HESI RN MED SURG VERSION A & VERSION B ACTUAL EXAM
QUESTIONS AND ANSWERS LATEST AND COMPREHENSIVE
VERSION WITH VERIFIED ANSWERS GUARANTEED PASS WITH
INSTANT PDF DOWNLOAD.
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.
CORRECT ANS: B
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.
CORRECT 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
CORRECT 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?"
CORRECT 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
CORRECT 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
,CORRECT 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.
CORRECT 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.
CORRECT 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.
CORRECT ANS: A
, Rationale: Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal
cortex. Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of serum
glucose levels assesses for increased blood glucose levels so that treatment can begin early. A
common finding in Cushing syndrome is generalized edema. Although potassium is needed, it is
generally obtained from food intake, not by offering potassium-enhanced fluids. Fatigue is
usually not an overwhelming factor in Cushing syndrome, so an emphasis on the need for rest is
not indicated. A low-calorie, low-carbohydrate, low-sodium diet is not recommended.
A 58-year-old client who has no health problems asks the nurse about receiving the
pneumococcal vaccine. Which statement given by the nurse would offer the client accurate
information about this vaccine?
A. The vaccine is given annually before the flu season to those older than 50 years.
B. The immunization is administered once to older adults or those at risk for illness.
C. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas
of infection.
D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years.
CORRECT ANS: B
Rationale: It is usually recommended that persons older than 65 years and those with a history
of chronic illness should receive the vaccine once in their lifetime. Some recommend receiving
the vaccine at 50 years of age. The influenza vaccine is given once a year. Although the vaccine
might be given to a person traveling overseas, that is not the main rationale for administering
the vaccine. The vaccine is usually given once in a lifetime, but with immunosuppressed clients
or clients with a history of pneumonia, revaccination is sometimes required.
A client is admitted to the hospital with severe lower left abdominal pain, nausea, vomiting,
fever, and chills. Which nursing action has the highest priority?
A. Place the client on NPO status.
B. Assess the client's temperature.
C. Obtain a stool specimen.
D. Administer IV fluids.
CORRECT ANS: A
Rationale: A client is showing signs of acute severe diverticulitis and is at risk for peritonitis and
intestinal obstruction. The nurse should make the client NPO to reduce risk of intestinal rupture.
Options B, C, and D are important but are less of a priority than option A, which is implemented
to prevent a severe complication.
A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular
response. Based on this finding, the nurse anticipates assisting the physician with which
treatment?
A. Administer lidocaine, 75 mg intravenous push.
B. Perform synchronized cardioversion.
QUESTIONS AND ANSWERS LATEST AND COMPREHENSIVE
VERSION WITH VERIFIED ANSWERS GUARANTEED PASS WITH
INSTANT PDF DOWNLOAD.
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.
CORRECT ANS: B
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.
CORRECT 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
CORRECT 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?"
CORRECT 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
CORRECT 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
,CORRECT 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.
CORRECT 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.
CORRECT 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.
CORRECT ANS: A
, Rationale: Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal
cortex. Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of serum
glucose levels assesses for increased blood glucose levels so that treatment can begin early. A
common finding in Cushing syndrome is generalized edema. Although potassium is needed, it is
generally obtained from food intake, not by offering potassium-enhanced fluids. Fatigue is
usually not an overwhelming factor in Cushing syndrome, so an emphasis on the need for rest is
not indicated. A low-calorie, low-carbohydrate, low-sodium diet is not recommended.
A 58-year-old client who has no health problems asks the nurse about receiving the
pneumococcal vaccine. Which statement given by the nurse would offer the client accurate
information about this vaccine?
A. The vaccine is given annually before the flu season to those older than 50 years.
B. The immunization is administered once to older adults or those at risk for illness.
C. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas
of infection.
D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years.
CORRECT ANS: B
Rationale: It is usually recommended that persons older than 65 years and those with a history
of chronic illness should receive the vaccine once in their lifetime. Some recommend receiving
the vaccine at 50 years of age. The influenza vaccine is given once a year. Although the vaccine
might be given to a person traveling overseas, that is not the main rationale for administering
the vaccine. The vaccine is usually given once in a lifetime, but with immunosuppressed clients
or clients with a history of pneumonia, revaccination is sometimes required.
A client is admitted to the hospital with severe lower left abdominal pain, nausea, vomiting,
fever, and chills. Which nursing action has the highest priority?
A. Place the client on NPO status.
B. Assess the client's temperature.
C. Obtain a stool specimen.
D. Administer IV fluids.
CORRECT ANS: A
Rationale: A client is showing signs of acute severe diverticulitis and is at risk for peritonitis and
intestinal obstruction. The nurse should make the client NPO to reduce risk of intestinal rupture.
Options B, C, and D are important but are less of a priority than option A, which is implemented
to prevent a severe complication.
A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular
response. Based on this finding, the nurse anticipates assisting the physician with which
treatment?
A. Administer lidocaine, 75 mg intravenous push.
B. Perform synchronized cardioversion.
