Test Bank for HESI Med-Surg

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Sample questions from Test Bank for HESI Med-Surg

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

1. 1.In the emergency department, a 68-year-old client with chest pressure has ST-segment elevation in leads II, III, and aVF. Which action should the nurse take first?

   • A.Encourage the client to walk to determine whether activity worsens the pain
   • B.Schedule a fasting lipid panel before initiating treatment
   • C.Obtain a 12-lead ECG and notify the cardiac catheterization team
   • D.Administer an oral antacid and reassess the pain in 30 minutes

   Rationale: ST elevation in the inferior leads indicates an acute myocardial infarction that requires rapid reperfusion evaluation. Obtaining and acting on the ECG finding supports timely activation of the catheterization team. An antacid, ambulation, or a lipid panel delays treatment and does not address the immediate threat to myocardial perfusion.

2. 2.A client states, "I was just diagnosed with heart failure, and I want to know what I can do at home to catch problems early." Which instructions should the nurse include? Select all that apply.

   • A.Limit sodium as directed and check food labels
   • B.Stop taking the prescribed diuretic when ankle swelling improves
   • C.Increase fluid intake substantially whenever you feel thirsty
   • D.Weigh yourself each morning after urinating and before breakfast
   • E.Report a gain of 2 lb (0.9 kg) in 24 hours or 5 lb (2.3 kg) in a week

   Rationale: Daily weights under consistent conditions help identify fluid retention before symptoms become severe, and the specified weight gains should be reported promptly. Following the prescribed sodium restriction can reduce fluid retention, so checking labels is useful. Stopping a diuretic without direction can worsen heart failure, and substantially increasing fluids may aggravate congestion rather than treat thirst safely.

3. 3.At change of shift, the nurse receives report on four clients. Which client should the nurse assess first?

   • A.A client with heart failure who has bilateral ankle edema unchanged from yesterday
   • B.A client 2 hours after cardiac catheterization with a cool, pale affected foot and a diminished pedal pulse
   • C.A client with chronic atrial fibrillation whose ventricular rate is 88/min and who denies symptoms
   • D.A client with stable angina who requests the scheduled dose of a long-acting nitrate

   Rationale: A cool, pale foot and diminished pulse after catheterization suggest impaired arterial perfusion and possible vascular complication. This requires immediate assessment and prompt escalation to protect the limb. The controlled atrial fibrillation, scheduled nitrate request, and unchanged edema are important but do not indicate the same immediate threat.

4. 4.The provider prescribes digoxin for a 16-year-old client with heart failure. Before administering the dose, which finding requires the nurse to hold the medication and notify the provider?

   • A.Apical pulse of 54/min
   • B.Oxygen saturation of 97% on room air
   • C.Blood pressure of 108/68 mm Hg
   • D.Respiratory rate of 18/min

   Answer and rationale are in the full material.

5. 5.Refer to the client's chart. Which action should the nurse take first?

   • A.Administer the next scheduled dose of an ACE inhibitor
   • B.Offer a potassium-rich snack and repeat the laboratory test tomorrow
   • C.Encourage the client to ambulate to improve potassium distribution
   • D.Stop the potassium infusion and place the client on continuous cardiac monitoring

   Answer and rationale are in the full material.