HESI RN MED SURG VERSION A & VERSION B ACTUAL
EXAM EACH EXAM CONTAINS 125 QUESTIONS AND
CORRECT DETAILED ANSWERS| GUARANTEE PASS AND
100% ACCURATE| LATEST EXAM AND BRAND NEW
VERSION!!!
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
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 resident in a long-term care facility is diagnosed with hepatitis B. Which action
should the nurse take with the staff caring for this client?
A.
Determine if all employees have had the hepatitis B vaccine series.
B.
Explain that this type of hepatitis can be transmitted when feeding the client.
C.
,Assure the employees that they cannot contract hepatitis B when providing
direct care.
D.
Tell the employees that wearing gloves and a gown are required when providing
all care.
ANSWER: A
Rationale:Hepatitis B vaccine should be administered to all health care
providers. Hepatitis A(not hepatitis B) can be transmitted by fecal-oral
contamination. There is a chance that staff could contract hepatitis B if exposed
to the client's blood and/or body fluids; therefore, option C is incorrect. There is
no need to wear gloves and gowns except with blood or body fluid contact.
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
D.
Inflation is not required
ANSWER: 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.
ANSWER: 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
EXAM EACH EXAM CONTAINS 125 QUESTIONS AND
CORRECT DETAILED ANSWERS| GUARANTEE PASS AND
100% ACCURATE| LATEST EXAM AND BRAND NEW
VERSION!!!
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
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 resident in a long-term care facility is diagnosed with hepatitis B. Which action
should the nurse take with the staff caring for this client?
A.
Determine if all employees have had the hepatitis B vaccine series.
B.
Explain that this type of hepatitis can be transmitted when feeding the client.
C.
,Assure the employees that they cannot contract hepatitis B when providing
direct care.
D.
Tell the employees that wearing gloves and a gown are required when providing
all care.
ANSWER: A
Rationale:Hepatitis B vaccine should be administered to all health care
providers. Hepatitis A(not hepatitis B) can be transmitted by fecal-oral
contamination. There is a chance that staff could contract hepatitis B if exposed
to the client's blood and/or body fluids; therefore, option C is incorrect. There is
no need to wear gloves and gowns except with blood or body fluid contact.
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
D.
Inflation is not required
ANSWER: 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.
ANSWER: 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
