HESI RN MED SURG
VERSION A & VERSION B
2024-2026 ACTUAL EXAM
EACH EXAM CONTAINS
125 QUESTIONS AND
CORRECT DETAILED
ANSWERS
C
Terms in this set (125)
The nurse is assessing a client with acute B
pancreatitis. Which finding requires the most The nurse is assessing a client with acute
pancreatitis. Which immediate intervention by the nurse? finding requires the most immediate
intervention by the
A. nurse?
The client's amylase level is three times Rationale:A positive Trousseau sign indicates
hypocalcemia higher than the normal level. and always requires further assessment and intervention,
B. regardless of the cause (40% to 75% of those with
acute The client has a carpal spasm when taking a pancreatitis experience hypocalcemia, which
can have blood pressure. serious, systemic effects). A key diagnostic finding of
C. pancreatitis is serum amylase and lipase levels that are two to
On a 1 to 10 scale, the client tells the nurse five times higher than the normal value. Severe boring pain
is that her epigastric pain is at 7. an expected symptom for this diagnosis, but dealing with the
D. hypocalcemia is a priority over administering an
analgesic. The client states that she will continue to Long-term planning and teaching do not have
the same drink alcohol after going home. immediate importance as a positive Trousseau sign.
,A 55-year-old male client has been C
admitted to the hospital with a medical Rationale:Smoking, considered to be a modifiable risk
factor, diagnosis of chronic obstructive pulmonary is the most significant risk factor for the
development of disease (COPD). Which risk factor is the COPD. The exact mechanism of
genetic and hereditary
most significant in the development of this implications for the development of COPD is still under
client's COPD? investigation, although exposure to similar predisposing
A. factors (e.g., smoking or inhaling secondhand smoke) may
The client's father was diagnosed with increase the likelihood of COPD incidence among
family
COPD in his 50s. members. Options B and D do not exceed the risks associated
B. with cigarette smoking in the development of COPD.
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.
In assessing a client diagnosed with primary C
aldosteronism, the nurse expects the Rationale:Clients with primary aldosteronism exhibit a
laboratory test results to indicate a profound decline in serum levels of potassium;
hypokalemia; decreased serum level of which substance? hypertension is the most prominent and
universal sign. The
A. serum sodium level is normal or elevated, depending on the
Sodium amount of water resorbed with the sodium. Option B is
B. influenced by parathyroid hormone (PTH). Option D is not
Phosphate affected by primary
aldosteronism. C.
Potassium
D.
Glucose
The nurse is completing an admission C
interview for a client with Parkinson disease. Rationale:Clients with Parkinson disease frequently
Which question will provide additional experience difficulty in initiating, maintaining, and performing
information about manifestations that the motor activities. They may even experience being rooted
to client is likely to experience? the spot and unable to move. Parkinson disease does
not
A. typically cause option A, B, or D.
"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?"
,Client census is often used to determine C
staffing needs. Which method of obtaining Rationale:An average daily census is determined by trend
data census determination for a particular unit and takes into account seasonal and daily
fluctuations, so it is provides the best formula for determining the best method for determining staffing
needs. Options A long-range staffing patterns? and B provide data at a certain point in time, and
that data
A. could change quickly. It is unrealistic to expect to obtain an
Midnight census hourly census, and such data would only provide information
B. about a certain point in time.
Oncoming shift census
C.
Average daily census
D.
Hourly census
A male client has just undergone a B
laryngectomy and has a cuffed Rationale:The cuff should be inflated before the feeding to
tracheostomy tube in place. When initiating block the trachea and prevent food from entering if
oral bolus tube feedings postoperatively, when feedings are started while a cuffed tracheostomy
tube is in should the nurse inflate the cuff? place. It should remain inflated throughout the feeding to
A. prevent aspiration of food into the respiratory system. Options
Immediately after feeding A and D place the client at risk for aspiration. Option C places
B. the client at risk for tracheal wall necrosis.
Just prior to tube feeding
C.
Continuous inflation is required
D.
Inflation is not required
A client with a nasogastric tube attached to B
low suction states that she is nauseated. The Rationale:The immediate priority is to determine if
the tube is nurse assesses that there has been no functioning correctly, which would then relieve
the client's drainage through the nasogastric tube in the nausea. The least invasive intervention,
repositioning the
last 2 hours. Which action should the nurse client, should be attempted first, followed by options A and C,
take first? unless either of these interventions is contraindicated. If
these
A. measures are unsuccessful, the client may require option D.
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.
, The nurse is conducting an osteoporosis A, C, D
screening clinic at a health fair. What Rationale:Options A, C, and D are factors that decrease
the information should the nurse provide to risk for developing osteoporosis. Vitamin D and calcium
are individuals who are at risk for osteoporosis? important supplements to aid in the decrease of
bone loss. (Select all that apply.) Regular sleep patterns are important to overall health but
are
A. not identified with a decreasing risk for
osteoporosis. 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.
Which nursing action would be appropriate A
for a client who is newly diagnosed with Rationale:Cushing syndrome results from a hypersecretion
of Cushing syndrome? glucocorticoids in the adrenal cortex. Clients with
Cushing
A. syndrome often develop diabetes mellitus. Monitoring
of Monitor blood glucose levels daily. serum glucose levels assesses for increased blood glucose
B. levels so that treatment can begin early. A common finding
in Increase intake of fluids high in potassium. Cushing syndrome is generalized edema. Although
potassium
C. is needed, it is generally obtained from food intake, not
by Encourage adequate rest between activities. offering potassium-enhanced fluids. Fatigue is
usually not an
D. overwhelming factor in Cushing syndrome, so an emphasis
on Offer the client a sodium-enriched menu. 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 B
problems asks the nurse about receiving the Rationale:It is usually recommended that persons
older than pneumococcal vaccine. Which statement 65 years and those with a history of chronic illness
should given by the nurse would offer the client receive the vaccine once in their lifetime. Some
recommend accurate information about this vaccine? receiving the vaccine at 50 years of age. The
influenza vaccine
A. is given once a year. Although the vaccine might be given to
a The vaccine is given annually before the flu person traveling overseas, that is not the main
rationale for season to those older than 50 years. administering the vaccine. The vaccine is usually
given once in
B. a lifetime, but with immunosuppressed clients or clients with a
The immunization is administered once to history of pneumonia, revaccination is sometimes required.
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.
VERSION A & VERSION B
2024-2026 ACTUAL EXAM
EACH EXAM CONTAINS
125 QUESTIONS AND
CORRECT DETAILED
ANSWERS
C
Terms in this set (125)
The nurse is assessing a client with acute B
pancreatitis. Which finding requires the most The nurse is assessing a client with acute
pancreatitis. Which immediate intervention by the nurse? finding requires the most immediate
intervention by the
A. nurse?
The client's amylase level is three times Rationale:A positive Trousseau sign indicates
hypocalcemia higher than the normal level. and always requires further assessment and intervention,
B. regardless of the cause (40% to 75% of those with
acute The client has a carpal spasm when taking a pancreatitis experience hypocalcemia, which
can have blood pressure. serious, systemic effects). A key diagnostic finding of
C. pancreatitis is serum amylase and lipase levels that are two to
On a 1 to 10 scale, the client tells the nurse five times higher than the normal value. Severe boring pain
is that her epigastric pain is at 7. an expected symptom for this diagnosis, but dealing with the
D. hypocalcemia is a priority over administering an
analgesic. The client states that she will continue to Long-term planning and teaching do not have
the same drink alcohol after going home. immediate importance as a positive Trousseau sign.
,A 55-year-old male client has been C
admitted to the hospital with a medical Rationale:Smoking, considered to be a modifiable risk
factor, diagnosis of chronic obstructive pulmonary is the most significant risk factor for the
development of disease (COPD). Which risk factor is the COPD. The exact mechanism of
genetic and hereditary
most significant in the development of this implications for the development of COPD is still under
client's COPD? investigation, although exposure to similar predisposing
A. factors (e.g., smoking or inhaling secondhand smoke) may
The client's father was diagnosed with increase the likelihood of COPD incidence among
family
COPD in his 50s. members. Options B and D do not exceed the risks associated
B. with cigarette smoking in the development of COPD.
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.
In assessing a client diagnosed with primary C
aldosteronism, the nurse expects the Rationale:Clients with primary aldosteronism exhibit a
laboratory test results to indicate a profound decline in serum levels of potassium;
hypokalemia; decreased serum level of which substance? hypertension is the most prominent and
universal sign. The
A. serum sodium level is normal or elevated, depending on the
Sodium amount of water resorbed with the sodium. Option B is
B. influenced by parathyroid hormone (PTH). Option D is not
Phosphate affected by primary
aldosteronism. C.
Potassium
D.
Glucose
The nurse is completing an admission C
interview for a client with Parkinson disease. Rationale:Clients with Parkinson disease frequently
Which question will provide additional experience difficulty in initiating, maintaining, and performing
information about manifestations that the motor activities. They may even experience being rooted
to client is likely to experience? the spot and unable to move. Parkinson disease does
not
A. typically cause option A, B, or D.
"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?"
,Client census is often used to determine C
staffing needs. Which method of obtaining Rationale:An average daily census is determined by trend
data census determination for a particular unit and takes into account seasonal and daily
fluctuations, so it is provides the best formula for determining the best method for determining staffing
needs. Options A long-range staffing patterns? and B provide data at a certain point in time, and
that data
A. could change quickly. It is unrealistic to expect to obtain an
Midnight census hourly census, and such data would only provide information
B. about a certain point in time.
Oncoming shift census
C.
Average daily census
D.
Hourly census
A male client has just undergone a B
laryngectomy and has a cuffed Rationale:The cuff should be inflated before the feeding to
tracheostomy tube in place. When initiating block the trachea and prevent food from entering if
oral bolus tube feedings postoperatively, when feedings are started while a cuffed tracheostomy
tube is in should the nurse inflate the cuff? place. It should remain inflated throughout the feeding to
A. prevent aspiration of food into the respiratory system. Options
Immediately after feeding A and D place the client at risk for aspiration. Option C places
B. the client at risk for tracheal wall necrosis.
Just prior to tube feeding
C.
Continuous inflation is required
D.
Inflation is not required
A client with a nasogastric tube attached to B
low suction states that she is nauseated. The Rationale:The immediate priority is to determine if
the tube is nurse assesses that there has been no functioning correctly, which would then relieve
the client's drainage through the nasogastric tube in the nausea. The least invasive intervention,
repositioning the
last 2 hours. Which action should the nurse client, should be attempted first, followed by options A and C,
take first? unless either of these interventions is contraindicated. If
these
A. measures are unsuccessful, the client may require option D.
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.
, The nurse is conducting an osteoporosis A, C, D
screening clinic at a health fair. What Rationale:Options A, C, and D are factors that decrease
the information should the nurse provide to risk for developing osteoporosis. Vitamin D and calcium
are individuals who are at risk for osteoporosis? important supplements to aid in the decrease of
bone loss. (Select all that apply.) Regular sleep patterns are important to overall health but
are
A. not identified with a decreasing risk for
osteoporosis. 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.
Which nursing action would be appropriate A
for a client who is newly diagnosed with Rationale:Cushing syndrome results from a hypersecretion
of Cushing syndrome? glucocorticoids in the adrenal cortex. Clients with
Cushing
A. syndrome often develop diabetes mellitus. Monitoring
of Monitor blood glucose levels daily. serum glucose levels assesses for increased blood glucose
B. levels so that treatment can begin early. A common finding
in Increase intake of fluids high in potassium. Cushing syndrome is generalized edema. Although
potassium
C. is needed, it is generally obtained from food intake, not
by Encourage adequate rest between activities. offering potassium-enhanced fluids. Fatigue is
usually not an
D. overwhelming factor in Cushing syndrome, so an emphasis
on Offer the client a sodium-enriched menu. 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 B
problems asks the nurse about receiving the Rationale:It is usually recommended that persons
older than pneumococcal vaccine. Which statement 65 years and those with a history of chronic illness
should given by the nurse would offer the client receive the vaccine once in their lifetime. Some
recommend accurate information about this vaccine? receiving the vaccine at 50 years of age. The
influenza vaccine
A. is given once a year. Although the vaccine might be given to
a The vaccine is given annually before the flu person traveling overseas, that is not the main
rationale for season to those older than 50 years. administering the vaccine. The vaccine is usually
given once in
B. a lifetime, but with immunosuppressed clients or clients with a
The immunization is administered once to history of pneumonia, revaccination is sometimes required.
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.
