HESI RN MED SURG VERSION A &
VERSION B 2024-2025 ACTUAL
EXAM EACH EXAM CONTAINS 125
QUESTIONS AND CORRECT
DETAILED ANSWERS
The nurse observes ventricular fibrillation on telemetry and, on entering the client's bathroom,
finds the client unconscious on the floor. Which action should the nurse take first?
A.
Administer an antidysrhythmic medication.
B.
Start cardiopulmonary resuscitation.
C.
Prepare for mechanical ventilation.
D.
Assess the client's pulse oximetry. - ANSWER-B
Rationale:Ventricular fibrillation is a life-threatening dysrhythmia, and CPR should be started
immediately until the crash cart arrives. Options A and C are appropriate, but CPR is the priority
action until a defibrillator is available, which is the most effective treatment for ventricular
fibrillation. The client is dying, and option D does not address the seriousness of this situation.
A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic
studies have shown a basal skull fracture in the middle fossa. Assessment on admission revealed
both halo and Battle signs. Which new symptom indicates that the client is likely to be
experiencing a common life-threatening complication associated with a basal skull fracture?
A.
Bilateral jugular venous distention
,B.
Oral temperature of 102°F
C.
Intermittent focal motor seizures
D.
Intractable pain in the cervical region - ANSWER-B
Rationale:Clients with basilar skull fractures are at high risk for infection of the brain, as
indicated by an increased oral temperature, because the fracture leaves the meninges open to
bacterial invasion. Clients may experience options C and D, but these findings do not pose as
great a life-threatening risk as infection. Jugular distention is not a typical complication of basal
skull fractures.
The nurse witnesses a baseball player receive a blunt trauma to the back of the head with a
softball. What assessment data should the nurse collect immediately? (Select all that apply.)
A.
Reactivity of deep tendon reflexes
B.
Heart rate and respiratory rate
C.
Memory of recent events
D.
Ability to open the eyes spontaneously
E.
Dizziness
F.
Ringing in the ears - ANSWER-B, C, D, E, F
Rationale:The level of consciousness (LOC) should be established immediately when a head
injury has occurred. Deep tendon reflexes are not an indicator of LOC or concussion.
,Spontaneous eye opening is a simple measure of alertness that indicates that arousal
mechanisms are intact. The remaining assessments are included in the concussion protocol.
After attending a class on reducing cancer risk factors, a client selects bran flakes with 2% milk
and orange slices from a breakfast menu. In evaluating the client's learning, the nurse affirms
that the client has made good choices and makes what additional recommendation?
A.
Switch to skim milk.
B.
Switch to orange juice.
C.
Add a source of protein.
D.
Add herbal tea. - ANSWER-A
Rationale:Dietary recommendations to reduce cancer risk include reduced consumption of fats,
with increased consumption of fruits, vegetables, and fiber. Option A promotes reduced fat
consumption. Orange slices provide more fiber than orange juice. Options B, C, and D are not
standard recommendations for reducing cancer risk.
An 81-year-old client has emphysema. The client lives at home with a cat and manages self-care
with no difficulty. When making a home visit, the nurse notices that this client's tongue is
somewhat cracked and his eyeballs appear sunken. Which nursing action is indicated?
A.
Help the client determine ways to increase fluid intake.
B.
Obtain an appointment for the client to have an eye examination.
C.
Instruct the client to use oxygen at night and increase the humidification.
D.
Schedule the client for tests to determine his sensitivity to cat hair. - ANSWER-A
, Rationale:Clients with COPD should ingest 3 L of fluids daily but may experience a fluid deficit
because of shortness of breath. The nurse should suggest creative methods to increase the
intake of fluids, such as having fruit juices in disposable containers readily available. Option B is
not indicated. Humidified oxygen will not effectively treat the client's fluid deficit, and there is
no indication that the client needs supplemental oxygen at night. These symptoms are not
indicative of option D and may unnecessarily upset the client, who depends on his pet for
socialization.
When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge
nurse to assign which client to the PN?
A.
A young adult with bacterial meningitis with recent seizures
B.
An older adult client with pneumonia and viral meningitis
C.
A female client in isolation with meningococcal meningitis
D.
A male client 1 day postoperative after drainage of a brain abscess - ANSWER-B
Rationale:The most stable client is option B. Options A, C, and D are all at high risk for increased
intracranial pressure and require the expertise of the RN for assessment and management of
care.
Which instruction is best for the nurse to provide to a client with emphysema and chronic
fatigue?
A.
"Pace your activities and schedule rest periods."
B.
"Increase the amount of oxygen you use at night."
C.
"Obtain medical evaluation for antibiotic therapy."
D.
VERSION B 2024-2025 ACTUAL
EXAM EACH EXAM CONTAINS 125
QUESTIONS AND CORRECT
DETAILED ANSWERS
The nurse observes ventricular fibrillation on telemetry and, on entering the client's bathroom,
finds the client unconscious on the floor. Which action should the nurse take first?
A.
Administer an antidysrhythmic medication.
B.
Start cardiopulmonary resuscitation.
C.
Prepare for mechanical ventilation.
D.
Assess the client's pulse oximetry. - ANSWER-B
Rationale:Ventricular fibrillation is a life-threatening dysrhythmia, and CPR should be started
immediately until the crash cart arrives. Options A and C are appropriate, but CPR is the priority
action until a defibrillator is available, which is the most effective treatment for ventricular
fibrillation. The client is dying, and option D does not address the seriousness of this situation.
A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic
studies have shown a basal skull fracture in the middle fossa. Assessment on admission revealed
both halo and Battle signs. Which new symptom indicates that the client is likely to be
experiencing a common life-threatening complication associated with a basal skull fracture?
A.
Bilateral jugular venous distention
,B.
Oral temperature of 102°F
C.
Intermittent focal motor seizures
D.
Intractable pain in the cervical region - ANSWER-B
Rationale:Clients with basilar skull fractures are at high risk for infection of the brain, as
indicated by an increased oral temperature, because the fracture leaves the meninges open to
bacterial invasion. Clients may experience options C and D, but these findings do not pose as
great a life-threatening risk as infection. Jugular distention is not a typical complication of basal
skull fractures.
The nurse witnesses a baseball player receive a blunt trauma to the back of the head with a
softball. What assessment data should the nurse collect immediately? (Select all that apply.)
A.
Reactivity of deep tendon reflexes
B.
Heart rate and respiratory rate
C.
Memory of recent events
D.
Ability to open the eyes spontaneously
E.
Dizziness
F.
Ringing in the ears - ANSWER-B, C, D, E, F
Rationale:The level of consciousness (LOC) should be established immediately when a head
injury has occurred. Deep tendon reflexes are not an indicator of LOC or concussion.
,Spontaneous eye opening is a simple measure of alertness that indicates that arousal
mechanisms are intact. The remaining assessments are included in the concussion protocol.
After attending a class on reducing cancer risk factors, a client selects bran flakes with 2% milk
and orange slices from a breakfast menu. In evaluating the client's learning, the nurse affirms
that the client has made good choices and makes what additional recommendation?
A.
Switch to skim milk.
B.
Switch to orange juice.
C.
Add a source of protein.
D.
Add herbal tea. - ANSWER-A
Rationale:Dietary recommendations to reduce cancer risk include reduced consumption of fats,
with increased consumption of fruits, vegetables, and fiber. Option A promotes reduced fat
consumption. Orange slices provide more fiber than orange juice. Options B, C, and D are not
standard recommendations for reducing cancer risk.
An 81-year-old client has emphysema. The client lives at home with a cat and manages self-care
with no difficulty. When making a home visit, the nurse notices that this client's tongue is
somewhat cracked and his eyeballs appear sunken. Which nursing action is indicated?
A.
Help the client determine ways to increase fluid intake.
B.
Obtain an appointment for the client to have an eye examination.
C.
Instruct the client to use oxygen at night and increase the humidification.
D.
Schedule the client for tests to determine his sensitivity to cat hair. - ANSWER-A
, Rationale:Clients with COPD should ingest 3 L of fluids daily but may experience a fluid deficit
because of shortness of breath. The nurse should suggest creative methods to increase the
intake of fluids, such as having fruit juices in disposable containers readily available. Option B is
not indicated. Humidified oxygen will not effectively treat the client's fluid deficit, and there is
no indication that the client needs supplemental oxygen at night. These symptoms are not
indicative of option D and may unnecessarily upset the client, who depends on his pet for
socialization.
When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge
nurse to assign which client to the PN?
A.
A young adult with bacterial meningitis with recent seizures
B.
An older adult client with pneumonia and viral meningitis
C.
A female client in isolation with meningococcal meningitis
D.
A male client 1 day postoperative after drainage of a brain abscess - ANSWER-B
Rationale:The most stable client is option B. Options A, C, and D are all at high risk for increased
intracranial pressure and require the expertise of the RN for assessment and management of
care.
Which instruction is best for the nurse to provide to a client with emphysema and chronic
fatigue?
A.
"Pace your activities and schedule rest periods."
B.
"Increase the amount of oxygen you use at night."
C.
"Obtain medical evaluation for antibiotic therapy."
D.
