HESI RN MED SURG VERSION A &
VERSION B 2025 REAL EXAM WITH
QUESTIONS AND VERIFIED ANSWERS
GRADED A+
The home health nurse is assessing a male client being treated for Parkinson
disease with carbidopa-levodopa. The nurse observes that he does not
demonstrate any apparent emotion when speaking and rarely blinks. Which
action should the nurse take first?
A.
Perform a complete cranial nerve assessment.
B.
Instruct the client that he may be experiencing medication toxicity.
C.
Document the presence of these assessment findings.
D.
Advise the client to seek immediate medical evaluation.
C
Rationale:A masklike expression and infrequent blinking are common clinical
features of parkinsonism. The nurse should document these expected findings.
Options A and D are not necessary. Signs of toxicity of levodopa-carbidopa include
dyskinesia, hallucinations, and psychosis.
A 77-year-old client is admitted to the hospital with confusion and anorexia of
several days' duration. Additional symptoms reported are nausea and
vomiting, and current complaints of a headache. The client's pulse rate is 43
beats/min. The nurse is most concerned about the client's history related to
which medication?
A.
Warfarin
B.
Ibuprofen
,C.
Nitroglycerin
D.
Digoxin
D
Rationale:Older persons are particularly susceptible to the buildup of cardiac
glycosides, such as digoxin or digitoxin (medications derived from digitalis), to a toxic
level in their systems. Toxicity can cause anorexia, nausea, vomiting, diarrhea,
headache, and fatigue. Options A, B, and C are unlikely to result in the symptoms
described.
The nurse is caring for a client with a fractured right elbow. Which assessment
finding has the highest priority and requires immediate intervention?
A.
Ecchymosis over the right elbow area
B.
Deep unrelenting pain in the right arm
C.
An edematous right elbow
D.
The presence of crepitus in the right elbow
B
Rationale:Compartment syndrome is a condition involving increased pressure and
constriction of the nerves and vessels within an anatomic compartment, causing pain
uncontrolled by opioids and neurovascular compromise. Option A is an expected
finding. Option C related to compartment syndrome cannot be seen, and any visible
edema is an expected finding related to the injury. Option D is an expected finding.
The clinic nurse is providing post-operative teaching for a client scheduled for
a myringoplasty. Which client statements indicate to the nurse that the
teaching has been effective? (Select all that apply.)
A.
"I can wash my hair in the shower when I get home."
B.
"I will avoid forceful and deep coughing until my post-op checkup."
C.
,"I must lay flat on my non-operative side for the first 12 hours after surgery."
D.
"My hearing may be less or muffled until the packing comes out."
E.
"I need to only take the first two doses of antibiotics and save the rest for
another time."
B, C, D
Rationale:The client must keep the ear bandage clean and dry until the packing is
removed. Showering and hair washing is discouraged. As with all prescriptions for
antibiotics, the client must take the full course of treatment. The remaining client
statements do indicate effective teaching.
The nurse is performing a skin assessment on a client who is transferred from
a long-term care facility to an in-patient hospital unit. The client is unable to
move independently while in bed. The nurse observes reddened areas to the
sacrum and on the heals bilaterally. What is the next nursing action?
A.
Document the size and shape of the reddened areas.
B.
Massage the reddened areas with a hospital-approved lotion.
C.
Call the nurse from the transferring facility to determine the client's baseline.
D.
Culture the wounds.
A
Rationale:The nurse must document any pressure wounds upon admission to
establish the client's baseline and for insurance purposes. Insurance will not
reimburse from hospital-acquired pressure ulcers. Massaging is not recommended
as it may dislodge the existing tissue. A call is not a good use of the nurse's time as
the pressure ulcers exist upon transfer, and the baseline is determined upon
admission. The health care provider will order cultures, if needed.
A client with type 2 diabetes takes metformin daily. The client is scheduled for
major surgery requiring general anesthesia the next day. The nurse anticipates
which approach to manage the client's diabetes best while the client is NPO
during the perioperative period?
, A.
NPO except for metformin and regular snacks
B.
NPO except for oral antidiabetic agent
C.
Novolin N insulin subcutaneously twice daily
D.
Regular insulin subcutaneously per sliding scale
D
Rationale:Regular insulin dosing based on the client's blood glucose levels (sliding
scale) is the best method to achieve control of the client's blood glucose while the
client is NPO and coping with the major stress of surgery. Option A increases the
risk of vomiting and aspiration. Options B and C provide less precise control of the
blood glucose level.
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
VERSION B 2025 REAL EXAM WITH
QUESTIONS AND VERIFIED ANSWERS
GRADED A+
The home health nurse is assessing a male client being treated for Parkinson
disease with carbidopa-levodopa. The nurse observes that he does not
demonstrate any apparent emotion when speaking and rarely blinks. Which
action should the nurse take first?
A.
Perform a complete cranial nerve assessment.
B.
Instruct the client that he may be experiencing medication toxicity.
C.
Document the presence of these assessment findings.
D.
Advise the client to seek immediate medical evaluation.
C
Rationale:A masklike expression and infrequent blinking are common clinical
features of parkinsonism. The nurse should document these expected findings.
Options A and D are not necessary. Signs of toxicity of levodopa-carbidopa include
dyskinesia, hallucinations, and psychosis.
A 77-year-old client is admitted to the hospital with confusion and anorexia of
several days' duration. Additional symptoms reported are nausea and
vomiting, and current complaints of a headache. The client's pulse rate is 43
beats/min. The nurse is most concerned about the client's history related to
which medication?
A.
Warfarin
B.
Ibuprofen
,C.
Nitroglycerin
D.
Digoxin
D
Rationale:Older persons are particularly susceptible to the buildup of cardiac
glycosides, such as digoxin or digitoxin (medications derived from digitalis), to a toxic
level in their systems. Toxicity can cause anorexia, nausea, vomiting, diarrhea,
headache, and fatigue. Options A, B, and C are unlikely to result in the symptoms
described.
The nurse is caring for a client with a fractured right elbow. Which assessment
finding has the highest priority and requires immediate intervention?
A.
Ecchymosis over the right elbow area
B.
Deep unrelenting pain in the right arm
C.
An edematous right elbow
D.
The presence of crepitus in the right elbow
B
Rationale:Compartment syndrome is a condition involving increased pressure and
constriction of the nerves and vessels within an anatomic compartment, causing pain
uncontrolled by opioids and neurovascular compromise. Option A is an expected
finding. Option C related to compartment syndrome cannot be seen, and any visible
edema is an expected finding related to the injury. Option D is an expected finding.
The clinic nurse is providing post-operative teaching for a client scheduled for
a myringoplasty. Which client statements indicate to the nurse that the
teaching has been effective? (Select all that apply.)
A.
"I can wash my hair in the shower when I get home."
B.
"I will avoid forceful and deep coughing until my post-op checkup."
C.
,"I must lay flat on my non-operative side for the first 12 hours after surgery."
D.
"My hearing may be less or muffled until the packing comes out."
E.
"I need to only take the first two doses of antibiotics and save the rest for
another time."
B, C, D
Rationale:The client must keep the ear bandage clean and dry until the packing is
removed. Showering and hair washing is discouraged. As with all prescriptions for
antibiotics, the client must take the full course of treatment. The remaining client
statements do indicate effective teaching.
The nurse is performing a skin assessment on a client who is transferred from
a long-term care facility to an in-patient hospital unit. The client is unable to
move independently while in bed. The nurse observes reddened areas to the
sacrum and on the heals bilaterally. What is the next nursing action?
A.
Document the size and shape of the reddened areas.
B.
Massage the reddened areas with a hospital-approved lotion.
C.
Call the nurse from the transferring facility to determine the client's baseline.
D.
Culture the wounds.
A
Rationale:The nurse must document any pressure wounds upon admission to
establish the client's baseline and for insurance purposes. Insurance will not
reimburse from hospital-acquired pressure ulcers. Massaging is not recommended
as it may dislodge the existing tissue. A call is not a good use of the nurse's time as
the pressure ulcers exist upon transfer, and the baseline is determined upon
admission. The health care provider will order cultures, if needed.
A client with type 2 diabetes takes metformin daily. The client is scheduled for
major surgery requiring general anesthesia the next day. The nurse anticipates
which approach to manage the client's diabetes best while the client is NPO
during the perioperative period?
, A.
NPO except for metformin and regular snacks
B.
NPO except for oral antidiabetic agent
C.
Novolin N insulin subcutaneously twice daily
D.
Regular insulin subcutaneously per sliding scale
D
Rationale:Regular insulin dosing based on the client's blood glucose levels (sliding
scale) is the best method to achieve control of the client's blood glucose while the
client is NPO and coping with the major stress of surgery. Option A increases the
risk of vomiting and aspiration. Options B and C provide less precise control of the
blood glucose level.
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
