HESI RN MED SURG VERSION A & VERSION B 2024-2025 ACTUAL EXAM EA
EXAM CONTAINS 125 QUESTIONS AND CORRECT DETAILED ANSWERS
Study online at https://quizlet.com/_flv4jr
1. The nurse is assessing a client with acute pancreatitis. Which finding re-
quires the most immediate intervention by the nurse?
A.
The client's amylase level is three times higher than the normal level.
B.
The client has a carpal spasm when taking a blood pressure.
C.
On a 1 to 10 scale, the client tells the nurse that her epigastric pain is at 7.
D.
The client states that she will continue to drink alcohol after going home.: B
The nurse is assessing a client with acute pancreatitis. Which finding requires the
most immediate intervention by the nurse?
Rationale:A positive Trousseau sign indicates hypocalcemia and always requires
further assessment and intervention, regardless of the cause (40% to 75% of those
with acute pancreatitis experience hypocalcemia, which can have serious, systemic
effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels
that are two to five times higher than the normal value. Severe boring pain is an
expected symptom for this diagnosis, but dealing with the hypocalcemia is a priority
over administering an analgesic. Long-term planning and teaching do not have the
same immediate importance as a positive Trousseau sign.
2. A 55-year-old male client has been admitted to the hospital with a medical
diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor
is the most significant in the development of this client's COPD?
A.
The client's father was diagnosed with COPD in his 50s.
B.
A close family member contracted 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.: C
Rationale:Smoking, considered to be a modifiable risk factor, is the most significant
risk factor for the development of COPD. The exact mechanism of genetic and hered-
itary implications for the development of COPD is still under investigation, although
exposure to similar predisposing factors (e.g., smoking or inhaling secondhand
smoke) may increase the likelihood of COPD incidence among family members.
Options B and D do not exceed the risks associated with cigarette smoking in the
development of COPD.
, HESI RN MED SURG VERSION A & VERSION B 2024-2025 ACTUAL EXAM EA
EXAM CONTAINS 125 QUESTIONS AND CORRECT DETAILED ANSWERS
Study online at https://quizlet.com/_flv4jr
3. In assessing a client diagnosed with primary aldosteronism, the nurse
expects the laboratory test results to indicate a decreased serum level of
which substance?
A.
Sodium
B.
Phosphate
C.
Potassium
D.
Glucose: C
Rationale:Clients with primary aldosteronism exhibit a profound decline in serum
levels of potassium; hypokalemia; hypertension is the most prominent and universal
sign. The serum sodium level is normal or elevated, depending on the amount of
water resorbed with the sodium. Option B is influenced by parathyroid hormone
(PTH). Option D is not affected by primary aldosteronism.
4. The nurse is completing an admission interview for a client with Parkinson
disease. Which question will provide additional information about manifesta-
tions that the client is likely to experience?
A.
"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?": C
Rationale:Clients with Parkinson disease frequently experience difficulty in initiating,
maintaining, and performing motor activities. They may even experience being
rooted to the spot and unable to move. Parkinson disease does not typically cause
option A, B, or D.
5. Client census is often used to determine staffing needs. Which method of
obtaining census determination for a particular unit provides the best formula
for determining long-range staffing patterns?
A.
Midnight census
B.
Oncoming shift census
, HESI RN MED SURG VERSION A & VERSION B 2024-2025 ACTUAL EXAM EA
EXAM CONTAINS 125 QUESTIONS AND CORRECT DETAILED ANSWERS
Study online at https://quizlet.com/_flv4jr
C.
Average daily census
D.
Hourly census: C
Rationale:An average daily census is determined by trend data and takes into
account seasonal and daily fluctuations, so it is the best method for determining
staffing needs. Options A and B provide data at a certain point in time, and that data
could change quickly. It is unrealistic to expect to obtain an hourly census, and such
data would only provide information about a certain point in time.
6. A male client has just undergone a laryngectomy and has a cuffed tra-
cheostomy tube in place. When initiating bolus tube feedings postoperatively,
when should the nurse inflate the cuff?
A.
Immediately after feeding
B.
Just prior to tube feeding
C.
Continuous inflation is required
D.
Inflation is not required: B
Rationale:The cuff should be inflated before the feeding to block the trachea and
prevent food from entering if oral feedings are started while a cuffed tracheostomy
tube is in place. It should remain inflated throughout the feeding to prevent aspiration
of food into the respiratory system. Options A and D place the client at risk for
aspiration. Option C places the client at risk for tracheal wall necrosis.
7. A client with a nasogastric tube attached to low suction states that she is
nauseated. The nurse assesses that there has been no drainage through the
nasogastric tube in the last 2 hours. Which action should the nurse take first?
A.
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.: B
Rationale:The immediate priority is to determine if the tube is functioning correctly,
which would then relieve the client's nausea. The least invasive intervention, repo-
, HESI RN MED SURG VERSION A & VERSION B 2024-2025 ACTUAL EXAM EA
EXAM CONTAINS 125 QUESTIONS AND CORRECT DETAILED ANSWERS
Study online at https://quizlet.com/_flv4jr
sitioning the client, should be attempted first, followed by options A and C, unless
either of these interventions is contraindicated. If these measures are unsuccessful,
the client may require option D.
8. The nurse is conducting an osteoporosis screening clinic at a health fair.
What information should the nurse provide to individuals who are at risk for
osteoporosis? (Select all that apply.)
A.
Encourage alcohol and smoking cessation.
B.
Suggest supplementing diet with vitamin E.
C.
Promote regular weight-bearing exercises.
D.
Implement a home safety plan to prevent falls.
E.
Propose a regular sleep pattern of 8 hours nightly.: A, C, D
Rationale:Options A, C, and D are factors that decrease the risk for developing
osteoporosis. Vitamin D and calcium are important supplements to aid in the de-
crease of bone loss. Regular sleep patterns are important to overall health but are
not identified with a decreasing risk for osteoporosis.
9. Which nursing action would be appropriate for a client who is newly diag-
nosed with Cushing syndrome?
A.
Monitor blood glucose levels daily.
B.
Increase intake of fluids high in potassium.
C.
Encourage adequate rest between activities.
D.
Offer the client a sodium-enriched menu.: A
Rationale:Cushing syndrome results from a hypersecretion of glucocorticoids in
the adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus.
Monitoring of serum glucose levels assesses for increased blood glucose levels
so that treatment can begin early. A common finding in Cushing syndrome is
generalized edema. Although potassium is needed, it is generally obtained from
food intake, not by offering potassium-enhanced fluids. Fatigue is usually not an
overwhelming factor in Cushing syndrome, so an emphasis on the need for rest is
not indicated. A low-calorie, low-carbohydrate, low-sodium diet is not recommended.
EXAM CONTAINS 125 QUESTIONS AND CORRECT DETAILED ANSWERS
Study online at https://quizlet.com/_flv4jr
1. The nurse is assessing a client with acute pancreatitis. Which finding re-
quires the most immediate intervention by the nurse?
A.
The client's amylase level is three times higher than the normal level.
B.
The client has a carpal spasm when taking a blood pressure.
C.
On a 1 to 10 scale, the client tells the nurse that her epigastric pain is at 7.
D.
The client states that she will continue to drink alcohol after going home.: B
The nurse is assessing a client with acute pancreatitis. Which finding requires the
most immediate intervention by the nurse?
Rationale:A positive Trousseau sign indicates hypocalcemia and always requires
further assessment and intervention, regardless of the cause (40% to 75% of those
with acute pancreatitis experience hypocalcemia, which can have serious, systemic
effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels
that are two to five times higher than the normal value. Severe boring pain is an
expected symptom for this diagnosis, but dealing with the hypocalcemia is a priority
over administering an analgesic. Long-term planning and teaching do not have the
same immediate importance as a positive Trousseau sign.
2. A 55-year-old male client has been admitted to the hospital with a medical
diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor
is the most significant in the development of this client's COPD?
A.
The client's father was diagnosed with COPD in his 50s.
B.
A close family member contracted 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.: C
Rationale:Smoking, considered to be a modifiable risk factor, is the most significant
risk factor for the development of COPD. The exact mechanism of genetic and hered-
itary implications for the development of COPD is still under investigation, although
exposure to similar predisposing factors (e.g., smoking or inhaling secondhand
smoke) may increase the likelihood of COPD incidence among family members.
Options B and D do not exceed the risks associated with cigarette smoking in the
development of COPD.
, HESI RN MED SURG VERSION A & VERSION B 2024-2025 ACTUAL EXAM EA
EXAM CONTAINS 125 QUESTIONS AND CORRECT DETAILED ANSWERS
Study online at https://quizlet.com/_flv4jr
3. In assessing a client diagnosed with primary aldosteronism, the nurse
expects the laboratory test results to indicate a decreased serum level of
which substance?
A.
Sodium
B.
Phosphate
C.
Potassium
D.
Glucose: C
Rationale:Clients with primary aldosteronism exhibit a profound decline in serum
levels of potassium; hypokalemia; hypertension is the most prominent and universal
sign. The serum sodium level is normal or elevated, depending on the amount of
water resorbed with the sodium. Option B is influenced by parathyroid hormone
(PTH). Option D is not affected by primary aldosteronism.
4. The nurse is completing an admission interview for a client with Parkinson
disease. Which question will provide additional information about manifesta-
tions that the client is likely to experience?
A.
"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?": C
Rationale:Clients with Parkinson disease frequently experience difficulty in initiating,
maintaining, and performing motor activities. They may even experience being
rooted to the spot and unable to move. Parkinson disease does not typically cause
option A, B, or D.
5. Client census is often used to determine staffing needs. Which method of
obtaining census determination for a particular unit provides the best formula
for determining long-range staffing patterns?
A.
Midnight census
B.
Oncoming shift census
, HESI RN MED SURG VERSION A & VERSION B 2024-2025 ACTUAL EXAM EA
EXAM CONTAINS 125 QUESTIONS AND CORRECT DETAILED ANSWERS
Study online at https://quizlet.com/_flv4jr
C.
Average daily census
D.
Hourly census: C
Rationale:An average daily census is determined by trend data and takes into
account seasonal and daily fluctuations, so it is the best method for determining
staffing needs. Options A and B provide data at a certain point in time, and that data
could change quickly. It is unrealistic to expect to obtain an hourly census, and such
data would only provide information about a certain point in time.
6. A male client has just undergone a laryngectomy and has a cuffed tra-
cheostomy tube in place. When initiating bolus tube feedings postoperatively,
when should the nurse inflate the cuff?
A.
Immediately after feeding
B.
Just prior to tube feeding
C.
Continuous inflation is required
D.
Inflation is not required: B
Rationale:The cuff should be inflated before the feeding to block the trachea and
prevent food from entering if oral feedings are started while a cuffed tracheostomy
tube is in place. It should remain inflated throughout the feeding to prevent aspiration
of food into the respiratory system. Options A and D place the client at risk for
aspiration. Option C places the client at risk for tracheal wall necrosis.
7. A client with a nasogastric tube attached to low suction states that she is
nauseated. The nurse assesses that there has been no drainage through the
nasogastric tube in the last 2 hours. Which action should the nurse take first?
A.
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.: B
Rationale:The immediate priority is to determine if the tube is functioning correctly,
which would then relieve the client's nausea. The least invasive intervention, repo-
, HESI RN MED SURG VERSION A & VERSION B 2024-2025 ACTUAL EXAM EA
EXAM CONTAINS 125 QUESTIONS AND CORRECT DETAILED ANSWERS
Study online at https://quizlet.com/_flv4jr
sitioning the client, should be attempted first, followed by options A and C, unless
either of these interventions is contraindicated. If these measures are unsuccessful,
the client may require option D.
8. The nurse is conducting an osteoporosis screening clinic at a health fair.
What information should the nurse provide to individuals who are at risk for
osteoporosis? (Select all that apply.)
A.
Encourage alcohol and smoking cessation.
B.
Suggest supplementing diet with vitamin E.
C.
Promote regular weight-bearing exercises.
D.
Implement a home safety plan to prevent falls.
E.
Propose a regular sleep pattern of 8 hours nightly.: A, C, D
Rationale:Options A, C, and D are factors that decrease the risk for developing
osteoporosis. Vitamin D and calcium are important supplements to aid in the de-
crease of bone loss. Regular sleep patterns are important to overall health but are
not identified with a decreasing risk for osteoporosis.
9. Which nursing action would be appropriate for a client who is newly diag-
nosed with Cushing syndrome?
A.
Monitor blood glucose levels daily.
B.
Increase intake of fluids high in potassium.
C.
Encourage adequate rest between activities.
D.
Offer the client a sodium-enriched menu.: A
Rationale:Cushing syndrome results from a hypersecretion of glucocorticoids in
the adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus.
Monitoring of serum glucose levels assesses for increased blood glucose levels
so that treatment can begin early. A common finding in Cushing syndrome is
generalized edema. Although potassium is needed, it is generally obtained from
food intake, not by offering potassium-enhanced fluids. Fatigue is usually not an
overwhelming factor in Cushing syndrome, so an emphasis on the need for rest is
not indicated. A low-calorie, low-carbohydrate, low-sodium diet is not recommended.
