2020 Hesi RN Medical Surgical Specialty Exam 55 rationales

1. A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the

best initial nursing action?

Answer: Administer the first dose of prescribed antibiotic therapy

2. A client is brought to the Emergency Department by ambulation in cardiac arrest with cardiopulmonary

resuscitation (CPR) in progress. The client is intubated and receiving 100% oxygen per self‐inflating (ambu)

bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most

important for the nurse to obtain?

Answer: deep tendon reflexes.

3. After hospitalization for Syndrome of Inappropriate Antidiuretic hormone (SIADH), a client develops

myelinolysis. Which intervention should the nurse implement first?

Answer: Reorient client to his room.

4. A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because

they are too tight. Which additional information should the nurse obtain?

Answer: Has his weight changed in the last several days?

5. An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a

persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse

implement?

Answer: Apply a high‐flow venturi mask.

6. A client with a history of asthma and bronchitis arrives at the clinic with SOB, productive cough with

thickened, tenacious mucous, and the inability to walk up flight of stairs without experiencing

breathlessness. Which action is most important for the nurse to instruct the client about self‐care?

Answer: Increase the daily intake of oral fluids to liquefy secretions.

7. A cardiac catheterization of a client with heart disease indicates the following blockages: 95% LAD, 99%

proximal circumflex, and 95% proximal RCA. The client later asks the nurse “what does all that mean for

me?”

Answer: Three main arteries have major blockage with only 1 to 5% of the blood flow getting through to

the heart muscle.

8. A client who weighs 175 pounds is receiving an IV bolus dose of heparin 80 units/kg. The heparin is

available in a 2 mL vial, labeled 10,000 units/mL. How many mL should the nurse administer? (enter

numeric value only. If rounding, round to nearest tenth.)

Answer: 1.3 mL

after calculations: the calculator will show 1.272727272727273, but you must round to the nearest tenth.

So, the answer is 1.3 mL.

9. What information should the nurse include in the teaching plan of a client diagnosed with

gastroesophageal reflux disease (GERD)?

2020 HESI RN MEDICAL SURGICAL SPECIALTY EXAM ALL 55 CORRECT ANSWERS VERSION 1

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2020 Hesi RN Medical Surgical Specialty Exam 55 rationales

Answer: minimize symptoms by wearing loose, comfortable clothing.

10. The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse

instruct the client to maintain?

Answer: Left Lateral.