HESI RN MED SURG VERSION A & VERSION B 2024-2025
ACTUAL EXAM EACH EXAM CONTAINS 125 QUESTIONS
AND CORRECT DETAILED ANSWERS AND RATIONALES
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.
1
,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?
2
,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.
3
, 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 intervention, repositioning
the client, should be attempted first, followed by options A and C, unless either of these
4
ACTUAL EXAM EACH EXAM CONTAINS 125 QUESTIONS
AND CORRECT DETAILED ANSWERS AND RATIONALES
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.
1
,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?
2
,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.
3
, 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 intervention, repositioning
the client, should be attempted first, followed by options A and C, unless either of these
4
