HESI RN MED SURG VERSION A & VERSION B 2023-2024 ACTUAL EXAM EACH EXAM CONTAINS 55
QUESTIONS AND CORRECT DETAILED ANSWERS
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
,HESI RN MED SURG VERSION A & VERSION B 2023-2024 ACTUAL EXAM EACH EXAM CONTAINS 55
QUESTIONS AND CORRECT DETAILED ANSWERS
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
,HESI RN MED SURG VERSION A & VERSION B 2023-2024 ACTUAL EXAM EACH EXAM CONTAINS 55
QUESTIONS AND CORRECT DETAILED ANSWERS
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
, HESI RN MED SURG VERSION A & VERSION B 2023-2024 ACTUAL EXAM EACH EXAM CONTAINS 55
QUESTIONS AND CORRECT DETAILED ANSWERS
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 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.
QUESTIONS AND CORRECT DETAILED ANSWERS
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
,HESI RN MED SURG VERSION A & VERSION B 2023-2024 ACTUAL EXAM EACH EXAM CONTAINS 55
QUESTIONS AND CORRECT DETAILED ANSWERS
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
,HESI RN MED SURG VERSION A & VERSION B 2023-2024 ACTUAL EXAM EACH EXAM CONTAINS 55
QUESTIONS AND CORRECT DETAILED ANSWERS
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
, HESI RN MED SURG VERSION A & VERSION B 2023-2024 ACTUAL EXAM EACH EXAM CONTAINS 55
QUESTIONS AND CORRECT DETAILED ANSWERS
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 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.
