HESI RN MED SURG VERSION A & VERSION B 2024-
2025 ACTUAL EXAM EACH EXAM CONTAINS 125
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.
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,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.
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,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.
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, 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.
© 2025 Get it right Stuvia US All rights reserved
2025 ACTUAL EXAM EACH EXAM CONTAINS 125
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.
© 2025 Get it right Stuvia US All rights reserved
,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.
© 2025 Get it right Stuvia US All rights reserved
,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.
© 2025 Get it right Stuvia US All rights reserved
, 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.
© 2025 Get it right Stuvia US All rights reserved
