HESI-RN MED-SURG TEST BANK |
Reviews Questions and Verified
Answers 100% Correct
1. A client with heart failure is prescribed furosemide 40 mg IV. Four hours after administration,
the nurse assesses the client. Which finding best indicates the medication is effective?
A. Urine output of 240 mL over 4 hours B. Blood pressure decreased from 158/96 to 120/78
mmHg C. Urine output of 800 mL over 4 hours (Correct Answer) D. Weight gain of 0.5 kg
Rationale: Furosemide is a loop diuretic. Effectiveness is measured by a significant increase
in urine output — 800 mL in 4 hours reflects appropriate diuresis, reducing preload and
relieving fluid overload in heart failure. Weight loss, not gain, would further confirm
effectiveness.
2. A client is admitted with acute pancreatitis. Which assessment finding requires immediate
intervention?
A. Serum amylase of 400 units/L B. Nausea and vomiting C. Cullen's sign (periumbilical
ecchymosis) (Correct Answer) D. Epigastric pain radiating to the back
Rationale: Cullen's sign indicates retroperitoneal hemorrhage and internal bleeding — a
life-threatening complication of severe acute pancreatitis (hemorrhagic pancreatitis). This
requires immediate escalation. Elevated amylase, nausea, and epigastric pain are expected
findings in pancreatitis.
3. A client with a serum potassium of 6.9 mEq/L has the following ECG changes: peaked T
waves, widened QRS, and a prolonged PR interval. The nurse's priority intervention is:
,A. Administer sodium polystyrene sulfonate (Kayexalate) orally B. Restrict dietary potassium
intake C. Administer IV calcium gluconate as ordered (Correct Answer) D. Initiate cardiac
monitoring
Rationale: IV calcium gluconate is the first-line emergency treatment for severe
hyperkalemia with ECG changes. It does not lower potassium levels but stabilizes the
cardiac membrane, preventing fatal dysrhythmias (ventricular fibrillation). Kayexalate
and dietary restriction are not fast enough in this emergency.
4. A client post-thyroidectomy develops stridor and has a positive Chvostek's sign. The nurse
should prepare to administer:
A. Potassium chloride IV B. Sodium bicarbonate IV C. Calcium gluconate IV (Correct Answer)
D. Magnesium sulfate IV
Rationale: Stridor and a positive Chvostek's sign after thyroidectomy indicate
hypocalcemia from inadvertent parathyroid removal. Calcium gluconate IV is the
emergency treatment. If untreated, laryngospasm and airway obstruction can occur. The
nurse must keep calcium gluconate at the bedside postoperatively.
5. A client with a pulmonary embolism has the following arterial blood gas results: pH 7.48,
PaCO2 28 mmHg, PaO2 58 mmHg, HCO3 22 mEq/L. The nurse interprets this as:
A. Metabolic acidosis with hypoxemia B. Respiratory alkalosis with hypoxemia (Correct
Answer) C. Respiratory acidosis with hypoxemia D. Metabolic alkalosis with hypoxemia
Rationale: pH >7.45 = alkalosis. PaCO2 <35 = respiratory cause (CO2 is blown off due to
tachypnea/hyperventilation in response to PE). HCO3 is normal = uncompensated. PaO2
<80 = hypoxemia. This is uncompensated respiratory alkalosis with hypoxemia — classic
ABG pattern in pulmonary embolism.
,6. The nurse is caring for a client on mechanical ventilation. The high-pressure alarm sounds.
The priority action is:
A. Suction the endotracheal tube B. Increase the FiO2 C. Assess the client for the cause of the
alarm (Correct Answer) D. Silence the alarm and call respiratory therapy
Rationale: High-pressure alarms indicate increased resistance to ventilation — possible
causes include secretions, biting the tube, bronchospasm, pneumothorax, or a kink in
tubing. The nurse must assess the client first before any intervention. Never silence alarms
without assessing the client.
7. A client is receiving a heparin infusion at 1,400 units/hour. The aPTT result is 180 seconds
(normal therapeutic range 60–100 seconds). The nurse should:
A. Continue the current infusion rate B. Increase the infusion rate by 100 units/hour C. Stop the
infusion and notify the provider (Correct Answer) D. Decrease the infusion rate by 100
units/hour
Rationale: An aPTT of 180 seconds is significantly supratherapeutic (>100 seconds = above
therapeutic range). The heparin infusion must be stopped or markedly reduced and the
provider notified immediately due to high risk of hemorrhage. Most institutions use a
nomogram-based protocol for adjustments.
8. A client with COPD exacerbation has the following ABG results: pH 7.28, PaCO2 62 mmHg,
PaO2 54 mmHg, HCO3 30 mEq/L. The nurse interprets this as:
A. Uncompensated respiratory acidosis B. Partially compensated respiratory acidosis with
hypoxemia (Correct Answer) C. Fully compensated respiratory acidosis D. Metabolic alkalosis
, Rationale: pH <7.35 = acidosis. PaCO2 >45 = respiratory cause (CO2 retention in COPD).
HCO3 >26 = kidneys are retaining bicarbonate to compensate, but pH is still acidotic =
partial compensation. PaO2 <80 = hypoxemia. This pattern is classic for COPD
exacerbation.
9. A client with a traumatic brain injury has a Glasgow Coma Scale (GCS) score of 7 in the
emergency department. The nurse should prepare for which priority intervention?
A. Administration of IV mannitol B. Insertion of an intracranial pressure monitor C.
Endotracheal intubation to protect the airway (Correct Answer) D. CT scan of the head
Rationale: A GCS score of ≤8 indicates severe brain injury and the inability to protect the
airway. Endotracheal intubation is the priority to establish and secure a patent airway. All
other interventions, while important, depend on first having a protected airway.
10. A client who had abdominal surgery 3 days ago develops a fever of 38.9°C (102°F),
productive cough, and decreased breath sounds at the left base. The most likely complication is:
A. Pulmonary embolism B. Wound infection C. Atelectasis progressing to pneumonia (Correct
Answer) D. Deep vein thrombosis
Rationale: Fever on postoperative day 3 with productive cough and diminished breath
sounds at the lung base is consistent with postoperative pneumonia, typically preceded by
atelectasis from splinting and inadequate deep breathing. The "5 Ws" of post-op fever
include Wind (atelectasis/pneumonia) on days 1–3.
11. A client with acute kidney injury has a urine output of 20 mL/hour over the past 8 hours. The
nurse recognizes this as:
Reviews Questions and Verified
Answers 100% Correct
1. A client with heart failure is prescribed furosemide 40 mg IV. Four hours after administration,
the nurse assesses the client. Which finding best indicates the medication is effective?
A. Urine output of 240 mL over 4 hours B. Blood pressure decreased from 158/96 to 120/78
mmHg C. Urine output of 800 mL over 4 hours (Correct Answer) D. Weight gain of 0.5 kg
Rationale: Furosemide is a loop diuretic. Effectiveness is measured by a significant increase
in urine output — 800 mL in 4 hours reflects appropriate diuresis, reducing preload and
relieving fluid overload in heart failure. Weight loss, not gain, would further confirm
effectiveness.
2. A client is admitted with acute pancreatitis. Which assessment finding requires immediate
intervention?
A. Serum amylase of 400 units/L B. Nausea and vomiting C. Cullen's sign (periumbilical
ecchymosis) (Correct Answer) D. Epigastric pain radiating to the back
Rationale: Cullen's sign indicates retroperitoneal hemorrhage and internal bleeding — a
life-threatening complication of severe acute pancreatitis (hemorrhagic pancreatitis). This
requires immediate escalation. Elevated amylase, nausea, and epigastric pain are expected
findings in pancreatitis.
3. A client with a serum potassium of 6.9 mEq/L has the following ECG changes: peaked T
waves, widened QRS, and a prolonged PR interval. The nurse's priority intervention is:
,A. Administer sodium polystyrene sulfonate (Kayexalate) orally B. Restrict dietary potassium
intake C. Administer IV calcium gluconate as ordered (Correct Answer) D. Initiate cardiac
monitoring
Rationale: IV calcium gluconate is the first-line emergency treatment for severe
hyperkalemia with ECG changes. It does not lower potassium levels but stabilizes the
cardiac membrane, preventing fatal dysrhythmias (ventricular fibrillation). Kayexalate
and dietary restriction are not fast enough in this emergency.
4. A client post-thyroidectomy develops stridor and has a positive Chvostek's sign. The nurse
should prepare to administer:
A. Potassium chloride IV B. Sodium bicarbonate IV C. Calcium gluconate IV (Correct Answer)
D. Magnesium sulfate IV
Rationale: Stridor and a positive Chvostek's sign after thyroidectomy indicate
hypocalcemia from inadvertent parathyroid removal. Calcium gluconate IV is the
emergency treatment. If untreated, laryngospasm and airway obstruction can occur. The
nurse must keep calcium gluconate at the bedside postoperatively.
5. A client with a pulmonary embolism has the following arterial blood gas results: pH 7.48,
PaCO2 28 mmHg, PaO2 58 mmHg, HCO3 22 mEq/L. The nurse interprets this as:
A. Metabolic acidosis with hypoxemia B. Respiratory alkalosis with hypoxemia (Correct
Answer) C. Respiratory acidosis with hypoxemia D. Metabolic alkalosis with hypoxemia
Rationale: pH >7.45 = alkalosis. PaCO2 <35 = respiratory cause (CO2 is blown off due to
tachypnea/hyperventilation in response to PE). HCO3 is normal = uncompensated. PaO2
<80 = hypoxemia. This is uncompensated respiratory alkalosis with hypoxemia — classic
ABG pattern in pulmonary embolism.
,6. The nurse is caring for a client on mechanical ventilation. The high-pressure alarm sounds.
The priority action is:
A. Suction the endotracheal tube B. Increase the FiO2 C. Assess the client for the cause of the
alarm (Correct Answer) D. Silence the alarm and call respiratory therapy
Rationale: High-pressure alarms indicate increased resistance to ventilation — possible
causes include secretions, biting the tube, bronchospasm, pneumothorax, or a kink in
tubing. The nurse must assess the client first before any intervention. Never silence alarms
without assessing the client.
7. A client is receiving a heparin infusion at 1,400 units/hour. The aPTT result is 180 seconds
(normal therapeutic range 60–100 seconds). The nurse should:
A. Continue the current infusion rate B. Increase the infusion rate by 100 units/hour C. Stop the
infusion and notify the provider (Correct Answer) D. Decrease the infusion rate by 100
units/hour
Rationale: An aPTT of 180 seconds is significantly supratherapeutic (>100 seconds = above
therapeutic range). The heparin infusion must be stopped or markedly reduced and the
provider notified immediately due to high risk of hemorrhage. Most institutions use a
nomogram-based protocol for adjustments.
8. A client with COPD exacerbation has the following ABG results: pH 7.28, PaCO2 62 mmHg,
PaO2 54 mmHg, HCO3 30 mEq/L. The nurse interprets this as:
A. Uncompensated respiratory acidosis B. Partially compensated respiratory acidosis with
hypoxemia (Correct Answer) C. Fully compensated respiratory acidosis D. Metabolic alkalosis
, Rationale: pH <7.35 = acidosis. PaCO2 >45 = respiratory cause (CO2 retention in COPD).
HCO3 >26 = kidneys are retaining bicarbonate to compensate, but pH is still acidotic =
partial compensation. PaO2 <80 = hypoxemia. This pattern is classic for COPD
exacerbation.
9. A client with a traumatic brain injury has a Glasgow Coma Scale (GCS) score of 7 in the
emergency department. The nurse should prepare for which priority intervention?
A. Administration of IV mannitol B. Insertion of an intracranial pressure monitor C.
Endotracheal intubation to protect the airway (Correct Answer) D. CT scan of the head
Rationale: A GCS score of ≤8 indicates severe brain injury and the inability to protect the
airway. Endotracheal intubation is the priority to establish and secure a patent airway. All
other interventions, while important, depend on first having a protected airway.
10. A client who had abdominal surgery 3 days ago develops a fever of 38.9°C (102°F),
productive cough, and decreased breath sounds at the left base. The most likely complication is:
A. Pulmonary embolism B. Wound infection C. Atelectasis progressing to pneumonia (Correct
Answer) D. Deep vein thrombosis
Rationale: Fever on postoperative day 3 with productive cough and diminished breath
sounds at the lung base is consistent with postoperative pneumonia, typically preceded by
atelectasis from splinting and inadequate deep breathing. The "5 Ws" of post-op fever
include Wind (atelectasis/pneumonia) on days 1–3.
11. A client with acute kidney injury has a urine output of 20 mL/hour over the past 8 hours. The
nurse recognizes this as:
