hypoxemia, and
pink or frothy sputum due to fluid entering the alveoli.
