HESI RN MEDICAL SURGICAL
FINAL EXAM 2025 ACTUAL
EXAM COMPLETE 250
QUESTIONS WITH DETAILED
VERIFIED ANSWERS AND
RATIONALES (100% CORRECT
ANSWERS) /ALREADY GRADED
A+
The nurse is caring for a client with end stage liver
disease who is being assessed for the presence of
asterixis. To assess the client for asterixis, what
position should the nurse ask the client to
demonstrate?
A) Extend the left arm laterally with the left palm
upward.
B) Extend the arm, dorsiflex the wrist, and extend
the fingers.
,C) Extend the arms and hold this position for 30
seconds.
D) Extend arms with both legs adducted to shoulder
width. - ....ANSWER...B) Extend the arm, dorsiflex the
wrist, and extend the fingers.
Rationale: Asterixis (flapping tremor, liver flap) is a
hand-flapping tremor that is often seen frequently in
hepatic encephalopathy. The tremor is induced by
extending the arm and dorsiflexing the wrist causing
rapid, non-rhythmic extension and flexion of the
wrist while attempting to hold position (B). (A, C, and
D) do not illicit axterixis.
During the assessment of a client who is 24 hours
post-hemicolectomy with a temporary colostomy,
the nurse determines that the client's stoma is dry
and dark red in color. What action should the nurse
implement?
A) Notify the surgeon.
B) Document the assessment.
C) Secure a colostomy pouch over the stoma.
D) Place petrolatum gauze dressing over the stoma.
- ....ANSWER...A) Notify the surgeon.
,* The stoma should appear reddish pink and moist,
which indicates circulatory perfusion to the surgical
diversion of the intestine. If the stoma becomes dry,
firm, flaccid, or is dark red or purple, the stoma is
ischemic, and the surgeon should be notified
immediately (A). Although (B, C, and D) may be
implemented, the findings require immediate
medical attention.
What assessment finding should the nurse identify
that indicates a client with an acute asthma
exacerbation is beginning to improve after
treatment?
A) Wheezing becomes louder.
B) Cough remains unproductive.
C) Vesicular breath sounds decrease.
D) Bronchodilators stimulate coughing. -
....ANSWER...A) Wheezing becomes louder.
* In an acute asthma attack, air flow may be so
significantly restricted that wheezing is diminished.
If the client is successfully responding to
bronchodilators and respiratory treatments,
, wheezing becomes louder (A) as air flow increases
in the airways. As the airways open and mucous is
mobilized in response to treatment, the cough
becomes more productive, not (B). Vesicular sounds
are soft, low-pitched, gentle, rustling sounds heard
over lung fields (C) and is not an indicator of
improvement during asthma treatment.
Bronchodilators do not stimulate coughing (D).
A client is admitted to the emergency department
after being lost for four days while hiking in a
national forest. Upon review of the laboratory
results, the nurse determines the client's serum
level for thyroid-stimulating hormone (TSH) is
elevated. Which additional assessment should the
nurse make?
A) Body mass index.
B) Skin elasticity and turgor.
C) Thought processes and speech.
D) Exposure to cold environmental temperatures. -
....ANSWER...D) Exposure to cold environmental
temperatures.
FINAL EXAM 2025 ACTUAL
EXAM COMPLETE 250
QUESTIONS WITH DETAILED
VERIFIED ANSWERS AND
RATIONALES (100% CORRECT
ANSWERS) /ALREADY GRADED
A+
The nurse is caring for a client with end stage liver
disease who is being assessed for the presence of
asterixis. To assess the client for asterixis, what
position should the nurse ask the client to
demonstrate?
A) Extend the left arm laterally with the left palm
upward.
B) Extend the arm, dorsiflex the wrist, and extend
the fingers.
,C) Extend the arms and hold this position for 30
seconds.
D) Extend arms with both legs adducted to shoulder
width. - ....ANSWER...B) Extend the arm, dorsiflex the
wrist, and extend the fingers.
Rationale: Asterixis (flapping tremor, liver flap) is a
hand-flapping tremor that is often seen frequently in
hepatic encephalopathy. The tremor is induced by
extending the arm and dorsiflexing the wrist causing
rapid, non-rhythmic extension and flexion of the
wrist while attempting to hold position (B). (A, C, and
D) do not illicit axterixis.
During the assessment of a client who is 24 hours
post-hemicolectomy with a temporary colostomy,
the nurse determines that the client's stoma is dry
and dark red in color. What action should the nurse
implement?
A) Notify the surgeon.
B) Document the assessment.
C) Secure a colostomy pouch over the stoma.
D) Place petrolatum gauze dressing over the stoma.
- ....ANSWER...A) Notify the surgeon.
,* The stoma should appear reddish pink and moist,
which indicates circulatory perfusion to the surgical
diversion of the intestine. If the stoma becomes dry,
firm, flaccid, or is dark red or purple, the stoma is
ischemic, and the surgeon should be notified
immediately (A). Although (B, C, and D) may be
implemented, the findings require immediate
medical attention.
What assessment finding should the nurse identify
that indicates a client with an acute asthma
exacerbation is beginning to improve after
treatment?
A) Wheezing becomes louder.
B) Cough remains unproductive.
C) Vesicular breath sounds decrease.
D) Bronchodilators stimulate coughing. -
....ANSWER...A) Wheezing becomes louder.
* In an acute asthma attack, air flow may be so
significantly restricted that wheezing is diminished.
If the client is successfully responding to
bronchodilators and respiratory treatments,
, wheezing becomes louder (A) as air flow increases
in the airways. As the airways open and mucous is
mobilized in response to treatment, the cough
becomes more productive, not (B). Vesicular sounds
are soft, low-pitched, gentle, rustling sounds heard
over lung fields (C) and is not an indicator of
improvement during asthma treatment.
Bronchodilators do not stimulate coughing (D).
A client is admitted to the emergency department
after being lost for four days while hiking in a
national forest. Upon review of the laboratory
results, the nurse determines the client's serum
level for thyroid-stimulating hormone (TSH) is
elevated. Which additional assessment should the
nurse make?
A) Body mass index.
B) Skin elasticity and turgor.
C) Thought processes and speech.
D) Exposure to cold environmental temperatures. -
....ANSWER...D) Exposure to cold environmental
temperatures.
