HESI-RN Med-Surg Test, MED
SURG HESI V 2025/2026
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. -
ANSWER-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. - ANSWER-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 - ANSWER-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?" - ANSWER-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 - ANSWER-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
SURG HESI V 2025/2026
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. -
ANSWER-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. - ANSWER-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 - ANSWER-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?" - ANSWER-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 - ANSWER-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
