HESI-RN Med-Surg Test
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1. The nurse is assessing a client B
with acute pancreatitis. Which The nurse is assessing a client with acute pancreatitis.
finding requires the most imme- Which finding requires the most immediate intervention
diate intervention by the nurse? by the nurse?
A. Rationale:A positive Trousseau sign indicates hypocal-
The client's amylase level is three cemia and always requires further assessment and inter-
times higher than the normal lev- vention, regardless of the cause (40% to 75% of those
el. with acute pancreatitis experience hypocalcemia, which
B. can have serious, systemic effects). A key diagnostic find-
The client has a carpal spasm ing of pancreatitis is serum amylase and lipase levels that
when taking a blood pressure. are two to five times higher than the normal value. Severe
C. boring pain is an expected symptom for this diagnosis,
On a 1 to 10 scale, the client tells but dealing with the hypocalcemia is a priority over ad-
the nurse that her epigastric pain ministering an analgesic. Long-term planning and teach-
is at 7. ing do not have the same immediate importance as a
D. positive Trousseau sign.
The client states that she will con-
tinue to drink alcohol after going
home.
2. A 55-year-old male client has C
been admitted to the hospi- Rationale:Smoking, considered to be a modifiable risk
tal with a medical diagnosis of factor, is the most significant risk factor for the devel-
chronic obstructive pulmonary opment of COPD. The exact mechanism of genetic and
disease (COPD). Which risk factor hereditary implications for the development of COPD is
is the most significant in the de- still under investigation, although exposure to similar
velopment of this client's COPD? predisposing factors (e.g., smoking or inhaling second-
A. hand smoke) may increase the likelihood of COPD inci-
The client's father was diagnosed dence among family members. Options B and D do not
with COPD in his 50s. exceed the risks associated with cigarette smoking in the
B. development of COPD.
A close family member contract-
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Study online at https://quizlet.com/_jajy4n
ed 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.
3. In assessing a client diagnosed C
with primary aldosteronism, the Rationale:Clients with primary aldosteronism exhibit a
nurse expects the laboratory test profound decline in serum levels of potassium; hy-
results to indicate a decreased pokalemia; hypertension is the most prominent and uni-
serum level of which substance? versal sign. The serum sodium level is normal or elevated,
A. depending on the amount of water resorbed with the
Sodium sodium. Option B is influenced by parathyroid hormone
B. (PTH). Option D is not affected by primary aldosteronism.
Phosphate
C.
Potassium
D.
Glucose
4. The nurse is completing an ad- C
mission interview for a client with Rationale:Clients with Parkinson disease frequently expe-
Parkinson disease. Which ques- rience difficulty in initiating, maintaining, and performing
tion will provide additional in- motor activities. They may even experience being rooted
formation about manifestations to the spot and unable to move. Parkinson disease does
that the client is likely to experi- not typically cause option A, B, or D.
ence?
A.
"Have you ever experienced any
paralysis of your arms or legs?"
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B.
"Do you have frequent blackout
spells?"
C.
"Have you ever been frozen in
one spot, unable to move?"
D.
"Do you have headaches, espe-
cially ones with throbbing pain?"
5. Client census is often used to C
determine staffing needs. Which Rationale:An average daily census is determined by trend
method of obtaining census de- data and takes into account seasonal and daily fluctua-
termination for a particular unit tions, so it is the best method for determining staffing
provides the best formula for needs. Options A and B provide data at a certain point in
determining long-range staffing time, and that data could change quickly. It is unrealistic
patterns? to expect to obtain an hourly census, and such data would
A. only provide information about a certain point in time.
Midnight census
B.
Oncoming shift census
C.
Average daily census
D.
Hourly census
6. A male client has just under- B
gone a laryngectomy and has Rationale:The cuff should be inflated before the feeding
a cuffed tracheostomy tube in to block the trachea and prevent food from entering if oral
place. When initiating bolus tube feedings are started while a cuffed tracheostomy tube is
feedings postoperatively, when in place. It should remain inflated throughout the feeding
should the nurse inflate the cuff? to prevent aspiration of food into the respiratory system.
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Study online at https://quizlet.com/_jajy4n
A. Options A and D place the client at risk for aspiration.
Immediately after feeding Option C places the client at risk for tracheal wall necrosis.
B.
Just prior to tube feeding
C.
Continuous inflation is required
D.
Inflation is not required
7. A client with a nasogastric tube B
attached to low suction states Rationale:The immediate priority is to determine if the
that she is nauseated. The nurse tube is functioning correctly, which would then relieve
assesses that there has been no the client's nausea. The least invasive intervention, repo-
drainage through the nasogastric sitioning the client, should be attempted first, followed
tube in the last 2 hours. Which ac- by options A and C, unless either of these interventions is
tion should the nurse take first? contraindicated. If these measures are unsuccessful, the
A. client may require option D.
Irrigate the nasogastric tube with
sterile normal saline.
B.
Reposition the client on her side.
C.
Advance the nasogastric tube 5
cm.
D.
Administer an intravenous
antiemetic as prescribed.
8. The nurse is conducting an os- A, C, D
teoporosis screening clinic at Rationale:Options A, C, and D are factors that decrease
a health fair. What information the risk for developing osteoporosis. Vitamin D and calci-
should the nurse provide to indi- um are important supplements to aid in the decrease of
Study online at https://quizlet.com/_jajy4n
1. The nurse is assessing a client B
with acute pancreatitis. Which The nurse is assessing a client with acute pancreatitis.
finding requires the most imme- Which finding requires the most immediate intervention
diate intervention by the nurse? by the nurse?
A. Rationale:A positive Trousseau sign indicates hypocal-
The client's amylase level is three cemia and always requires further assessment and inter-
times higher than the normal lev- vention, regardless of the cause (40% to 75% of those
el. with acute pancreatitis experience hypocalcemia, which
B. can have serious, systemic effects). A key diagnostic find-
The client has a carpal spasm ing of pancreatitis is serum amylase and lipase levels that
when taking a blood pressure. are two to five times higher than the normal value. Severe
C. boring pain is an expected symptom for this diagnosis,
On a 1 to 10 scale, the client tells but dealing with the hypocalcemia is a priority over ad-
the nurse that her epigastric pain ministering an analgesic. Long-term planning and teach-
is at 7. ing do not have the same immediate importance as a
D. positive Trousseau sign.
The client states that she will con-
tinue to drink alcohol after going
home.
2. A 55-year-old male client has C
been admitted to the hospi- Rationale:Smoking, considered to be a modifiable risk
tal with a medical diagnosis of factor, is the most significant risk factor for the devel-
chronic obstructive pulmonary opment of COPD. The exact mechanism of genetic and
disease (COPD). Which risk factor hereditary implications for the development of COPD is
is the most significant in the de- still under investigation, although exposure to similar
velopment of this client's COPD? predisposing factors (e.g., smoking or inhaling second-
A. hand smoke) may increase the likelihood of COPD inci-
The client's father was diagnosed dence among family members. Options B and D do not
with COPD in his 50s. exceed the risks associated with cigarette smoking in the
B. development of COPD.
A close family member contract-
, HESI-RN Med-Surg Test
Study online at https://quizlet.com/_jajy4n
ed 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.
3. In assessing a client diagnosed C
with primary aldosteronism, the Rationale:Clients with primary aldosteronism exhibit a
nurse expects the laboratory test profound decline in serum levels of potassium; hy-
results to indicate a decreased pokalemia; hypertension is the most prominent and uni-
serum level of which substance? versal sign. The serum sodium level is normal or elevated,
A. depending on the amount of water resorbed with the
Sodium sodium. Option B is influenced by parathyroid hormone
B. (PTH). Option D is not affected by primary aldosteronism.
Phosphate
C.
Potassium
D.
Glucose
4. The nurse is completing an ad- C
mission interview for a client with Rationale:Clients with Parkinson disease frequently expe-
Parkinson disease. Which ques- rience difficulty in initiating, maintaining, and performing
tion will provide additional in- motor activities. They may even experience being rooted
formation about manifestations to the spot and unable to move. Parkinson disease does
that the client is likely to experi- not typically cause option A, B, or D.
ence?
A.
"Have you ever experienced any
paralysis of your arms or legs?"
, HESI-RN Med-Surg Test
Study online at https://quizlet.com/_jajy4n
B.
"Do you have frequent blackout
spells?"
C.
"Have you ever been frozen in
one spot, unable to move?"
D.
"Do you have headaches, espe-
cially ones with throbbing pain?"
5. Client census is often used to C
determine staffing needs. Which Rationale:An average daily census is determined by trend
method of obtaining census de- data and takes into account seasonal and daily fluctua-
termination for a particular unit tions, so it is the best method for determining staffing
provides the best formula for needs. Options A and B provide data at a certain point in
determining long-range staffing time, and that data could change quickly. It is unrealistic
patterns? to expect to obtain an hourly census, and such data would
A. only provide information about a certain point in time.
Midnight census
B.
Oncoming shift census
C.
Average daily census
D.
Hourly census
6. A male client has just under- B
gone a laryngectomy and has Rationale:The cuff should be inflated before the feeding
a cuffed tracheostomy tube in to block the trachea and prevent food from entering if oral
place. When initiating bolus tube feedings are started while a cuffed tracheostomy tube is
feedings postoperatively, when in place. It should remain inflated throughout the feeding
should the nurse inflate the cuff? to prevent aspiration of food into the respiratory system.
, HESI-RN Med-Surg Test
Study online at https://quizlet.com/_jajy4n
A. Options A and D place the client at risk for aspiration.
Immediately after feeding Option C places the client at risk for tracheal wall necrosis.
B.
Just prior to tube feeding
C.
Continuous inflation is required
D.
Inflation is not required
7. A client with a nasogastric tube B
attached to low suction states Rationale:The immediate priority is to determine if the
that she is nauseated. The nurse tube is functioning correctly, which would then relieve
assesses that there has been no the client's nausea. The least invasive intervention, repo-
drainage through the nasogastric sitioning the client, should be attempted first, followed
tube in the last 2 hours. Which ac- by options A and C, unless either of these interventions is
tion should the nurse take first? contraindicated. If these measures are unsuccessful, the
A. client may require option D.
Irrigate the nasogastric tube with
sterile normal saline.
B.
Reposition the client on her side.
C.
Advance the nasogastric tube 5
cm.
D.
Administer an intravenous
antiemetic as prescribed.
8. The nurse is conducting an os- A, C, D
teoporosis screening clinic at Rationale:Options A, C, and D are factors that decrease
a health fair. What information the risk for developing osteoporosis. Vitamin D and calci-
should the nurse provide to indi- um are important supplements to aid in the decrease of
