HESI Med-Surg 2

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Sample questions from HESI Med-Surg 2

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

1. 1.Refer to the client's chart. Which actions should the nurse take now to address the client's changing condition? Select all that apply.

   • A.Obtain a 12-lead ECG promptly.
   • B.Activate the rapid response system.
   • C.Administer the prescribed sublingual nitroglycerin after checking blood pressure.
   • D.Place the client on continuous cardiac monitoring.
   • E.Encourage the client to walk to reduce anxiety.

   Rationale: The new chest pressure, diaphoresis, and evolving ST changes require urgent escalation, continuous monitoring, prompt ECG evaluation, and prescribed nitroglycerin if blood pressure permits. Walking increases myocardial oxygen demand and is unsafe during suspected acute coronary syndrome. The rising troponin supports myocardial injury and makes delay especially hazardous.

2. 2.A client with chronic heart failure is being discharged after treatment for fluid overload. Which statement indicates the client understands home monitoring?

   • A.I can stop my diuretic when my ankle swelling goes away.
   • B.I should drink extra fluids whenever I feel short of breath.
   • C.I will weigh myself each morning after urinating, using the same scale.
   • D.I will call the clinic if I gain 1 kg over a month.

   Rationale: A consistent daily weight detects fluid retention before symptoms become severe. A rapid gain such as 2 to 3 lb (about 1 kg) in a day or 5 lb (about 2.3 kg) in a week should be reported according to the care plan, not delayed for a month. Diuretics should not be stopped independently, and extra fluid can worsen congestion.

3. 3.Which assessment finding in a client taking digoxin requires the nurse to hold the medication and notify the provider?

   • A.Respiratory rate 18 breaths/min
   • B.Apical pulse 54 beats/min
   • C.Potassium 4.2 mEq/L
   • D.Blood pressure 138/82 mm Hg

   Rationale: A slow apical pulse may indicate digoxin-related bradycardia, so the dose should be held and the provider notified according to parameters. The blood pressure and respiratory rate are not concerning in isolation. A potassium of 4.2 mEq/L is within the usual range; hypokalemia, rather than this value, increases digoxin toxicity risk.

4. 4.Refer to the client's chart. Which action is the priority for the nurse to take?

   • A.Encourage coughing and deep breathing, then reassess in 1 hour.
   • B.Place the client in Trendelenburg position.
   • C.Increase the IV fluid rate without a prescription.
   • D.Assess the client for signs of cardiac tamponade and notify the surgeon.

   Answer and rationale are in the full material.

5. 5.A client with peripheral arterial disease asks how to protect the feet at home. Which instructions should the nurse include? Select all that apply.

   • A.Apply a heating pad to cold feet each evening.
   • B.Avoid smoking and discuss cessation support.
   • C.Report a nonhealing foot sore promptly.
   • D.Wear well-fitting shoes and clean socks.
   • E.Inspect the feet every day, including between the toes.

   Answer and rationale are in the full material.