HESI RN MED SURG VERSION A & VERSION B 2026-2027
ACTUAL EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALE
The nurse is assessing a client with acute pancreatitis. Which finding requires 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. - ANS... -
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.
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. - ANS... -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 hereditary 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.
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 - ANS... -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.
The nurse is completing an admission interview for a client with Parkinson disease.
Which question will provide additional information about manifestations 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?" - ANS... -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.
,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
C.
Average daily census
D.
Hourly census - ANS... -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.
A male client has just undergone a laryngectomy and has a cuffed tracheostomy
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 - ANS... -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.
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. - ANS... -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, repositioning 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.
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. - ANS... -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
decrease of bone loss. Regular sleep patterns are important to overall health but are
not identified with a decreasing risk for osteoporosis.
Which nursing action would be appropriate for a client who is newly diagnosed
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. - ANS... -A
ACTUAL EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALE
The nurse is assessing a client with acute pancreatitis. Which finding requires 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. - ANS... -
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.
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. - ANS... -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 hereditary 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.
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 - ANS... -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.
The nurse is completing an admission interview for a client with Parkinson disease.
Which question will provide additional information about manifestations 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?" - ANS... -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.
,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
C.
Average daily census
D.
Hourly census - ANS... -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.
A male client has just undergone a laryngectomy and has a cuffed tracheostomy
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 - ANS... -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.
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. - ANS... -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, repositioning 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.
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. - ANS... -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
decrease of bone loss. Regular sleep patterns are important to overall health but are
not identified with a decreasing risk for osteoporosis.
Which nursing action would be appropriate for a client who is newly diagnosed
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. - ANS... -A
