HESI Med-Surg 2 Study Guide

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Sample questions from HESI Med-Surg 2 Study Guide

This material has 24 questions with answers and rationales. Here are the first 5.

1. 1.A client admitted with acute heart failure suddenly becomes severely dyspneic and coughs pink, frothy sputum. Blood pressure is 166/94 mm Hg and oxygen saturation is 82% on room air. Which action should the nurse take first?

   • A.Place the client flat and elevate both legs.
   • B.Obtain a standing weight before administering treatment.
   • C.Place the client upright, initiate oxygen support, and summon urgent assistance.
   • D.Offer oral fluids to thin respiratory secretions.

   Rationale: A is correct because the findings indicate acute pulmonary edema with severe hypoxemia; positioning, oxygen support, and emergency escalation address the immediate threat. B can worsen fluid overload and aspiration risk. C is useful for stable fluid monitoring but delays stabilization. D can worsen pulmonary congestion and breathing.

2. 2.A client with chest pressure has a prescription for sublingual nitroglycerin. Which information requires the nurse to withhold the medication and notify the provider?

   • A.The client reports taking sildenafil four hours ago.
   • B.The pain began while climbing stairs.
   • C.The client took aspirin this morning.
   • D.The heart rate is 92/min.

   Rationale: B is correct because recent sildenafil exposure combined with nitroglycerin can produce profound hypotension. A is not a routine contraindication and aspirin may be part of acute coronary care. C alone is not a contraindication. D supports possible exertional ischemia but does not make nitroglycerin unsafe.

3. 3.A telemetry alarm shows a rapid, wide-complex rhythm. The nurse finds the client unresponsive and without a pulse. After activating the emergency response, which intervention is appropriate?

   • A.Obtain a 12-lead ECG before starting compressions.
   • B.Administer an oral antiarrhythmic medication.
   • C.Prepare synchronized cardioversion and wait for sedation.
   • D.Begin CPR and prepare immediate defibrillation.

   Rationale: C is correct because pulseless ventricular tachycardia requires high-quality CPR and unsynchronized defibrillation as soon as available. A is used for selected unstable tachyarrhythmias with a pulse, not pulseless arrest. B is ineffective and unsafe in an unresponsive client. D delays lifesaving circulation and defibrillation.

4. 4.A client with a COPD exacerbation is receiving prescribed controlled oxygen. Which finding most strongly suggests worsening ventilatory failure?

   • A.The client reports a dry mouth.
   • B.The client becomes increasingly somnolent and breathes shallowly.
   • C.The client requests assistance with bathing.
   • D.The oxygen saturation remains within the prescribed target.

   Answer and rationale are in the full material.

5. 5.A nurse observes continuous bubbling in the water-seal chamber of a chest drainage system. The client is comfortable and the oxygen saturation is unchanged. What should the nurse do next?

   • A.Raise the drainage system above the client's chest.
   • B.Assess the tubing and connections for an air leak.
   • C.Clamp the chest tube for the remainder of the shift.
   • D.Strip the chest tube vigorously to remove clots.

   Answer and rationale are in the full material.