Practice Mode Assessment

End

No.

1 :
A client is discharged with a prescription for warfarin. Which discharge instruction should the nurse emphasize to the client?

Avoid going barefoot, especially outside.

Use an astringent lotion for superficial bleeding.

Add large amounts of spinach to the diet

Take a multi-vitamin supplement daily.

Hint : 🧠Think about the safest way to reduce injury when a person is taking a blood thinner.

Correct Answers:

Avoid going barefoot, especially outside.

Rationale :

🩸Warfarin increases the risk for bleeding, so the most important discharge teaching focuses on injury prevention.

👣Avoiding walking barefoot lowers the chance of cuts, punctures, and trauma, which could lead to prolonged bleeding.

🍃Clients taking warfarin should keep vitamin K intake consistent, so adding large amounts of spinach would be unsafe teaching.

🛡️The best instruction is the one that directly helps prevent bleeding complications in daily life.

📌Core Message

The key teaching for warfarin is bleeding prevention, and avoiding barefoot walking helps reduce injury risk.

2 :
The nurse determines that an adult client who is admitted to the postanesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6° F (34.8° C), a heart rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/68 mm Hg. Which action should the nurse implement?

Ask the client to cough and deep breathe.

Take the client's temperature using another method. C

Check the blood pressure every five minutes for one hour.

Raise the head of the bed to 60 to 90 degrees.

Hint : 📏An unexpected vital sign should be confirmed before other actions are taken.

Correct Answers:

Take the client's temperature using another method. C

Rationale :

🌡️A tympanic temperature of 94.6°F (34.8°C) is abnormally low and may reflect either true hypothermia or an inaccurate reading.

🔍Before acting on that value alone, the nurse should verify the temperature with another method to ensure the assessment is correct.

🏥Postoperative clients may have altered readings due to environmental exposure or device placement, so validation of unexpected findings is essential.

✅Confirming the temperature first supports safe clinical judgment and prevents unnecessary or incorrect interventions.

📌Core Message

When a postop client has an unexpectedly low temperature, the nurse should first verify the finding with a more reliable assessment.

3 :
A nurse is caring for a patient.

A 65-year-old female arrived in the emergency department (ED) with symptoms of shortness of breath, feeling lightheaded, a heart rate that feels "funny," and swelling in both the legs and feet. She reports the symptoms started a week ago but have worsened in the last 24 hours. Has a surgical history of hysterectomy and hiatal hernia repair approximately 20 years ago. No smoking history. Takes medication for hypertension. Developed atrial fibrillation (A-fib) and has been on antiarrhythmic medication for approximately 10 years. Sees the cardiologist every 6 months for follow up and electrocardiogram (ECG) which she states is "OK." Admit to the hospital for monitoring.

1000

Assessment reveals crackles in lower bases bilaterally, heart rate is fast and irregular, S3 heart sounds heard per auscultation, 3+ edema in legs bilaterally.

1000

Temperature: 98° F (36.8° C) orally

Heart rate: 94 beats/minute

Respirations: 22 breaths/minute

Blood pressure: 156/92 mm Hg

1015

Admit to hospital

Chest x-ray

Echocardiogram (ECHO)

Insert peripheral IV (PIV) access device

Maintain PIV per facility protocol

Brain-type natriuretic peptide (BNP),

serum electrolytes,

blood urea nitrogen (BUN)

creatinine, complete blood count (CBC) with differential

The nurse is assessing the client to develop a plan of care. Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse recognizescould be related to

Hint : 🔄Think about the condition that commonly causes fluid to back up into both the lungs and lower extremities.

Correct Answers

Blank 1 Correct Option: Edema of legs
Blank 2 Correct Option: Heart failure

Rationale :

💓Bilateral leg edema is a classic finding of fluid volume overload, which commonly occurs in heart failure.

🫁This client also has crackles, shortness of breath, and an S3 heart sound, which strengthen the pattern of cardiac dysfunction with congestion.

📈Heart failure causes poor pumping ability, leading to backup of blood and fluid into the lungs and peripheral tissues.

🦵Because the swelling is in both legs and occurs with other heart-related findings, edema of legs most strongly points to heart failure.

📌Core Message

In this case, bilateral leg edema is most consistent with heart failure because it reflects systemic fluid overload.

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4 :
A nurse is caring for a patient.

1000

Assessment reveals crackles in lower bases bilaterally, heart rate is fast and irregular, S3 heart sounds heard per auscultation, 3+ edema in legs bilaterally.

1000

Temperature: 98° F (36.8° C) orally

Heart rate: 94 beats/minute

Respirations: 22 breaths/minute

Blood pressure: 156/92 mm Hg

1015

Admit to hospital

Chest x-ray

Echocardiogram (ECHO)

Insert peripheral IV (PIV) access device

Maintain PIV per facility protocol

Brain-type natriuretic peptide (BNP),

serum electrolytes,

blood urea nitrogen (BUN)

creatinine, complete blood count (CBC) with differential

1300

Admitted to telemetry medical surgical nursing unit. Peripheral IV (PIV) inserted in right forearm with 20 gauge catheter. Laboratory specimens drawn and sent for analysis. Weight 186 lb. (84.4 kg). Connected to telemetry monitor. Healthcare provider (HCP) notified for diet and medication for blood pressure and antiarrhythmic drug prescriptions.

1400

Rivaroxaban 20 mg PO once daily with evening meal

Heart healthy diet

Verapamil 140 mg PO twice daily

Daily weights

Clonidine 0.6 mg PO twice daily, hold if systolic blood pressure is less than 110 mm Hg

The nurse is developing a plan of care for the client. For each assessment finding, click to indicate whether findings from assessments that are generally associated with right heart failure (RHF), left heart failure (LHF) or both right and left heart.

Assessment Finding	Right HF	Left HF
Crackles in lower bases
Pulmonary edema
3+ leg edema
S3 heart sound
Shortness of breath

Hint : 🌬️Pulmonary findings point one way, and peripheral swelling points the other way.

Correct Answers

Crackles in lower bases [ Left HF ]
Pulmonary edema [ Left HF ]
3+ leg edema [ Right HF ]
S3 heart sound [ Right HF ; Left HF ]
Shortness of breath [ Left HF ]

Rationale :

🫁Left-sided heart failure causes blood to back up into the lungs, producing crackles, pulmonary edema, and shortness of breath.

🦶Right-sided heart failure leads to backup in the systemic circulation, which commonly causes peripheral edema, especially in the legs.

🎧An S3 heart sound reflects volume overload and can be associated with heart failure involving either side of the heart.

💡Recognizing whether findings are pulmonary or systemic helps distinguish left-sided from right-sided manifestations.

📌Core Message

Left heart failure mainly causes lung congestion, right heart failure causes systemic edema, and an S3 suggests volume overload in heart failure.

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5 :
A nurse is caring for a patient.

1000

Assessment reveals crackles in lower bases bilaterally, heart rate is fast and irregular, S3 heart sounds heard per auscultation, 3+ edema in legs bilaterally.

1300

1500

Weight 186 lb. (84.5 kg). Client reports normal weight is 175 lb. (79.4 kg) and has been at that weight for "a long time." Reports having voided only twice today. Becomes lightheaded and dizzy when standing. Crackles heard in all lung fields. Blood pressure 170/90 mm Hg. Edema noted at 3+ in lower extremities

1000

Temperature: 98° F (36.8° C) orally

Heart rate: 94 beats/minute

Respirations: 22 breaths/minute

Blood pressure: 156/92 mm Hg

1500

Heart rate: 90 beats/minute

Respirations: 24 breaths/minute

Blood pressure: 170/90 mm Hg

1015

Admit to hospital

Chest x-ray

Echocardiogram (ECHO)

Insert peripheral IV (PIV) access device

Maintain PIV per facility protocol

Brain-type natriuretic peptide (BNP),

serum electrolytes,

blood urea nitrogen (BUN)

creatinine, complete blood count (CBC) with differential

1400

Rivaroxaban 20 mg PO once daily with evening meal

Heart healthy diet

Verapamil 140 mg PO twice daily

Daily weights

Clonidine 0.6 mg PO twice daily, hold if systolic blood pressure is less than 110 mm Hg

Reference Range

1500

BNP: 500 pg/mL (500 ng/L) — less than 100 pg/mL (100 ng/L)
Red blood cells (RBC): 3.5 × 10⁶/µL (3.5 × 10¹²/L) — 4.2 to 5.4 × 10⁶/µL (4.2 to 5.4 × 10¹²/L)
White blood cells (WBC): 5,000/mm³ (5 × 10⁹/L) — 5,000 to 10,000/mm³ (5 to 10 × 10⁹/L)
Blood urea nitrogen (BUN): 18 mg/dL (6.4 mmol/L) — 8 to 20 mg/dL (2.9 to 7.1 mmol/L)
Creatinine: 2.8 mg/dL (248 µmol/L) — 0.6 to 1.3 mg/dL (53 to 115 µmol/L)
Potassium: 4.5 mEq/L (4.5 mmol/L) — 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)
Sodium: 150 mEq/L (150 mmol/L) — 136 to 145 mEq/L (136 to 145 mmol/L)

The nurse is evaluating objective and subjective data to prioritize care. Select 4 findings that require immediate follow up by the nurse.

Answer Options

Crackles in all lung fields

3+ edema in lower extremities

Ejection fraction (EF) 50%

Increased weight

B-type natriuretic peptide (BNP) 500 pg/mL (500 ng/L)

Dizzy when standing

Hint : 🎯Focus first on findings that suggest worsening fluid overload or reduced perfusion.

Correct Answers:

Crackles in all lung fields
Increased weight
B-type natriuretic peptide (BNP) 500 pg/mL (500 ng/L)
Dizzy when standing

Rationale :

🚨Crackles in all lung fields suggest worsening pulmonary congestion, which may indicate deteriorating fluid overload and impaired oxygenation.

⚖️A marked increase in weight reflects rapid fluid retention, which is a significant sign of worsening heart failure.

🧪A BNP of 500 pg/mL strongly supports cardiac volume overload and indicates significant heart failure activity.

💫Being dizzy when standing suggests poor perfusion or orthostatic instability, which increases immediate safety concerns and requires prompt nursing follow-up.

📌Core Message

The priority findings are those showing worsening heart failure, especially pulmonary congestion, fluid retention, elevated BNP, and dizziness.

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6 :
A nurse is caring for a patient.

1000

Assessment reveals crackles in lower bases bilaterally, heart rate is fast and irregular, S3 heart sounds heard per auscultation, 3+ edema in legs bilaterally.

1300

1500

1530

HCP notified of client worsening symptoms, laboratory and imaging study results. Prescription received.

1600

Administered furosemide 40 mg IV push (IVP) through PIV. Site with no signs or symptoms of inflammation. Flushed easily. Provided bed side commode for safety since client is dizzy when getting up.

2000

Has voided 3,500 mL clear urine in 4 hours. Client reports it is easier to breathe and not as dizzy. Edema in lower extremities 2+. Appears more alert but says she is feeling very tired.

1015

Admit to hospital

Chest x-ray

Echocardiogram (ECHO)

Insert peripheral IV (PIV) access device

Maintain PIV per facility protocol

Brain-type natriuretic peptide (BNP),

serum electrolytes,

blood urea nitrogen (BUN)

creatinine, complete blood count (CBC) with differential

1400

Rivaroxaban 20 mg PO once daily with evening meal

Heart healthy diet

Verapamil 140 mg PO twice daily

Daily weights

Clonidine 0.6 mg PO twice daily, hold if systolic blood pressure is less than 110 mm Hg

Reference Range

1500

1000

Temperature: 98° F (36.8° C) orally

Heart rate: 94 beats/minute

Respirations: 22 breaths/minute

Blood pressure: 156/92 mm Hg

1500

Heart rate: 90 beats/minute

Respirations: 24 breaths/minute

Blood pressure: 170/90 mm Hg

2000

Heart rate: 84 beats/minute

Respirations: 22 breaths/minute

Blood pressure: 148/82 mm Hg

The nurse is evaluating objective and subjective data to plan care for the client. For each body system, click to specify the potential nursing intervention that would be appropriate for the care of the client.

Body System	Renal	Cardiovascular	Respiratory
Monitor blood urea nitrogen (BUN) and creatinine
Strict intake and output
Assess edema
Monitor blood pressure
Provide medication education
Teach heart healthy diet
Assess for increased shortness of breath
Assess lung sounds

Hint : 🩺Match each intervention to the body system most directly affected by fluid overload and cardiac dysfunction.

Correct Answers

Monitor blood urea nitrogen (BUN) and creatinine [ Renal ]
Strict intake and output [ Renal ]
Assess edema [ Cardiovascular ]
Monitor blood pressure [ Cardiovascular ]
Provide medication education [ Cardiovascular ]
Teach heart healthy diet [ Cardiovascular ]
Assess for increased shortness of breath [ Respiratory ]
Assess lung sounds [ Respiratory ]

Rationale :

🧫The renal system must be monitored with BUN, creatinine, and intake/output because fluid shifts and diuretic therapy can affect kidney function.

❤️The cardiovascular system requires monitoring of edema and blood pressure because this client has heart failure, hypertension, and atrial fibrillation.

💊Teaching about medications and a heart healthy diet supports long-term control of cardiac workload and fluid status.

🌬️The respiratory system needs close assessment of shortness of breath and lung sounds because fluid backup can worsen pulmonary congestion.

📌Core Message

This client’s care should target renal monitoring, cardiovascular management, and respiratory assessment because heart failure affects all three systems.

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7 :
A nurse is caring for a patient.

1000

Assessment reveals crackles in lower bases bilaterally, heart rate is fast and irregular, S3 heart sounds heard per auscultation, 3+ edema in legs bilaterally.

1300

1500

1530

HCP notified of client worsening symptoms, laboratory and imaging study results. Prescription received.

1600

Administered furosemide 40 mg IV push (IVP) through PIV. Site with no signs or symptoms of inflammation. Flushed easily. Provided bed side commode for safety since client is dizzy when getting up.

2000

Has voided 3,500 mL clear urine in 4 hours. Client reports it is easier to breathe and not as dizzy. Edema in lower extremities 2+. Appears more alert but says she is feeling very tired.

1015

Admit to hospital

Chest x-ray

Echocardiogram (ECHO)

Insert peripheral IV (PIV) access device

Maintain PIV per facility protocol

Brain-type natriuretic peptide (BNP),

serum electrolytes,

blood urea nitrogen (BUN)

creatinine, complete blood count (CBC) with differential

1400

Rivaroxaban 20 mg PO once daily with evening meal

Heart healthy diet

Verapamil 140 mg PO twice daily

Daily weights

Clonidine 0.6 mg PO twice daily, hold if systolic blood pressure is less than 110 mm Hg

Results Reference

1500

1000

Temperature: 98° F (36.8° C) orally

Heart rate: 94 beats/minute

Respirations: 22 breaths/minute

Blood pressure: 156/92 mm Hg

1500

Heart rate: 90 beats/minute

Respirations: 24 breaths/minute

Blood pressure: 170/90 mm Hg

2000

Heart rate: 84 beats/minute

Respirations: 22 breaths/minute

Blood pressure: 148/82 mm Hg

The nurse implements the plan of care for the client. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The nurse would teach the client takingto reportand.

Hint : 🛑Think about the warning signs a patient on a blood thinner must report right away.

Correct Answers

Blank 1 Correct Option: Novel oral anticoagulants (NOAC)
Blank 2 Correct Option: Bruising that worsens
Blank 3 Correct Option: Dark colored urine

Rationale :

💉Rivaroxaban is a novel oral anticoagulant, so the nurse should teach the client to watch for signs of bleeding.

🟣Bruising that worsens can indicate excessive anticoagulation or abnormal bleeding under the skin.

🚽Dark colored urine may signal blood in the urine, which is an important adverse effect to report immediately.

📚Early recognition of bleeding helps prevent serious complications while taking anticoagulant therapy.

📌Core Message

Clients taking a NOAC should report signs of bleeding, including worsening bruising and dark urine.

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8 :
A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?

Provide a bedside commode for immediate use in the client's room.

Teach the client techniques for performing intermittent catheterization.

Explain the need to limit intake of oral fluids to reduce client discomfort.

Remind the client to practice pelvic floor (Kegel) exercises regularly.

Hint : 🚰The best intervention directly helps the bladder empty when nerve control is impaired.

Correct Answers:

Teach the client techniques for performing intermittent catheterization.

Rationale :

🧠Multiple sclerosis can cause neurogenic bladder, leading to impaired emptying and urinary retention.

🚻Intermittent catheterization helps empty the bladder effectively and lowers the risk of overdistention and urinary complications.

🛡️This approach promotes better bladder management while reducing the chance of infection compared with long-term indwelling catheter use.

📖Teaching the client this technique supports independence and safe long-term care of sensorimotor-related retention.

📌Core Message

For urinary retention in multiple sclerosis, intermittent catheterization is a practical and effective bladder-management strategy.

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9 :
The nurse is performing the preoperative assessment for a client scheduled for a vertebroplasty of the cervical spine. Which finding should the nurse alert the healthcare provider of prior to the procedure?
Reference Range
Hematocrit [42% to 52% (0.42 to 0.52 volume fraction)]
Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]
White blood cells [5,000 to 10,000/mm³ (5 to 10 x 109/L)]
Platelets [150,000 to 400,000/mm³ (150 to 400 x 109/L)]

Platelet count 40,000/mm³ (40 × 10/L).

Hematocrit 38% (0.38 volume fraction).

Hemoglobin 12 g/dL (120 g/L).

White blood cells 9,000/mm³ (9×109/L).

Hint : 🧪Identify the lab value most closely tied to clotting and bleeding risk before surgery.

Correct Answers:

Platelet count 40,000/mm³ (40 × 10/L).

Rationale :

🩸A platelet count of 40,000/mm³ is severely low and creates a major risk for bleeding, especially before an invasive procedure.

⚠️Vertebroplasty involves needle access into the spine, so adequate clotting ability is essential for safety.

🔬Platelets are necessary for hemostasis, and such a low level requires urgent provider notification before proceeding.

🏥This finding is the most clinically significant abnormality because it directly increases the chance of procedural hemorrhage.

📌Core Message

A very low platelet count is the priority preoperative concern because it greatly increases bleeding risk during an invasive procedure.

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10 :
A client receives a new prescription for simvastatin 5 mg PO daily at bedtime. Which action should the nurse take?

Contact the prescriber about changing the time of administration

Administer the medication as prescribed with a glass of water

Check the client's blood pressure prior to administering the medication.

Provide a bedtime snack to be eaten before taking the medication.

Hint : 🕒Think about when the body makes the most cholesterol.

Correct Answers:

Administer the medication as prescribed with a glass of water

Rationale :

🌙Simvastatin is commonly prescribed at bedtime because cholesterol production by the liver is higher at night.

💊There is no need to change the administration time when it is already scheduled correctly for the drug’s best effect.

🚰Giving the medication with water is an appropriate and standard nursing action for safe oral administration.

✅The nurse should follow the prescription as written because it matches correct statin therapy timing.

📌Core Message

Simvastatin is best taken at bedtime, so the nurse should administer it as prescribed.

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Total Questions: 10

Choose Different Exam !

HESI RN Med-Surg 2026 Exam-2

No.

1 : A client is discharged with a prescription for warfarin. Which discharge instruction should the nurse emphasize to the client?

3 : A nurse is caring for a patient.

Correct Answers

4 : A nurse is caring for a patient.

Correct Answers

5 : A nurse is caring for a patient.

Answer Options

6 : A nurse is caring for a patient.

Correct Answers

7 : A nurse is caring for a patient.

Correct Answers

8 : A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?

10 : A client receives a new prescription for simvastatin 5 mg PO daily at bedtime. Which action should the nurse take?

1 :
A client is discharged with a prescription for warfarin. Which discharge instruction should the nurse emphasize to the client?

3 :
A nurse is caring for a patient.

4 :
A nurse is caring for a patient.

5 :
A nurse is caring for a patient.

6 :
A nurse is caring for a patient.

7 :
A nurse is caring for a patient.

8 :
A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?

10 :
A client receives a new prescription for simvastatin 5 mg PO daily at bedtime. Which action should the nurse take?