HESI RN MED SURG VERSION A & VERSION B
ACTUAL EXAM EACH EXAM CONTAINS 125 QU
CORRECT DETAILED ANSWERS
The cnurse cis cassessing ca cclient cwith cacute cpancreatitis. cWhich cfinding crequires cthe cmost cimm
cnurse?
A. c
The cclient's camylase clevel cis cthree ctimes chigher cthan cthe cnormal clevel.
cB.
The cclient chas ca ccarpal cspasm cwhen ctaking ca cblood cpressure.
cC.
On ca c1 cto c10 cscale, cthe cclient ctells cthe cnurse cthat cher cepigastric cpain cis cat c7.
cD.
The cclient cstates cthat cshe cwill ccontinue cto cdrink calcohol cafter cgoing chome. c- cCORRECT cANS
The cnurse cis cassessing ca cclient cwith cacute cpancreatitis. cWhich cfinding crequires cthe cmost cimm
cnurse?
Rationale:A cpositive cTrousseau csign cindicates chypocalcemia cand calways crequires cfurther casse
cregardless cof cthe ccause c(40% cto c75% cof cthose cwith cacute cpancreatitis cexperience chypocalce
csystemic ceffects). cA ckey cdiagnostic cfinding cof cpancreatitis cis cserum camylase cand clipase clevel
chigher cthan cthe cnormal cvalue. cSevere cboring cpain cis can cexpected csymptom cfor cthis cdiagnosi
chypocalcemia cis ca cpriority cover cadministering can canalgesic. cLong-term cplanning cand cteaching
cimmediate cimportance cas ca cpositive cTrousseau csign.
A c55-year-old cmale cclient chas cbeen cadmitted cto cthe chospital cwith ca cmedical cdiagnosis cof cchr
cdisease c(COPD). cWhich crisk cfactor cis cthe cmost csignificant cin cthe cdevelopment cof cthis cclient's
A.
The cclient's cfather cwas cdiagnosed cwith cCOPD cin chis c50s.
cB.
A cclose cfamily cmember ccontracted ctuberculosis clast cyear.
cC.
The cclient csmokes cone cto ctwo cpacks cof ccigarettes cper cday.
cD.
The cclient chas cbeen c40 cpounds coverweight cfor c15 cyears. c- cCORRECT cANS✔✔C
,The cnurse cis ccompleting can cadmission cinterview cfor ca cclient cwith cParkinson cdisease. cWhich cq
cinformation cabout cmanifestations cthat cthe cclient cis clikely cto cexperience?
A.
"Have cyou cever cexperienced cany cparalysis cof cyour carms cor clegs?"
cB.
"Do cyou chave cfrequent cblackout cspells?"
cC.
"Have cyou cever cbeen cfrozen cin cone cspot, cunable cto cmove?"
cD.
"Do cyou chave cheadaches, cespecially cones cwith cthrobbing cpain?" c- cCORRECT cANS✔✔C
Rationale:Clients cwith cParkinson cdisease cfrequently cexperience cdifficulty cin cinitiating, cmaintainin
cactivities. cThey cmay ceven cexperience cbeing crooted cto cthe cspot cand cunable cto cmove. cParkins
ccause coption cA, cB, cor cD.
Client ccensus cis coften cused cto cdetermine cstaffing cneeds. cWhich cmethod cof cobtaining ccensus c
cunit cprovides cthe cbest cformula cfor cdetermining clong-range cstaffing cpatterns?
A.
Midnight ccensus
cB.
Oncoming cshift ccensus
cC.
Average cdaily ccensus
cD.
Hourly ccensus c- cCORRECT cANS✔✔C
Rationale:An caverage cdaily ccensus cis cdetermined cby ctrend cdata cand ctakes cinto caccount cseas
cit cis cthe cbest cmethod cfor cdetermining cstaffing cneeds. cOptions cA cand cB cprovide cdata cat ca cce
cdata ccould cchange cquickly. cIt cis cunrealistic cto cexpect cto cobtain can chourly ccensus, cand csuch c
cinformation cabout ca ccertain cpoint cin ctime.
A cmale cclient chas cjust cundergone ca claryngectomy cand chas ca ccuffed ctracheostomy ctube cin cpla
cfeedings cpostoperatively, cwhen cshould cthe cnurse cinflate cthe ccuff?
A.
Immediately cafter cfeeding
cB.
Just cprior cto ctube cfeeding
cC.
Continuous cinflation cis crequired
cD.
Inflation cis cnot crequired c- cCORRECT cANS✔✔B
Rationale:The ccuff cshould cbe cinflated cbefore cthe cfeeding cto cblock cthe ctrachea cand cprevent cfo
cfeedings care cstarted cwhile ca ccuffed ctracheostomy ctube cis cin cplace. cIt cshould cremain cinflated c
cprevent caspiration cof cfood cinto cthe crespiratory csystem. cOptions cA cand cD cplace cthe cclient cat c
cplaces cthe cclient cat crisk cfor ctracheal cwall cnecrosis.
A cclient cwith ca cnasogastric ctube cattached cto clow csuction cstates cthat cshe cis cnauseated. cThe cn
cbeen cno cdrainage cthrough cthe cnasogastric ctube cin cthe clast c2 chours. cWhich caction cshould cthe
A.
Irrigate cthe cnasogastric ctube cwith csterile cnormal csaline.
cB.
Reposition cthe cclient con cher cside.
cC.
Advance cthe cnasogastric ctube c5 ccm.
cD.
Administer can cintravenous cantiemetic cas cprescribed. c- cCORRECT cANS✔✔B
, Which cnursing caction cwould cbe cappropriate cfor ca cclient cwho cis cnewly cdiagnosed cwith cCushing
A.
Monitor cblood cglucose clevels cdaily.
cB.
Increase cintake cof cfluids chigh cin cpotassium.
cC.
Encourage cadequate crest cbetween cactivities.
cD.
Offer cthe cclient ca csodium-enriched cmenu. c- cCORRECT cANS✔✔A
Rationale:Cushing csyndrome cresults cfrom ca chypersecretion cof cglucocorticoids cin cthe cadrenal cc
csyndrome coften cdevelop cdiabetes cmellitus. cMonitoring cof cserum cglucose clevels cassesses cfor c
cso cthat ctreatment ccan cbegin cearly. cA ccommon cfinding cin cCushing csyndrome cis cgeneralized ce
cneeded, cit cis cgenerally cobtained cfrom cfood cintake, cnot cby coffering cpotassium-enhanced cfluids
coverwhelming cfactor cin cCushing csyndrome, cso can cemphasis con cthe cneed cfor crest cis cnot cindi
carbohydrate, clow-sodium cdiet cis cnot crecommended.
A c58-year-old cclient cwho chas cno chealth cproblems casks cthe cnurse cabout creceiving cthe cpneum
cstatement cgiven cby cthe cnurse cwould coffer cthe cclient caccurate cinformation cabout cthis cvaccine?
A.
The cvaccine cis cgiven cannually cbefore cthe cflu cseason cto cthose colder cthan c50 cyears.
cB.
The cimmunization cis cadministered conce cto colder cadults cor cthose cat crisk cfor cillness.
cC.
The cvaccine cis cfor call cages cand cis cgiven cprimarily cto cthose cpersons ctraveling coverseas cto care
cD.
The cvaccine cwill cprevent cthe coccurrence cof cpneumococcal cpneumonia cfor cup cto c5 cyears. c- cC
Rationale:It cis cusually crecommended cthat cpersons colder cthan c65 cyears cand cthose cwith ca chisto
creceive cthe cvaccine conce cin ctheir clifetime. cSome crecommend creceiving cthe cvaccine cat c50 cye
cvaccine cis cgiven conce ca cyear. cAlthough cthe cvaccine cmight cbe cgiven cto ca cperson ctraveling co
crationale cfor cadministering cthe cvaccine. cThe cvaccine cis cusually cgiven conce cin ca clifetime, cbut c
cclients cor cclients cwith ca chistory cof cpneumonia, crevaccination cis csometimes crequired.
A cclient cis cadmitted cto cthe chospital cwith csevere clower cleft cabdominal cpain, cnausea, cvomiting, c
cnursing caction chas cthe chighest cpriority?
A.
Place cthe cclient con cNPO cstatus.
cB.
Assess cthe cclient's ctemperature.
cC.
Obtain ca cstool cspecimen.
cD.
Administer cIV cfluids. c- cCORRECT cANS✔✔A
Rationale:A cclient cis cshowing csigns cof cacute csevere cdiverticulitis cand cis cat crisk cfor cperitonitis c
cnurse cshould cmake cthe cclient cNPO cto creduce crisk cof cintestinal crupture. cOptions cB, cC, cand cD
ca cpriority cthan coption cA, cwhich cis cimplemented cto cprevent ca csevere ccomplication.
A cclient con ctelemetry chas ca cpattern cof cuncontrolled catrial cfibrillation cwith ca crapid cventricular cre
cfinding, cthe cnurse canticipates cassisting cthe cphysician cwith cwhich ctreatment?
A.
Administer clidocaine, c75 cmg cintravenous cpush.
cB.
Perform csynchronized ccardioversion.
cC.
Defibrillate cthe cclient cas csoon cas cpossible.
ACTUAL EXAM EACH EXAM CONTAINS 125 QU
CORRECT DETAILED ANSWERS
The cnurse cis cassessing ca cclient cwith cacute cpancreatitis. cWhich cfinding crequires cthe cmost cimm
cnurse?
A. c
The cclient's camylase clevel cis cthree ctimes chigher cthan cthe cnormal clevel.
cB.
The cclient chas ca ccarpal cspasm cwhen ctaking ca cblood cpressure.
cC.
On ca c1 cto c10 cscale, cthe cclient ctells cthe cnurse cthat cher cepigastric cpain cis cat c7.
cD.
The cclient cstates cthat cshe cwill ccontinue cto cdrink calcohol cafter cgoing chome. c- cCORRECT cANS
The cnurse cis cassessing ca cclient cwith cacute cpancreatitis. cWhich cfinding crequires cthe cmost cimm
cnurse?
Rationale:A cpositive cTrousseau csign cindicates chypocalcemia cand calways crequires cfurther casse
cregardless cof cthe ccause c(40% cto c75% cof cthose cwith cacute cpancreatitis cexperience chypocalce
csystemic ceffects). cA ckey cdiagnostic cfinding cof cpancreatitis cis cserum camylase cand clipase clevel
chigher cthan cthe cnormal cvalue. cSevere cboring cpain cis can cexpected csymptom cfor cthis cdiagnosi
chypocalcemia cis ca cpriority cover cadministering can canalgesic. cLong-term cplanning cand cteaching
cimmediate cimportance cas ca cpositive cTrousseau csign.
A c55-year-old cmale cclient chas cbeen cadmitted cto cthe chospital cwith ca cmedical cdiagnosis cof cchr
cdisease c(COPD). cWhich crisk cfactor cis cthe cmost csignificant cin cthe cdevelopment cof cthis cclient's
A.
The cclient's cfather cwas cdiagnosed cwith cCOPD cin chis c50s.
cB.
A cclose cfamily cmember ccontracted ctuberculosis clast cyear.
cC.
The cclient csmokes cone cto ctwo cpacks cof ccigarettes cper cday.
cD.
The cclient chas cbeen c40 cpounds coverweight cfor c15 cyears. c- cCORRECT cANS✔✔C
,The cnurse cis ccompleting can cadmission cinterview cfor ca cclient cwith cParkinson cdisease. cWhich cq
cinformation cabout cmanifestations cthat cthe cclient cis clikely cto cexperience?
A.
"Have cyou cever cexperienced cany cparalysis cof cyour carms cor clegs?"
cB.
"Do cyou chave cfrequent cblackout cspells?"
cC.
"Have cyou cever cbeen cfrozen cin cone cspot, cunable cto cmove?"
cD.
"Do cyou chave cheadaches, cespecially cones cwith cthrobbing cpain?" c- cCORRECT cANS✔✔C
Rationale:Clients cwith cParkinson cdisease cfrequently cexperience cdifficulty cin cinitiating, cmaintainin
cactivities. cThey cmay ceven cexperience cbeing crooted cto cthe cspot cand cunable cto cmove. cParkins
ccause coption cA, cB, cor cD.
Client ccensus cis coften cused cto cdetermine cstaffing cneeds. cWhich cmethod cof cobtaining ccensus c
cunit cprovides cthe cbest cformula cfor cdetermining clong-range cstaffing cpatterns?
A.
Midnight ccensus
cB.
Oncoming cshift ccensus
cC.
Average cdaily ccensus
cD.
Hourly ccensus c- cCORRECT cANS✔✔C
Rationale:An caverage cdaily ccensus cis cdetermined cby ctrend cdata cand ctakes cinto caccount cseas
cit cis cthe cbest cmethod cfor cdetermining cstaffing cneeds. cOptions cA cand cB cprovide cdata cat ca cce
cdata ccould cchange cquickly. cIt cis cunrealistic cto cexpect cto cobtain can chourly ccensus, cand csuch c
cinformation cabout ca ccertain cpoint cin ctime.
A cmale cclient chas cjust cundergone ca claryngectomy cand chas ca ccuffed ctracheostomy ctube cin cpla
cfeedings cpostoperatively, cwhen cshould cthe cnurse cinflate cthe ccuff?
A.
Immediately cafter cfeeding
cB.
Just cprior cto ctube cfeeding
cC.
Continuous cinflation cis crequired
cD.
Inflation cis cnot crequired c- cCORRECT cANS✔✔B
Rationale:The ccuff cshould cbe cinflated cbefore cthe cfeeding cto cblock cthe ctrachea cand cprevent cfo
cfeedings care cstarted cwhile ca ccuffed ctracheostomy ctube cis cin cplace. cIt cshould cremain cinflated c
cprevent caspiration cof cfood cinto cthe crespiratory csystem. cOptions cA cand cD cplace cthe cclient cat c
cplaces cthe cclient cat crisk cfor ctracheal cwall cnecrosis.
A cclient cwith ca cnasogastric ctube cattached cto clow csuction cstates cthat cshe cis cnauseated. cThe cn
cbeen cno cdrainage cthrough cthe cnasogastric ctube cin cthe clast c2 chours. cWhich caction cshould cthe
A.
Irrigate cthe cnasogastric ctube cwith csterile cnormal csaline.
cB.
Reposition cthe cclient con cher cside.
cC.
Advance cthe cnasogastric ctube c5 ccm.
cD.
Administer can cintravenous cantiemetic cas cprescribed. c- cCORRECT cANS✔✔B
, Which cnursing caction cwould cbe cappropriate cfor ca cclient cwho cis cnewly cdiagnosed cwith cCushing
A.
Monitor cblood cglucose clevels cdaily.
cB.
Increase cintake cof cfluids chigh cin cpotassium.
cC.
Encourage cadequate crest cbetween cactivities.
cD.
Offer cthe cclient ca csodium-enriched cmenu. c- cCORRECT cANS✔✔A
Rationale:Cushing csyndrome cresults cfrom ca chypersecretion cof cglucocorticoids cin cthe cadrenal cc
csyndrome coften cdevelop cdiabetes cmellitus. cMonitoring cof cserum cglucose clevels cassesses cfor c
cso cthat ctreatment ccan cbegin cearly. cA ccommon cfinding cin cCushing csyndrome cis cgeneralized ce
cneeded, cit cis cgenerally cobtained cfrom cfood cintake, cnot cby coffering cpotassium-enhanced cfluids
coverwhelming cfactor cin cCushing csyndrome, cso can cemphasis con cthe cneed cfor crest cis cnot cindi
carbohydrate, clow-sodium cdiet cis cnot crecommended.
A c58-year-old cclient cwho chas cno chealth cproblems casks cthe cnurse cabout creceiving cthe cpneum
cstatement cgiven cby cthe cnurse cwould coffer cthe cclient caccurate cinformation cabout cthis cvaccine?
A.
The cvaccine cis cgiven cannually cbefore cthe cflu cseason cto cthose colder cthan c50 cyears.
cB.
The cimmunization cis cadministered conce cto colder cadults cor cthose cat crisk cfor cillness.
cC.
The cvaccine cis cfor call cages cand cis cgiven cprimarily cto cthose cpersons ctraveling coverseas cto care
cD.
The cvaccine cwill cprevent cthe coccurrence cof cpneumococcal cpneumonia cfor cup cto c5 cyears. c- cC
Rationale:It cis cusually crecommended cthat cpersons colder cthan c65 cyears cand cthose cwith ca chisto
creceive cthe cvaccine conce cin ctheir clifetime. cSome crecommend creceiving cthe cvaccine cat c50 cye
cvaccine cis cgiven conce ca cyear. cAlthough cthe cvaccine cmight cbe cgiven cto ca cperson ctraveling co
crationale cfor cadministering cthe cvaccine. cThe cvaccine cis cusually cgiven conce cin ca clifetime, cbut c
cclients cor cclients cwith ca chistory cof cpneumonia, crevaccination cis csometimes crequired.
A cclient cis cadmitted cto cthe chospital cwith csevere clower cleft cabdominal cpain, cnausea, cvomiting, c
cnursing caction chas cthe chighest cpriority?
A.
Place cthe cclient con cNPO cstatus.
cB.
Assess cthe cclient's ctemperature.
cC.
Obtain ca cstool cspecimen.
cD.
Administer cIV cfluids. c- cCORRECT cANS✔✔A
Rationale:A cclient cis cshowing csigns cof cacute csevere cdiverticulitis cand cis cat crisk cfor cperitonitis c
cnurse cshould cmake cthe cclient cNPO cto creduce crisk cof cintestinal crupture. cOptions cB, cC, cand cD
ca cpriority cthan coption cA, cwhich cis cimplemented cto cprevent ca csevere ccomplication.
A cclient con ctelemetry chas ca cpattern cof cuncontrolled catrial cfibrillation cwith ca crapid cventricular cre
cfinding, cthe cnurse canticipates cassisting cthe cphysician cwith cwhich ctreatment?
A.
Administer clidocaine, c75 cmg cintravenous cpush.
cB.
Perform csynchronized ccardioversion.
cC.
Defibrillate cthe cclient cas csoon cas cpossible.
