HESI. Admissions2026- BSN / ASN Medical-Surgical

Question 1

HESI. Admissions2026- BSN / ASN Medical-SurgicalA client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?

• A Drink 1 to 2 glasses of wine at bedtime.
• B Take sedatives prior to sleep.
• C Begin a weight loss program.
• D Sleep with the head of the bed flat.

Case Study Summary

Patient: 48-year-old female, post-operative Day 1 following laparoscopic Roux-en-Y gastric bypass surgery

Pre-Operative History:

• Weight: 300 lb (136 kg), BMI: 35 kg/m²
• Lost 50 lb (22.7 kg) pre-operatively through diet modification, nutrition therapy, mild exercise, and behavioral counseling
• Medical history: Hypothyroidism, depression, hypertension (HTN)
• Allergies: No known allergies (NKA)
• Medications: Levothyroxine sodium 150 mcg daily, fluoxetine 50 mg daily, atenolol 50 mg daily

Post-Operative Course (Day 1):

• Transferred to medical-surgical unit
• Drowsy but easily arousable, oriented
• Heart sounds S1 and S2 without murmur
• Lung sounds diminished bilaterally
• Abdomen soft without distention
• Four dressings noted to abdomen, serosanguineous drainage noted to lower dressings
• Bowel sounds hypoactive
• Client reports nausea
• Abdominal binder in place
• Client in semi-Fowler’s position
• Puleses palpable 2+, no edema noted
• Sequential compression stockings in place
• Pain rated 6 on a 0 to 10 scale
• IV site 18-gauge catheter in right hand, site patent, no redness or swelling
• Infusing normal saline at 100 mL/hr via IV pump
• Patient-controlled analgesia (PCA): Morphine sulfate 1 mg/mL, dosage 0.5 mg every hour continuous and 0.5 mg every 6 minutes as needed to a max dose of 5 mg/hr; 4.5 mg of morphine used in the last hour
• 16 French indwelling urinary catheter draining clear yellow urine 200 mL in the past 4 hours

Vital Signs (1800):

• Temperature: 98.8°F (37.1°C)
• Heart rate: 62 beats/minute
• Respirations: 16 breaths/minute
• Blood pressure: 88/50 mm Hg
• Oxygen saturation: 96% via 2L nasal cannula
• Pain: 6 on a 0 to 10 scale
• BMI: 35 kg/m²

Intake and Output (1800):

• Intake: 104 mL IV
• Output: 200 mL

Pre-Operative Laboratory Results (0700):

• WBC: 8,000/mm³ (normal)
• RBC: 5 x 10⁶/μL (normal)
• Hemoglobin: 17 g/dL (elevated)
• Hematocrit: 50% (elevated)
• Platelet count: 300,000/mm³ (normal)
• ESR: 10 mm/hr (normal)
• Reticulocyte count: 1.5% (normal)

Post-Operative Orders (1400):

• Admit to medical-surgical unit
• Normal saline continuous IV infusion at 100 mL/hr
• PCA: Morphine sulfate 1 mg/mL, dosage 0.5 mg every hour continuous and 0.5 mg every 6 minutes as needed to a max dose of 5 mg/hr
• Indwelling urinary catheter
• Abdominal binder
• Cough and deep breath every 2 hours
• Sequential compression devices
• NPO
• CBC and BMP at 1800

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Question 2 of 60

The nurse has performed an assessment on the client. Select the 2 findings that require immediate follow-up by the nurse.

• A. Lung sounds diminished
• B. Heart rate 62 beats/minute
• C. Bowel sounds hypoactive
• D. Respirations 16 breaths/minute
• E. Report of nausea ✓
• F. Blood pressure 88/50 mm Hg ✓
• G. Serosanguineous drainage on dressing
• H. Urine output 50 mL/hr

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Question 3 of 60

The nurse has performed an assessment on the client. Select the 2 findings that require immediate follow-up by the nurse.

• A. Lung sounds diminished
• B. Heart rate 62 beats/minute
• C. Bowel sounds hypoactive
• D. Respirations 16 breaths/minute
• E. Report of nausea ✓
• F. Blood pressure 88/50 mm Hg ✓
• G. Serosanguineous drainage on dressing
• H. Urine output 50 mL/hr

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Question 4 of 60

The nurse has performed an assessment on the client. Select the 2 findings that require immediate follow-up by the nurse.

• A. Lung sounds diminished
• B. Heart rate 62 beats/minute
• C. Bowel sounds hypoactive
• D. Respirations 16 breaths/minute
• E. Report of nausea ✓
• F. Blood pressure 88/50 mm Hg ✓
• G. Serosanguineous drainage on dressing
• H. Urine output 50 mL/hr

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Question 4 of 60

The nurse is reviewing the client’s assessment findings.

Drag the Word Choices to complete the sentence.HESI. Admissions2026- BSN / ASN Medical-Surgical

The nurse identifies that the client’s findings are most consistent with __________.

Word Choices:

• Venous thromboembolism
• Postoperative infection
• Morphine administration
• Anastomotic leak ✓
• Postoperative bleeding

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Question 5 of 60

The nurse is considering the priority concern for this client.

Choose the most likely options for the information missing from the statement by selecting from the list of options provided.

The nurse identifies that the priority findings to address are Blood pressure and Urine output.

Dropdown Options:

• Select response
• Urine output ✓
• Hypoactive bowel sounds
• Nausea

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Question 6 of 60

The nurse is anticipating immediate postoperative interventions.

Click to indicate which intervention would be appropriate in the immediate postoperative care of this client. Each column will have at least one response option selected.

Table

Intervention	Appropriate	Not Appropriate
Incentive spirometry at least every 2 hours	✓
Maintain head of bed at minimum 30-degree angle	✓
Remove abdominal binder		✓
Anticipate adjustment of the PCA dose	✓
Assist client to cough and deep breathe every 2 hours	✓
Provide full liquid diet as tolerated		✓
Anticipate prescription for enoxaparin	✓

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Question 7 of 60

The nurse is providing postoperative education appropriate for the client.

Which client teaching will the nurse include in the plan of care for discharge to home? Select all that apply.

• A. You can introduce soft foods within 7 days
• B. Avoid consuming liquids with meals ✓
• C. You will have your band adjusted in 4 weeks
• D. Increase intake of carbohydrates
• E. Your balloon will be in place for 6 months
• F. Plan to eat four small meals a day ✓
• G. Expect to take a multivitamin for life ✓
• H. Avoid drinking through a straw ✓

Question 9 of 60

During spring break, a young adult client presents to the urgent care clinic and reports a stiff neck, a fever for the past 6 hours, and a headache. Which intervention should the nurse implement first?

• A. Administer an antipyretic
• B. Draw blood cultures
• C. Initiate isolation precautions ✓
• D. Prepare for a lumbar puncture

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Question 10 of 60

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

• A. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus
• B. Report the COVID-19 result to the local health department according to Centers for Disease Control and Prevention (CDC) guidelines ✓
• C. Explain to the client to inform others that they may have been potentially exposed in the last 14 days
• D. Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE)

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Question 11 of 60

A client with a C-7 spinal cord injury (SCI) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

• A. Profuse forehead diaphoresis
• B. Skeletal traction misalignment
• C. An acutely distended bladder ✓
• D. A severe pounding headache

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Question 12 of 60

While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she is pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?

• A. Notify the surgical team to cancel the surgery
• B. Continue with surgery as scheduled
• C. Perform a bedside pregnancy test ✓
• D. Calculate gestation from last menstrual cycle

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Question 13 of 60

Case Study: 65-Year-Old Female with Heart Failure

A 65-year-old female presents to the emergency department from home reporting fatigue and progressive shortness of breath over 5 days.

Past Medical History: Hypertension, myocardial infarction with stent placement 6 years ago

Social History: Smokes one pack of cigarettes per day for the last 20 years. Drinks one or two glasses of wine per day. Retired retail worker. Lives at home with her spouse and adult child.

Medications: Lisinopril 20 mg daily, metoprolol 50 mg daily, aspirin 81 mg, hydrochlorothiazide 50 mg daily

Nurses’ Notes (0125): Client is alert and oriented to person, place, time, and situation. Client states, “It’s been hard to catch my breath.” Crackles are heard in the bases of bilateral lungs. S1 and S2 heart sounds noted. Heart rate is 118 beats/minute with a regular rhythm. Bilateral peripheral pitting edema of 2+ is present in both legs. Client denies pain. Reports voiding prior to coming to hospital.

Flow Sheet (0125):

• Temperature: 98.6°F (37°C)
• Heart rate: 118 beats/minute
• Respirations: 26 breaths/minute
• Blood pressure: 165/86 mm Hg
• Oxygen saturation via room air: 83%
• Pain: 4 on 0 to 10 scale
• Weight: 167 lb (75.7 kg)

Orders (0125):

• STAT chest x-ray
• STAT ECG
• STAT basic metabolic panel (BMP), B-type natriuretic peptide (BNP), complete blood count (CBC), D-dimer, troponin
• Apply oxygen via nasal cannula as needed to keep oxygen saturation above 92%

Imaging Studies (0140):

• Chest x-ray results: Right lower lobe pleural effusion
• ECG results: Sinus tachycardia

The emergency department nurse conducted an initial assessment.

Click to highlight the findings from the nurse’s assessment that warrant follow-up.

Findings to highlight:

• “It’s been hard to catch my breath”
• Crackles heard in the bases of bilateral lungs
• Heart rate 118 beats/minute
• Bilateral peripheral pitting edema of 2+ in both legs
• Respirations 26 breaths/minute
• Blood pressure 165/86 mm Hg
• Oxygen saturation 83% via room air

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Question 14 of 60

The nurse reviews the client’s assessment data and test results.

For each client finding, click to indicate if the data is consistent with heart failure, pulmonary embolism, or myocardial infarction. Each column must have at least one response option selected.

Table

Finding	Pulmonary Embolism	Heart Failure	Myocardial Infarction
Heart rate		✓
Weight gain		✓
Shortness of breath	✓	✓
Cardiac laboratory results			✓
Chest pain			✓
Chest x-ray results		✓

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Question 15 of 60

The nurse determines the highest priority concerns for the client. Choose the most likely option to complete the sentence. The nurse recognizes that the most immediate concern for the client is to improve her Oxygen saturation.

Options:

• Potassium level
• Pain level
• Oxygen saturation ✓

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Question 16 of 60

The nurse has received initial prescriptions for the client and is planning nursing care.

Select 2 outcomes that would be appropriate for the nurse to include for this client’s plan of care.

• A. Urine output will increase ✓
• B. Lung sounds will remain unchanged
• C. Weight will remain unchanged
• D. Oxygen demands will increase
• E. Potassium level will decrease
• F. BNP level will decrease ✓

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Question 17 of 60

The nurse is implementing new prescriptions.

Click to indicate if each nursing action is appropriate or not appropriate for the client at the current time. Each row must have one response option selected.

Table

Nursing Action	Appropriate	Not Appropriate
Ambulate the client in the hallway		✓
Encourage the client to drink 2 liters of fluids per day		✓
Increase oxygen by nasal cannula	✓
Administer daily potassium supplement		✓
Discuss the client’s readiness to quit smoking cigarettes	✓
Request a prescription for opioid pain medication		✓

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Question 18 of 60

The morning shift nurse reviews the client’s laboratory results and performs a shift assessment.

Which findings indicate that treatment has been effective? Select all that apply.

• A. Weight ✓
• B. Potassium level ✓
• C. Blood pressure ✓
• D. Edema assessment ✓
• E. BNP level ✓
• F. Pain score
• G. Oxygen saturation ✓
• H. Urine output ✓
• I. Creatinine level

Question 19 of 60

A client who received 6 units of packed red blood cells (PRBCs) 3 days ago for a lower gastrointestinal (GI) bleed is now displaying shortness of breath with occasional stridor and is reporting muscle cramping. Which serum laboratory value should the nurse immediately report to the healthcare provider (HCP)?

Reference Range: Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)] Magnesium [1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L)] Calcium [9 to 10.5 mg/dL (2.3 to 2.6 mmol/L)] Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]

• A Calcium 6.5 mg/dL (1.63 mmol/L).
• B Sodium 135 mEq/L (135 mmol/L).
• C Potassium 4.7 mEq/L (4.70 mmol/L).
• D Magnesium 2.1 mEq/L (0.86 mmol/L).

Question 20 of 60

An older adult woman is seen in the clinic 3 months following her diagnosis of type 2 diabetes mellitus (DM). She tells the nurse that she has had a difficult time keeping her blood sugar in control. The nurse reviews the client’s current fingerstick and daily log of blood glucose levels. Which intervention is most important for the nurse to implement?

• A Collect a voided urine specimen for ketone analysis.
• B Review the client’s glycosylated hemoglobin A1C (HbA1C) level.
• C Ask the client to recall her last 3 days of food intake.
• D Compare current weight with weight 3 months ago.

Question 21 of 60

A client with polycystic kidney disease is admitted to the emergency department with a history of developing a severe headache. Which action should the nurse take first?

• A Obtain a blood pressure measurement.
• B Complete a neurological assessment.
• C Collect a urine specimen.
• D Initiate cardiac monitoring.

Question 22 of 60

A client who had an external fixation placement of the left femur 48 hours ago has suddenly becomes anxious and restless. Vital signs are respirations 28 breathes per minute and heart rate 110 beats per minute. The client’s left foot and toes are pink and warm to touch, capillary refill is +2, and a slight macular rash located on the upper arms, chest, and neck. Based on these findings, which condition is the client most likely experiencing?

• A Fat embolism syndrome.
• B Compartment syndrome.
• C Acute osteomyelitis.
• D Post-traumatic stress.

Question 23 of 60

Which prescriptions should the nurse anticipate after an update is reported to the healthcare provider (HCP)? Select all that apply.

• A Administer antiemetic
• B Increase IV fluids to 150 mL/hr
• C Monitor for adverse reaction to antibiotics
• D Repeat CD4+ T-cell count STAT
• E Initiate airborne isolation

Question 24 of 60

The nurse observes that a newly admitted client with Parkinson’s disease exhibits a mask like facial appearance. Which additional nursing assessment takes priority in response to this finding?

• A Speech patterns.
• B Neck flexion.
• C Respiratory rate.
• D Swallowing ability.

Question 25 of 60

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

• A Restrict physical activities.
• B Use incentive spirometer.
• C Monitor urinary stream for decrease in output.
• D Report when hematuria becomes pink tinged.

Question 26 of 60

A client with a closed head injury demonstrates signs of syndrome of inappropriate antidiuretic hormone (SIADH). Which additional finding should the nurse expect to obtain?

Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)] Urine Specific Gravity [1.005 to 1.03]

• A Serum sodium of 150 mEq/L (150 mmol/L).
• B Urine specific gravity of 1.004.
• C Weight gain of 2 lb (0.91 kg) in one day.
• D Fremitus over the chest wall.HESI. Admissions2026- BSN / ASN Medical-Surgical

Question 27 of 60

A male client who reports feeling chronically fatigued has a hemoglobin of 11 g/dL (110 g/L), hematocrit of 34% (0.34 volume fraction), and both microcytic and hypochromic red blood cells (RBC). Based on these findings, which dinner selection should the nurse suggest to the client?

Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)] Hematocrit [42% to 52% (0.42 to 0.52 volume fraction)]

• A Broiled white fish with a baked sweet potato.
• B Grilled shrimp and seasoned rice with asparagus salad.
• C Cheese pasta and a lettuce and tomato salad.
• D Beef steak with steamed broccoli and orange slices.

Question 28 of 60

The client tells the clinic nurse, “I have been applying triple antibiotic ointment for two days, but there has been no improvement.” Which instruction should the nurse provide?

• A Continue using the ointment for a full week, even after the symptoms disappear.
• B Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration.
• C Antibiotics take two weeks to become effective against infections such as athlete’s foot.
• D Stop using the ointment and encourage complete drying of feet and wearing clean socks.

Question 29 of 60

The nurse has conducted a cancer prevention community education program. In evaluating the participants understanding of the carcinogens, which statement indicates an accurate understanding?

• A Environmental factors such as sunlight and chemicals can cause cancer to spread.
• B Substances that change a cell so that it becomes cancerous are potential sources of cancer.
• C Carcinogens are substances that contain cancerous cells.
• D Carcinogens are in the environment and cannot be avoided.

Question 30 of 60

Which intervention should the nurse implement with a client who has developed stomatitis after receiving radiation treatment?

• A Offer flavored ice frequently between meals.
• B Encourage the client to clean and rinse their mouth with anesthetic mouthwash.
• C Request a prescription for the client to become NPO and to initiate tube feedings.
• D Instruct the client to brush and floss their teeth before and after each meal.

Question 31 of 60

An older adult client recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. Which action should the nurse take?

• A Assist the client to a high Fowler’s position in bed.
• B Instruct the client in pursed lip breathing techniques.
• C Observe the client for the presence of a barrel chest.
• D Prepare to transfer the client to a critical care unit.

Question 32 of 60

A client with an external fixation device for a fractured left femur is troubled with left foot pain. Which intervention should the nurse implement first?

• A Assess peripheral pulses.
• B Auscultate blood pressure.
• C Observe the leg for swelling.
• D Administer PRN pain medication.

Question 33 of 60

Data is evaluated to determine possible condition and appropriate interventions. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

• Potential Condition:
  • Anastomosis leak
• Actions to Take:
  • Listen for bowel sounds
  • Prepare client to return to the operating room
• Parameters to Monitor:
  • Signs and symptoms of peritonitis
  • Vital signs

Question 37 of 60

A client with metastatic cancer reports a pain level of 10 on a 0 to 10 scale. Twenty minutes after the nurse administers an IV analgesic, the client states, “No relief yet.” Which intervention is most important for the nurse to include in this client’s plan of care (POC)?

• A Administer analgesics on a fixed and continuous schedule.
• B Monitor client for break through pain.
• C Replace transdermal analgesic patches every 72 hours.
• D Frequently evaluate the client’s pain.

Question 38 of 60

After teaching a male client with chronic kidney disease (CKD) about the therapeutic diet for his condition, the nurse provides the client with a menu to make breakfast selections. Which food choices by the client indicate that the teaching was effective? Select all that apply.

• A. Bananas and orange slicesHESI. Admissions2026- BSN / ASN Medical-Surgical
• B. A slice of whole-grain toast
• C. Four slices of well-done bacon
• D. Ham, cheese, and egg on toast
• E. A bowl of cream of Wheat ✓

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Question 39 of 60

An adult client presents to the urgent care clinic 5 days after being diagnosed with influenza. The client is short of breath, febrile, and coughing green-colored sputum. Which intervention should the nurse implement first?

• A. Administer an oral antipyretic
• B. Obtain a sputum sample for culture ✓
• C. Auscultate bilateral lung sounds
• D. Check the client’s oxygen saturation level

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Question 40 of 60

While completing a health assessment for a client with migraine headaches, the nurse discovers bilateral weakness in the client’s hand grips. The client reports joint pain and trouble climbing a door knob due to weakness. Which action should the nurse take in response to these findings?

• A. Implement fall precautions to reduce the client’s risk for injury
• B. Consult with the occupational therapist for a functional assessment
• C. Explain that relief of the migraine pain will reduce motor symptoms
• D. Gather additional assessment data about the pain and weakness ✓

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Question 41 of 60

The nurse determines that a client who arrives in the preoperative holding area before surgery is allergic to betadine. Which action should the nurse implement prior to sending the client to the operating room (OR)?

• A. Replace latex-containing devices in the operating room (OR) with alternative synthetic materials
• B. Avoid using skin preparation solutions that contain povidone-iodine
• C. Notify the surgeon and radiology to avoid the use of radiographic dyes ✓
• D. Attach an identification band on the client for allergy to penicillin in addition

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Question 42 of 60

A client with partial thickness and full thickness burns over 42% of the body is being cared for in the emergency department (ED). The healthcare provider (HCP) prescribes hydromorphone 4 mg IM every 4 hours for pain. The client is rating pain as a 9 on a 0 to 10 scale. Which intervention should the nurse implement first?

• A. Rule out any complications prior to administering the medication
• B. Contact the healthcare provider (HCP) and question the prescription ✓
• C. Assist the client with relaxation techniques and guided imagery
• D. Administer an additional dose of the medication to a non-burned area

Question 43 of 60

Case Study: 63-Year-Old Male with ALS HESI. Admissions2026- BSN / ASN Medical-Surgical

A 63-year-old male presents to the emergency department complaining that he cannot get out of bed. He is a medical history of hypertension, gastroesophageal reflux disease, and irritable bowel syndrome. Client is wheelchair bound, and states he has been coughing with eating for the past 3 days. His partner reports the client has been unable to transfer and has been sleeping on the sofa. Home medications include: atorvastatin, omeprazole, theophylline, diltiazem, hydrocodone-acetaminophen, albuterol inhaler, and diphenhydramine. The last dose of diphenhydramine, omeprazole, and theophylline was 6 days ago.

History and Physical: Client and his partner have spoken with other family to update them on the client’s condition. They have requested to meet with the healthcare provider to discuss code status, explaining that no life-sustaining measures should be attempted if respiratory or cardiac arrest would occur. Client does not want intubation to take place if respiratory status is failing. He would like to think he would recover from a profound illness. Of his condition does not improve, he would like a different antibiotic started. Client requested information about enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube. He says that he is fearful of what the end will be like but that he does not wish to continue to live like this.

Nurses’ Notes (1500): Client is brought to exam room, and an initial assessment is completed.

Assessment:

• Neurological: Alert and oriented x 4. Tearful.
• Cardiovascular: Upper and lower bilateral extremity capillary refill less than 3 seconds.
• Respiratory: Crackles in bilateral upper lobes with diminished lung bases bilaterally.
• Gastrointestinal/Genitourinary: Incontinent of bowel and bladder. Last bowel movement 2 days ago and firm per palpation.
• Integumentary: Extremities cool to touch. Reddened, non-blanchable, quarter-size area bilateral: lateral malleolus and heels.
• Musculoskeletal: 0 out of 5 bilateral lower extremity and 2 out of 5 upper extremity muscle strength. Able to shift shoulders forward and position head by self.

Orders (1545): 22-gauge intravenous (IV) access is placed in the left forearm. Blood for a complete blood count (CBC) is obtained and sent to the laboratory. Continuous infusion of 0.9% sodium chloride at 125 mL/hour is initiated. Oxygen is applied at 2 liters/minute via nasal cannula. Respiratory viral panel sample is obtained and sent to the laboratory. Acetaminophen 1000 mg is provided orally (PO). Client has difficulty swallowing the tablet with water, and his partner requests that the client take it in pudding which aids in his ability to swallow the tablet.

1615: To radiology for a chest x-ray.

1630: Returned from radiology.

1730: HCP meets with the client and his partner to discuss the chest X-ray and laboratory results. The healthcare team plans for admission. New prescriptions are obtained.

1800: Medical Unit Vital signs are obtained, and the client and family are oriented to the hospital floor. An assessment is completed. Client brief is changed, and a gait belt is performed.

1820: Ampicillin-sulbactam 1.5 grams is administered intravenously (IV). Spoke to the client and partner about advance directives. Both are tearful and explained the client had completed a living will and durable power of attorney for health care a little after the client was diagnosed with amyotrophic lateral sclerosis (ALS) and offered palliative care, but they have not wanted to talk about those choices since. The client’s partner asked to speak privately about options; however, the client asked that he be included in the conversation which was supported.

2100: The client and his partner have spoken with other family to update them on the client’s condition. They have requested to meet with the healthcare provider to discuss code status, explaining that no life-sustaining measures should be attempted if respiratory or cardiac arrest would occur. Client does not want intubation to take place if respiratory status is failing. He would like to think he would recover from a profound illness. Of his condition does not improve, he would like a different antibiotic started. Client requested information about enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube. He says that he is fearful of what the end will be like but that he does not wish to continue to live like this.

Imaging Studies (1630):

• Place peripheral intravenous (IV) access
• Chest x-ray: Right lower lobe pleural effusion

Click to highlight the client’s entries which indicate acceptance of hospice care.

Entries to highlight:

• “Client does not want intubation to take place if respiratory status is failing”
• “He would like to think he would recover from a profound illness. Of his condition does not improve, he would like a different antibiotic started”
• “Client requested information about enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube”
• “He says that he is fearful of what the end will be like but that he does not wish to continue to live like this”

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Question 44 of 60

A client admitted to the emergency department (ED) with an acute exacerbation of peptic ulcer disease (PUD) is vomiting and describing epigastric pain and nausea. After obtaining vital sign measurements, which priority action should the nurse implement first?

• A. Send the client to x-ray for a flat plate of the abdomen
• B. Give a prescribed analgesic for the moderate pain
• C. Place an indwelling urinary catheter and attach a bedside drainage unit
• D. Insert a nasogastric (NG) tube and attach to low intermittent suction ✓

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Question 45 of 60

A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse is reviewing the issues of immobility and efforts to allow the ankle to rest. The client expresses the need to lose weight. Which instruction should the nurse include in the discharge teaching?

• A. Eat high-protein foods to achieve an ideal body weight
• B. Use an electric heating pad on the painful joints for comfort
• C. Drink at least 8 cups (1,920 mL) of water per day
• D. Encourage active range of motion to limit stiffness ✓

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Question 46 of 60

During a home visit, the nurse assesses the skin of a client with eczema and is told that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

• A. Recently received an influenza immunization
• B. Corticosteroid cream was applied to eczema
• C. A six-year-old friend with eczema came for a visit
• D. A granddaughter has a new dog, creating a dander ✓

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Question 47 of 60

An older adult client with type 2 diabetes mellitus (DM) is hospitalized with an infected ulcer on his right great toe. Which instruction should the nurse emphasize during discharge teaching?

• A. Be sure that you only walk barefoot on soft surfaces, such as fully carpeted rooms
• B. Check the texture and height of all household shoes before putting them on
• C. Open-toed shoes allow air to circulate and help prevent fungal toenail growth ✓
• D. Nylon socks provide warmth without trapping excess moisture around your feet

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Question 48 of 60

The nurse is assessing a client’s arteriovenous (AV) fistula. Which finding provides evidence of its normal function?

• A. Enlarged vein
• B. Ecchymotic area
• C. Redness
• D. Palpable thrill ✓

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Question 49 of 60

A client experiencing a sudden onset of confusion and trouble speaking is transported to the emergency department (ED). The client does not understand simple commands and appears very frustrated. Which intervention should the nurse perform in the immediate management of the client?

• A. Test for a swallowing reflex and perform communication deficit assessments
• B. Initiate bilateral intermittent sequential pneumatic compression devices
• C. Administer aspirin to prevent further clot formation and publish out (DVT) ✓
• D. Determine when symptoms began and if improved or worsened since onset

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Question 50 of 60

The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

• A. Chest x-ray or computed tomography (CT)
• B. Hemoccult test on sputum collected from hemoptysis
• C. Positive purified protein derivative (PPD) skin test ✓
• D. Sputum culture positive for Mycobacterium tuberculosis

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Question 51 of 60

Following a total thyroidectomy, the nurse plans to observe a client for complications. Which finding indicates that the client has developed a complication?

• A. Reports of muscle twitching in hands and feet
• B. Decreased muscle spasms in extremities
• C. Diaphoretic, but denies any headache
• D. Troubled with back and joint tenderness and pain ✓

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Question 52 of 60

An older adult client is admitted with an acute onset of diverticulitis and IV antibiotic therapy is initiated. Which intervention should the nurse implement next?

• A. Elevate the head of the bed
• B. Maintain the client’s NPO status
• C. Initiate bowel prep protocol for surgery ✓
• D. Teach the client to increase dietary fiber

Question 53 of 60

Case Study: 24-Year-Old Female with Seizure Disorder

A 24-year-old woman is brought to the emergency department by her mother after experiencing a sudden episode at home. According to the mother, client became unresponsive, her body stiffened, and then began to shake for several moments that lasted about 60 seconds. After the episode, she appeared confused, drooling, and had difficulty answering questions for several minutes.

Client reports that just before the event, she experienced a strange metallic smell and a wave of dizziness. She claims she has experienced two episodes in the past month, but this is the first time it has progressed into a full-body event. She has a history of head trauma from a motor vehicle accident 6 months ago. Has not been previously evaluated for these symptoms.

Nurses’ Notes (0755): Client presents resting in bed with eyes partially closed, but responds to name being called. She follows simple commands slowly and is oriented to person and place, though disoriented to time. Speech remains slow with occasional slurring. Physical assessment reveals a healing laceration on the right side of the tongue. Appears tired and intermittently closes her eyes during conversation. Clothing was noted to be wet; the client was assisted with hygiene and changed into a dry gown.

1005: Client observed sitting upright in bed and engaging in a brief conversation with staff. She is fully oriented to person, place, and time. She describes feeling groggy and reports a dull headache and low energy. Accepted and tolerated oral fluids without nausea. Discussed the importance of documenting any future episodes involving unusual smells, dizziness, or loss of awareness. Advised to rest for the remainder of the day and avoid operating a vehicle or using sharp equipment until further evaluation by a neurologist.

Laboratory Results (0930): Comprehensive Metabolic Panel (CMP)

Table

Laboratory Test	Result	Reference Range
Sodium	134 mEq/L (134 mmol/L)	135 to 145 mEq/L (135 to 145 mmol/L)
Potassium	3.0 mEq/L (3.0 mmol/L)	3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)
Glucose	84 mg/dL (4.7 mmol/L)	70 to 100 mg/dL (3.9 to 5.6 mmol/L)
Creatinine	0.8 mg/dL (70.7 μmol/L)	0.6 to 1.2 mg/dL (53 to 106 μmol/L)

Flow Sheet:

0745 Vital Signs:

• Temperature: 98.4°F (36.9°C)
• Heart rate: 88 beats/minute
• Respirations: 18 breaths/minute
• Blood pressure: 112/72 mm Hg
• Oxygen saturation: 97% on room air
• Pain: 0 on 0 to 10 scale

0930 Vital Signs:

• Temperature: 99.1°F (37.3°C)
• Heart rate: 102 beats/minute
• Respirations: 22 breaths/minuteHESI. Admissions2026- BSN / ASN Medical-Surgical
• Blood pressure: 126/86 mm Hg
• Oxygen saturation: 96% on room air
• Pain: 0 on 0 to 10 scale

1000 Vital Signs:

• Temperature: 99.4°F (37.4°C)
• Heart rate: 108 beats/minute

Orders (0845):

• IV access with 0.9% normal saline (NS) to keep vein open (KVO)
• CMP
• Notify healthcare provider of any recurrent seizures
• Clear liquid diet as tolerated

The nurse is taking care of a client in the emergency department.

Complete the diagram by dragging from the list of options provided to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Table

Actions to Take	Potential Conditions	Parameters to Monitor
Hold carbamazepine and consult neurology consult	Generalized tonic-clonic seizure ✓	Oxygen saturation
Ensure suction is set up at the bedside		International normalized ratio (INR)
Apply soft wrist restraints to reduce injury risk during postictal state		Blood glucose
Reinforce the importance of consistent medication adherence		Hemoglobin and hematocrit
Encourage the client to ambulate		Level of consciousness ✓

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Question 54 of 60

The healthcare provider prescribed 2 liters of 5% Dextrose in water (D5W) to infuse in 24 hours. The IV administration set delivers 15 gtt/mL. How many mL/hour should the nurse program the infusion pump? (Enter the numerical value only. If rounding is required, round to the nearest whole number.)

Answer: 83 mL/hr

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Question 55 of 60

A client has an absolute neutrophil count (ANC) of 500/mm³ (0.5 x 10⁹/L) after completing chemotherapy. Which intervention is most important for the nurse to implement?

Reference Range: Neutrophils (ANC) [2,500 to 5,800/mm³ (2.5 to 5.8 x 10⁹/L)]

• A. Assess vital signs every 4 hours
• B. Review need for pneumococcal vaccine
• C. Implement bleeding precautions ✓
• D. Place the client in protective isolationHESI. Admissions2026- BSN / ASN Medical-Surgical

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Question 56 of 60

During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed at 50 mL of clear yellow-colored fluid drains within the first hour. Which action should the nurse implement?

• A. Send fluid to the laboratory for analysis
• B. Clamp drainage tube for 5 minutes
• C. Palpate for abdominal distention
• D. Continue to monitor the fluid output ✓

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Question 57 of 60

Which instruction should the nurse include in the discharge teaching plan for a client who has had a cataract extraction today?

• A. Administer eye ointment prior to applying eye drops
• B. Sexual activities may be resumed upon return home
• C. Use a metal eye shield on operative eye during the day
• D. Light housekeeping is safe to do, but avoid heavy lifting ✓

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Question 59 of 60

The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?

• A. Clarify that all STIs are transmitted through sexual intercourse
• B. Emphasize that using safe sex practices removes the risk of STIs
• C. Discuss that partners without visible symptoms may not be infected
• D. Teach importance of medication regimen and follow-up protocol ✓

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Question 60 of 60

The nurse determines that an adult client who is admitted to the postanesthesia care unit (PACU) following abdominal surgery has a decreased temperature of 96.7°F (35.9°C), a heart rate of 68 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 86/58 mm Hg. Which action should the nurse implement?

• A. Raise the head of the bed to 60 to 90 degrees
• B. Take the client’s temperature using another method
• C. Ask the client to cough and deep breathe
• D. Check the blood pressure every five minutes for one hour ✓HESI. Admissions2026- BSN / ASN Medical-Surgical