Nightingale HESI Med-Surg

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Sample questions from Nightingale HESI Med-Surg

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.A 68-year-old client with heart failure reports increasing shortness of breath when lying flat. Which assessment finding requires the nurse's most immediate action?

   • A.Weight gain of 0.5 kg (1.1 lb) over 1 week
   • B.Jugular venous pressure visible at 3 cm above the sternal angle
   • C.Bilateral ankle edema rated 1+
   • D.Oxygen saturation of 88% on room air

   Rationale: An oxygen saturation of 88% indicates impaired oxygenation and requires prompt assessment and intervention. Mild ankle edema, a small gradual weight gain, and modestly visible jugular venous pressure suggest fluid retention but are less urgent than hypoxemia. In heart failure, prioritize breathing and oxygenation while assessing for pulmonary congestion.

2. 2.A client taking digoxin has nausea, anorexia, and a new yellow tint to vision. The apical pulse is 54 beats/min. What should the nurse do first?

   • A.Hold the digoxin and notify the health care provider
   • B.Encourage the client to increase dietary potassium
   • C.Administer the scheduled dose with food
   • D.Recheck the client's pulse after the dose

   Rationale: The symptoms and bradycardia are consistent with digoxin toxicity, so the dose should be withheld and the provider notified. Giving the medication could worsen bradycardia, and waiting until after administration is unsafe. Potassium should be assessed because hypokalemia can increase digoxin toxicity, but supplementation should not be started without evaluation.

3. 3.A client arrives in the emergency department with suspected acute coronary syndrome. Which actions should the nurse anticipate during the initial assessment and stabilization? Select all that apply.

   • A.Establish intravenous access
   • B.Obtain a 12-lead ECG promptly
   • C.Encourage the client to walk to assess exercise tolerance
   • D.Give oxygen routinely even if oxygen saturation is 98%
   • E.Obtain blood samples for cardiac biomarkers

   Rationale: A prompt 12-lead ECG, intravenous access, and cardiac biomarker testing support rapid diagnosis and treatment of acute coronary syndrome. Routine oxygen is not indicated when oxygenation is adequate; it is used for hypoxemia or respiratory distress. Ambulation is unsafe during the initial evaluation of possible acute myocardial ischemia.

4. 4.A client with chronic hypertension is prescribed a new antihypertensive medication. Which teaching is most important to reduce the risk of injury?

   • A.Restrict fluids to prevent medication-related edema
   • B.Take an extra dose if a dose is missed
   • C.Rise slowly from lying or sitting positions
   • D.Stop the medication when blood pressure readings become normal

   Answer and rationale are in the full material.

5. 5.A client with atrial fibrillation is prescribed warfarin. Which laboratory result should the nurse use to evaluate the medication's therapeutic effect?

   • A.Activated partial thromboplastin time
   • B.International normalized ratio
   • C.Serum troponin
   • D.Platelet count

   Answer and rationale are in the full material.