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 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.: 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 hereditary implications for the development of COPD is still under
, 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
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.
3. In assessing a client diagnosed with primary aldosteronism, the nurse ex-
pects 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
, 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
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
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 tracheosto-
my 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
, 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
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, 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.
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
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 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.: 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 hereditary implications for the development of COPD is still under
, 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
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.
3. In assessing a client diagnosed with primary aldosteronism, the nurse ex-
pects 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
, 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
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
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 tracheosto-
my 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
, 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
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, 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.
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
