Scheduled maintenance: 10 April 2026 from 05:00 to 06:00
HESI RN MED SURG VERSION A & VERSION B
EXAM
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Terms in this set (125)
The nurse is assessing a client with B
acute pancreatitis. Which finding The nurse is assessing a client with acute
requires the most immediate pancreatitis. Which finding requires the most
intervention by the nurse? immediate intervention by the nurse?
A. Rationale:A positive Trousseau sign indicates
The client's amylase level is three hypocalcemia and always requires further
times higher than the normal level. assessment and intervention, regardless of the
B. cause (40% to 75% of those with acute pancreatitis
The client has a carpal spasm when experience hypocalcemia, which can have serious,
taking a blood pressure. systemic effects). A key diagnostic finding of
C. pancreatitis is serum amylase and lipase levels that
On a 1 to 10 scale, the client tells the are two to five times higher than the normal value.
nurse that her epigastric pain is at 7. Severe boring pain is an expected symptom for this
D. diagnosis, but dealing with the hypocalcemia is a
The client states that she will priority over administering an analgesic. Long-term
continue to drink alcohol after going planning and teaching do not have the same
home. immediate importance as a positive Trousseau sign.
,A 55-year-old male client has been C
admitted to the hospital with a Rationale:Smoking, considered to be a modifiable
medical diagnosis of chronic risk factor, is the most significant risk factor for the
obstructive pulmonary disease development of COPD. The exact mechanism of
(COPD). Which risk factor is the most genetic and hereditary implications for the
significant in the development of this development of COPD is still under investigation,
client's COPD? although exposure to similar predisposing factors
A. (e.g., smoking or inhaling secondhand smoke) may
The client's father was diagnosed increase the likelihood of COPD incidence among
with COPD in his 50s. family members. Options B and D do not exceed
B. the risks associated with cigarette smoking in the
A close family member contracted development of COPD.
tuberculosis last year.
C.
The client smokes one to two packs
of cigarettes per day.
D.
The client has been 40 pounds
overweight for 15 years.
In assessing a client diagnosed with C
primary aldosteronism, the nurse Rationale:Clients with primary aldosteronism exhibit
expects the laboratory test results to a profound decline in serum levels of potassium;
indicate a decreased serum level of hypokalemia; hypertension is the most prominent
which substance? and universal sign. The serum sodium level is
A. normal or elevated, depending on the amount of
Sodium water resorbed with the sodium. Option B is
B. influenced by parathyroid hormone (PTH). Option
Phosphate D is not affected by primary aldosteronism.
C.
Potassium
D.
Glucose
,The nurse is completing an admission C
interview for a client with Parkinson Rationale:Clients with Parkinson disease frequently
disease. Which question will provide experience difficulty in initiating, maintaining, and
additional information about performing motor activities. They may even
manifestations that the client is likely experience being rooted to the spot and unable to
to experience? move. Parkinson disease does not typically cause
A. option A, B, or D.
"Have you ever experienced any
paralysis of your arms or legs?"
B.
"Do you have frequent blackout
spells?"
C.
"Have you ever been frozen in one
spot, unable to move?"
D.
"Do you have headaches, especially
ones with throbbing pain?"
Client census is often used to C
determine staffing needs. Which Rationale:An average daily census is determined by
method of obtaining census trend data and takes into account seasonal and
determination for a particular unit daily fluctuations, so it is the best method for
provides the best formula for determining staffing needs. Options A and B
determining long-range staffing provide data at a certain point in time, and that data
patterns? could change quickly. It is unrealistic to expect to
A. obtain an hourly census, and such data would only
Midnight census provide information about a certain point in time.
B.
Oncoming shift census
C.
Average daily census
D.
Hourly census
, A male client has just undergone a B
laryngectomy and has a cuffed Rationale:The cuff should be inflated before the
tracheostomy tube in place. When feeding to block the trachea and prevent food
initiating bolus tube feedings from entering if oral feedings are started while a
postoperatively, when should the cuffed tracheostomy tube is in place. It should
nurse inflate the cuff? remain inflated throughout the feeding to prevent
A. aspiration of food into the respiratory system.
Immediately after feeding Options A and D place the client at risk for
B. aspiration. Option C places the client at risk for
Just prior to tube feeding tracheal wall necrosis.
C.
Continuous inflation is required
D.
Inflation is not required
A client with a nasogastric tube B
attached to low suction states that Rationale:The immediate priority is to determine if
she is nauseated. The nurse assesses the tube is functioning correctly, which would then
that there has been no drainage relieve the client's nausea. The least invasive
through the nasogastric tube in the intervention, repositioning the client, should be
last 2 hours. Which action should the attempted first, followed by options A and C, unless
nurse take first? either of these interventions is contraindicated. If
A. these measures are unsuccessful, the client may
Irrigate the nasogastric tube with require option D.
sterile normal saline.
B.
Reposition the client on her side.
C.
Advance the nasogastric tube 5 cm.
D.
Administer an intravenous antiemetic
as prescribed.
HESI RN MED SURG VERSION A & VERSION B
EXAM
Save
Terms in this set (125)
The nurse is assessing a client with B
acute pancreatitis. Which finding The nurse is assessing a client with acute
requires the most immediate pancreatitis. Which finding requires the most
intervention by the nurse? immediate intervention by the nurse?
A. Rationale:A positive Trousseau sign indicates
The client's amylase level is three hypocalcemia and always requires further
times higher than the normal level. assessment and intervention, regardless of the
B. cause (40% to 75% of those with acute pancreatitis
The client has a carpal spasm when experience hypocalcemia, which can have serious,
taking a blood pressure. systemic effects). A key diagnostic finding of
C. pancreatitis is serum amylase and lipase levels that
On a 1 to 10 scale, the client tells the are two to five times higher than the normal value.
nurse that her epigastric pain is at 7. Severe boring pain is an expected symptom for this
D. diagnosis, but dealing with the hypocalcemia is a
The client states that she will priority over administering an analgesic. Long-term
continue to drink alcohol after going planning and teaching do not have the same
home. immediate importance as a positive Trousseau sign.
,A 55-year-old male client has been C
admitted to the hospital with a Rationale:Smoking, considered to be a modifiable
medical diagnosis of chronic risk factor, is the most significant risk factor for the
obstructive pulmonary disease development of COPD. The exact mechanism of
(COPD). Which risk factor is the most genetic and hereditary implications for the
significant in the development of this development of COPD is still under investigation,
client's COPD? although exposure to similar predisposing factors
A. (e.g., smoking or inhaling secondhand smoke) may
The client's father was diagnosed increase the likelihood of COPD incidence among
with COPD in his 50s. family members. Options B and D do not exceed
B. the risks associated with cigarette smoking in the
A close family member contracted development of COPD.
tuberculosis last year.
C.
The client smokes one to two packs
of cigarettes per day.
D.
The client has been 40 pounds
overweight for 15 years.
In assessing a client diagnosed with C
primary aldosteronism, the nurse Rationale:Clients with primary aldosteronism exhibit
expects the laboratory test results to a profound decline in serum levels of potassium;
indicate a decreased serum level of hypokalemia; hypertension is the most prominent
which substance? and universal sign. The serum sodium level is
A. normal or elevated, depending on the amount of
Sodium water resorbed with the sodium. Option B is
B. influenced by parathyroid hormone (PTH). Option
Phosphate D is not affected by primary aldosteronism.
C.
Potassium
D.
Glucose
,The nurse is completing an admission C
interview for a client with Parkinson Rationale:Clients with Parkinson disease frequently
disease. Which question will provide experience difficulty in initiating, maintaining, and
additional information about performing motor activities. They may even
manifestations that the client is likely experience being rooted to the spot and unable to
to experience? move. Parkinson disease does not typically cause
A. option A, B, or D.
"Have you ever experienced any
paralysis of your arms or legs?"
B.
"Do you have frequent blackout
spells?"
C.
"Have you ever been frozen in one
spot, unable to move?"
D.
"Do you have headaches, especially
ones with throbbing pain?"
Client census is often used to C
determine staffing needs. Which Rationale:An average daily census is determined by
method of obtaining census trend data and takes into account seasonal and
determination for a particular unit daily fluctuations, so it is the best method for
provides the best formula for determining staffing needs. Options A and B
determining long-range staffing provide data at a certain point in time, and that data
patterns? could change quickly. It is unrealistic to expect to
A. obtain an hourly census, and such data would only
Midnight census provide information about a certain point in time.
B.
Oncoming shift census
C.
Average daily census
D.
Hourly census
, A male client has just undergone a B
laryngectomy and has a cuffed Rationale:The cuff should be inflated before the
tracheostomy tube in place. When feeding to block the trachea and prevent food
initiating bolus tube feedings from entering if oral feedings are started while a
postoperatively, when should the cuffed tracheostomy tube is in place. It should
nurse inflate the cuff? remain inflated throughout the feeding to prevent
A. aspiration of food into the respiratory system.
Immediately after feeding Options A and D place the client at risk for
B. aspiration. Option C places the client at risk for
Just prior to tube feeding tracheal wall necrosis.
C.
Continuous inflation is required
D.
Inflation is not required
A client with a nasogastric tube B
attached to low suction states that Rationale:The immediate priority is to determine if
she is nauseated. The nurse assesses the tube is functioning correctly, which would then
that there has been no drainage relieve the client's nausea. The least invasive
through the nasogastric tube in the intervention, repositioning the client, should be
last 2 hours. Which action should the attempted first, followed by options A and C, unless
nurse take first? either of these interventions is contraindicated. If
A. these measures are unsuccessful, the client may
Irrigate the nasogastric tube with require option D.
sterile normal saline.
B.
Reposition the client on her side.
C.
Advance the nasogastric tube 5 cm.
D.
Administer an intravenous antiemetic
as prescribed.
