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HESI MED SURG TESTBANK 2025 LATEST
REAL QUESTIONS AND CORRECT
ANSWERS GRADE A
Based on the clinical manifestations of Cushing syndrome, which nursing intervention would be appropriate for a client who is newly diagnosed with Cushing syndrome? A. Monitor blood glucose levels daily. B. Increase intake of fluids high in potassium. C. Encourage adequate rest between activities. D. Offer the client a sodium-enriched menu. - CORRECT ANSWER A. Monitor Blood Glucose Levels Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of serum glucose levels assesses for increased blood glucose levels so that treatment can begin early. A common finding in Cushing syndrome is generalized edema. Although potassium is needed, it is generally obtained from food intake, not by offering potassium-enhanced fluids. Fatigue is usually not an overwhelming factor in Cushing syndrome, so an emphasis on the need for rest is not indicated A low-calorie, low-carbohydrate, low-sodium diet is not recommended. The nurse is assessing a male 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.While the nurse is taking the client's blood pressure, he has a carpal spasm. C.On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7. D.The client states that he will continue to drink alcohol after going home. - CORRECT ANSWER B.While the nurse is taking the client's blood pressure, he has a carpal spasm. 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. 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?" - CORRECT ANSWER C. Have you ever been frozen in one spot, unable to move?" 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.
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 observing an unlicensed assistive personnel (UAP) performing morning care for a bedridden client with Huntington disease. Which care measure is most important for the nurse to supervise? A. Oral care B.Bathing C. Foot care D. Catheter care - CORRECT ANSWER A. Oral care Rationale: The client with Huntington disease experiences problems with motor skills such as swallowing and is at high risk for aspiration, so the highest priority for the nurse to observe is the UAP's ability to perform oral care safely. Options B, C, and D do not necessarily require registered nurse (RN) supervision because they do not ordinarily pose life-threatening consequences. A client who is receiving an angiotensin-converting enzyme (ACE) inhibitor for hypertension calls the clinic and reports the recent onset of a cough to the nurse. Which action should the nurse implement? A. Advise the client to come to the clinic immediately for further assessment. B. Instruct the client to discontinue use of the drug and to make an appointment at the clinic.
C. Suggest that the client learn to accept the cough as a side effect to a necessary prescription. D. Encourage the client to keep taking the drug until seen by the health care provider. - CORRECT ANSWER D. Encourage the client to keep taking the drug until seen by the health care provider. Rationale: Coughing is a common side effect of ACE inhibitors and is not an indication to discontinue the medication. Immediate evaluation is not needed. Antihypertensive medications should not be stopped abruptly because rebound hypertension may occur. Option C is demeaning because the cough may be very disruptive to the client, and other antihypertensive medications may produce the desired effect without the adverse effect. When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN? A. A young adult with bacterial meningitis with recent seizures B. An older adult client with pneumonia and viral meningitis C. A female client in isolation with meningococcal meningitis D. A male client 1 day postoperative after drainage of a brain abscess - CORRECT ANSWER B. An older adult client with pneumonia and viral meningitis Rationale: The most stable client is option B. Options A, C, and D are all at high risk for increased intracranial pressure and require the expertise of the RN for assessment and management of care. 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
A.Administer the prescribed dose at the scheduled time. B.Hold the dose and contact the health care provider. C.Hold the dose and recheck the blood pressure in 1 hour. D.Check the health care provider's prescription to clarify the dose. - CORRECT ANSWER A. Administer the prescribed dose at the scheduled time Rationale: The client's blood pressure is within normal limits, indicating that the ramipril, an antihypertensive, is having the desired effect and should be administered. Options B and C would be appropriate if the client's blood pressure was excessively low (<100 mm Hg systolic) or if the client were exhibiting signs of hypotension such as dizziness. This prescribed dose is within the normal dosage range, as defined by the manufacturer; therefore, option D is not necessary. Which consideration is most important when the nurse is assigning a room for a client being admitted with progressive systemic sclerosis (scleroderma)? A.Provide a room that can be kept warm. B.Make sure that the room can be kept dark. C.Keep the client close to the nursing unit. D.Select a room that is visible from the nurses' desk. - CORRECT ANSWER A.Provide a room that can be kept warm. Rationale: Abnormal blood flow in response to cold (Raynaud phenomenon) is precipitated in clients with scleroderma. Option B is not a significant factor. Stress can also precipitate the severe pain of Raynaud phenomenon, so a quiet environment is preferred to option C, which is often very noisy. Option D is not necessary.
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 - CORRECT ANSWER B. Just prior to tube feeding 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 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. - CORRECT ANSWER C. The client smokes one to two packs of cigarettes per day. 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
A.Increase the ventilator VT to 850 mL. B.Decrease the ventilator IMV to a rate of 8 breaths/min. C. Reduce the FiO2 to 0.70 and redraw ABGs. D.Add 5 cm positive end-expiratory pressure (PEEP). - CORRECT ANSWER D. Add 5 cm positive end-expiratory pressure (PEEP). Rationale: Adding PEEP helps improve oxygenation while reducing FiO2 to a less toxic level. Options A, B, and C will not result in improved oxygenation and could cause further complications for this client, who is experiencing respiratory failure. The nurse is administering a nystatin suspension for stomatitis. Which instruction will the nurse provide to the client when administering this medication? A."Hold the medication in your mouth for a few minutes before swallowing it." B. "Do not drink or eat milk products for 1 hour prior to taking this medication." C. "Dilute the medication with juice to reduce the unpleasant taste and odor." D. "Take the medication before meals to promote increased absorption." - CORRECT ANSWER A."Hold the medication in your mouth for a few minutes before swallowing it." Rationale: Nystatin suspension is prescribed for fungal infections of the mouth. The client should swish the medication in the mouth for 2 minutes and then swallow. Option B does not affect administration of this medication. The medication should not be diluted because this will reduce its effectiveness. Option D is not necessary. 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 - CORRECT ANSWER B. Deep unrelenting pain in the right arm 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. A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing pressure ulcers. Which physical characteristic of aging puts the client at risk? A.16% increase in overall body fat B.Reduced melanin production C.Thinning of the skin, with loss of elasticity D.Calcium loss in the bones - CORRECT ANSWER C.Thinning of the skin, with loss of elasticity Rationale: Thin nonelastic skin is an important factor in pressure formation. The proportion of body fat to lean mass increases with age and might help decrease ulcer tendency. Option B causes gray hair. Option D can contribute to broken bones, but it is probably not a factor in pressure ulcer formation.
Option A indicates disease progression but is not a side effect of the medication. Option C is not related to methotrexate. Option D indicates that inflammation associated with the disease has diminished. Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)? A.Tinnitus, vertigo, and hearing difficulties B.Sudden, stabbing, severe pain over the lip and chin C.Unilateral facial weakness and paralysis D.Difficulty in chewing, talking, and swallowing - CORRECT ANSWER B.Sudden, stabbing, severe pain over the lip and chin Rationale: Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (cranial V). Option A would be characteristic of Ménière syndrome (cranial nerve VIII). Option C would be characteristic of Bell palsy (cranial nerve VII). Option D would be characteristic of disorders of the hypoglossal (cranial nerve XII). An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked and his eyeballs appear sunken into his head. Which nursing intervention is indicated? A.Help the client determine ways to increase his fluid intake. B.Obtain an appointment for the client to have an eye examination. C.Instruct the client to use oxygen at night and increase the humidification.
D.Schedule the client for tests to determine his sensitivity to cat hair. - CORRECT ANSWER A.Help the client determine ways to increase his fluid intake. Rationale: Clients with COPD should ingest 3 L of fluids daily but may experience a fluid deficit because of shortness of breath. The nurse should suggest creative methods to increase the intake of fluids, such as having fruit juices in disposable containers readily available. Option B is not indicated. Humidified oxygen will not effectively treat the client's fluid deficit, and there is no indication that the client needs supplemental oxygen at night. These symptoms are not indicative of option D and may unnecessarily upset the client, who depends on his pet for socialization. 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 intervention should the nurse implement? 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. - CORRECT ANSWER C.Document the presence of these assessment findings 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.
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 - CORRECT ANSWER C.Average daily census 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 hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first? A.Auscultate the client's breath sounds. B.Turn off the continuous feeding pump. C.Check placement of the nasogastric tube. D.Measure the amount of residual feeding. - CORRECT ANSWER B.Turn off the continuous feeding pump. Rationale: A productive cough may indicate that the feeding has been aspirated. The nurse should first stop the feeding to prevent further aspiration. Options A, C, and D
should all be performed before restarting the tube feeding if no evidence of aspiration is present and the tube is in place. The nurse is caring for a client who is one day post-acute myocardial infarction. The client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral saline lock. The nurse notes that the client is having eight premature ventricular contractions (PVCs) per minute. Which intervention should the nurse implement first? A.Obtain an IV pump for antiarrhythmic infusion. B.Increase the client's oxygen flow rate. C.Prepare for immediate countershock. D.Gather equipment for endotracheal intubation. - CORRECT ANSWER B.Increase the client's oxygen flow rate. Rationale: Increasing the oxygen flow rate provides more oxygen to the client's myocardium and may decrease myocardial irritability as manifested by the frequent PVCs. Option A can be delegated and is a lower priority action than option B. Defibrillation may eventually be necessary, but option C is not the immediate treatment for frequent PVCs. Option D may become necessary if the client stops breathing but is not indicated at this time. 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.
The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect? A.Increased serum albumin level B.Decreased serum creatinine C.Decreased serum ammonia level D.Increased liver function test results - CORRECT ANSWER C.Decreased serum ammonia level Rationale: The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia. Options A, B, and D will not be significantly affected by the removal of blood. During assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear on auscultation, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement? A.Prepare the client for a pericardial tap. B.Administer intravenous furosemide (Lasix). C.Assist the client to cough and breathe deeply. D.Instruct the client to restrict oral fluid intake. - CORRECT ANSWER A.Prepare the client for a pericardial tap. Rationale: The client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the pericardial sac that results in a reduction in cardiac output, which is a potentially
fatal complication of pericarditis. Treatment for tamponade is a pericardial tap. Lasix IV is not indicated for treatment of pericarditis. Because the client's breath sounds are clear, option C is not a priority. Fluids are frequently increased in the initial treatment of tamponade to compensate for the decrease in cardiac output, but this is not the same priority as option A. During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first? A.Review the client's history for diabetes mellitus. B.Observe the extremity distal to the IV site C.Monitor the client's serum potassium and blood glucose levels. D.Evaluate the client's oxygen saturation and breath sounds. - CORRECT ANSWER C.Monitor the client's serum potassium and blood glucose levels. Rationale: Clients with tumor lysis syndrome may experience hyperkalemia, requiring the addition of insulin to the IV solution to reduce the serum potassium level. It is most important for the nurse to monitor the client's serum potassium and blood glucose levels to ensure that they are not at dangerous levels. Options A, B, and D provide valuable assessment data but are of less priority than option C. The nurse is giving preoperative instructions to a 14-year-old client scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place? A."I will read all the teaching booklets you gave me before surgery." B."I have had surgery before, so I know what to expect afterward."
