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HESI MED-SURG Exam Questions with Answers, Rationales, TestTaking Strategies and References.

1. A client who has undergone abdominal surgery calls the nurse and reports that she just felt

“something give way” in the abdominal incision. The nurse checks the incision and notes the

presence of wound dehiscence. The nurse immediately:

A. Contacts the physician

B. Documents the findings

C. Places the client in a supine position with the legs flat

D. Covers the abdominal wound with a sterile dressing moistened with sterile saline

solution

Rationale: Wound dehiscence is the disruption of a surgical incision or wound. When dehiscence

occurs, the nurse immediately places the client in a low Fowler’s position or supine with the

knees bent and instructs the client to lie quietly. These actions will minimize protrusion of the

underlying tissues. The nurse then covers the wound with a sterile dressing moistened with

sterile saline. The physician is notified, and the nurse documents the occurrence and the nursing

actions that were implemented in response.

Test-Taking Strategy: Use the process of elimination and note the strategic word “immediately.”

Visualize this occurrence and recall that the primary concern when wound dehiscence occurs is

the protrusion of underlying tissues. This will direct you to the correct option. Review the

nursing actions to be taken immediately in the event of wound dehiscence if you had difficulty

with this question.

Level of Cognitive Ability: Applying

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Implementation

Content Area: Perioperative Care

Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered

collaborative care (6th ed., pp. 291, 292, 296). St. Louis: Saunders.

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2. A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is

restless and her pulse rate is increased. As the nurse continues the assessment, the client begins

to vomit a copious amount of bright-red blood. The immediate nursing action is to:

A. Notify the surgeon

B. Continue the assessment

C. Check the client’s blood pressure

D. Obtain a flashlight, gauze, and a curved hemostat

Rationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the

client vomits a large amount of bright-red blood or the pulse rate increases and the patient is

restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror,

gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The nurse

should also gather additional assessment data, but the surgeon must be contacted immediately.

Test-Taking Strategy: Focus on the data in the question. Noting the words “bright-red blood”

will assist in directing you to the correct option. Remember that the presence of bright-red blood

indicates active bleeding. Review the nursing actions to be taken immediately when bleeding

occurs after a tonsillectomy and adenoidectomy if you had difficulty with this question.

Level of Cognitive Ability: Applying

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Implementation

Content Area: Delegating/Prioritizing

Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered

collaborative care (6th ed., p. 657). St. Louis: Saunders.

3. A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and

tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets

about:

A. Preparing the client for a perfusion scan

B. Attaching the client to a cardiac monitor

C. Administering oxygen by way of nasal cannula

D. Ensuring that the intravenous (IV) line is patent

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Rationale: Pulmonary embolism is a life-threatening emergency. Oxygen is immediately

administered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and the

physician is notified. IV infusion lines are needed to administer medications or fluids. A

perfusion scan, among other tests, may be performed. The electrocardiogram is monitored for the

presence of dysrhythmias. Additionally, a urinary catheter may be inserted and blood for arterial

blood gas determinations drawn. The immediate priority, however, is the administration of

oxygen.

Test-Taking Strategy: Focus on the client’s diagnosis and use the skills of prioritizing. Apply the

ABCs (airway, breathing, and circulation) to find the correct option. Review the nursing actions

to be taken immediately in the event of pulmonary embolism if you had difficulty with this

question.

Level of Cognitive Ability: Applying

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Implementation

Content Area: Delegating/Prioritizing

Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered

collaborative care (6th ed., p. 680). St. Louis: Saunders.

4. A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes

constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that

apply).

A. Clamping the chest tube

B. Changing the drainage system

C. Assessing the system for an external air leak

D. Reducing the degree of suction being applied

E. Documenting assessment findings, actions taken, and client response

Rationale: Constant bubbling in the water seal chamber of a closed chest tube drainage system

may indicate the presence of an air leak. The nurse would assess the chest tube system for the

presence of an external air leak if constant bubbling were noted in this chamber. If an external air

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leak is not present and the air leak is a new occurrence, the physician is notified immediately,

because an air leak may be present in the pleural space. Leakage and trapping of air in the pleural

space can result in a tension pneumothorax. Clamping the chest tube is incorrect. Additionally, a

chest tube is not clamped unless this has been specifically prescribed in the agency’s policies and

procedures. Changing the drainage system will not alleviate the problem. Reducing the degree of

suction being applied will not affect the bubbling in the water seal chamber and could be

harmful. The nurse would document the assessment findings and interventions taken in the

client’s medical record.

Test-Taking Strategy: Use the process of elimination and your knowledge regarding the priority

actions in the care of a closed chest tube drainage system. Focus on the data in the question,

noting that there is bubbling in the water seal chamber. Recalling that this may indicate an air

leak will direct you to the correct options. Review the nursing actions to be taken immediately in

the event that complications of a closed chest tube drainage system occur if you had difficulty

with this question.

Level of Cognitive Ability: Applying

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Implementation

Content Area: Adult Health/Respiratory

Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered

collaborative care (6th ed., pp. 648, 649). St. Louis: Saunders.

5. A nurse is helping a client with a closed chest tube drainage system get out of bed and into a

chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the

insertion site. The immediate priority on the part of the nurse is:

A. Contacting the physician

B. Reinserting the chest tube

C. Transferring the client back to bed

D. Covering the insertion site with a sterile occlusive dressing

Rationale: If a chest tube is dislodged from the insertion site, the nurse immediately covers the

site with sterile occlusive dressing. The nurse then performs a respiratory assessment, helps the

client back into bed, and contacts the physician. The nurse does not reinsert the chest tube. The

physician will reinsert the chest tube as necessary.

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HESI RN MED SURG EXAM PACK written by LARIJAWTEST HESI RN MED SURG EXAM PACK-EXAM MEREGED FROM 2019/2020/2021 ACTUAL EXAMS BEST FOR 2022 NEXT GEN ACTUAL EXAM REVIEW MED SURG EXAM PACK HESI RN MED SURG 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 th...

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