HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
An ER nurse is completing an assess-
A) A carotid bruit.
ment on a patient that is alert but strug-
gles to answer questions. When she at-
Rationale: the carotid artery (artery to
tempts to talk, she slurs her speech and
the brain) is narrowed in clients with
appears very frightened. What addition-
a brain attack. A bruit is an abnormal
al clinical manifestation does the nurse
sound heard on auscultation resulting
expect to find if nacy's sysmptoms have
from interference with normal blood flow.
been caused by a brain attack (stroke)?
Usually the blood pressure is hyperten-
sive. Initially flaccid paralysis occurs, re-
A. A carotid bruit
sulting in hyporefkexic deep tendon re-
B. A hypotensive blood pressure
flexes. Bowel sounds are not indicative of
C. hyperreflexic deep tendon relexes.
a brain attack.
D. Decreased bowel sounds
D) Global aphasia.
Which clinical manifestation further sup-
Rationale: Global aphasia refers to dif-
ports an assessment of a left-sided brain
ficulty speaking, listening, and under-
attack?
standing, as well as difficulty reading and
writing. Symptoms vary from person to
A) Visual field deficit on the left side.
person. Aphasia may occur secondary to
B) Spatial-perceptual deficits.
any brain injury involving the left hemi-
C) Paresthesia of the left side.
sphere. Visual field deficits, spatial-per-
D) Global aphasia.
ceptual deficits, and paresthsia of the left
D) Global aphasia.
side usually occur with right-sided brain
attack.
B) Explain that the client will not be able
When preparing a patient for a noncon-
to move her head throughout the CT
trast computed tomography (CT) scan
scan.
STAT, what nursing intervention should
the nurse implement?
Rationale: Because head motion will dis-
tort the images, Nancy will have to re-
A) Determine if the client has any aller-
main still throughout the procedure. Al-
gies to iodine
lergies to iodine is important if contrast
B) Explain that the client will not be able
dye is being used for the CT scan. Pre-
to move her head throughout the CT
medicating the client to decrease pain
scan.
prior to the procedure is unnecessary be-
C) Premedicate the client to decrease
cause CT scanning is a noninvasive and
pain prior to having the procedure.
painless procedure. Providing an expla-
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
nation of relaxation exercises prior to the
D) Provide an explanation of relaxation procedure is a worthwhile intervention to
exercises prior to the procedure. decrease anxiety but is not of highest
priority.
A neurologist prescribes a magnetic res- C) Right hip replacement.
onance imaging (MRI) of the head STAT
for a patient. Which data warrants imme- The magnetic field generated by the MRI
diate intervention by the nurse concern- is so strong that metal-containing items
ing this diagnostic test? are strongly attracted to the magnet. Be-
cause the hip joint is made of metal,
A) Elevated blood pressure. a lead shield must be used during the
B) Allergy to shell fish. procedure. Elevated blood pressure, an
C) Right hip replacement. allergy to shell fish, and a history of atrial
D) History of atrial fibrillation. fibrillation would not affect the MRI.
A client's daughter is sitting by her moth-
er's bedside who was recently trans-
ferred to the Intermediate Care Unit. She
states "I don't understand what a brain
attack is. The healthcare provider told me
B) "Your mother has had a stroke, and
my mother is in serious condition and
the blood supply to the brain has been
they are going to run several tests. I just
blocked."
don't know what is going on. What hap-
pened to my mother?" What is the best
Rationale: The nurse can discuss what
response by the nurse?
a diagnosis means. Nancy is unable to
make decisions, so the next of kin, her
A) "I am sorry, but according to the
daughter, Gail, needs sufficient informa-
Health Insurance Portability and Ac-
tion to make informed decisions. The
counting Act (HIPAA), I cannot give you
nurse has the knowledge, and the re-
any information."
sponsibility, to explain Nancy's condition
B) "Your mother has had a stroke, and
to Gail. The nurse should give facts first,
the blood supply to the brain has been
and then address her feelings after the
blocked."
information is provided.
C) "How do you feel about what the
healthcare provider said?"
D) "I will call the healthcare provider so
he/she can talk to you about your moth-
er's serious condition."
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
The normal range for cardiac output to
What is the normal range for cardiac out-
ensure cerebral blood flow and oxygen
put?
delivery is 4 to 8 L/min.
A client was admitted with the diagnosis Thrombolytic therapy is contraindicated
of a brain attack. Their symptoms be- in clients with symptom onset longer than
gan 24 hours before being admitted. Why 3 hours prior to admission. This client
would this client not be a candidate for had symptoms for 24 hours before being
for thrombolytic therapy? brought to the medical center
Plate guards prevent food from being
pushed off the plate. Using plate guards
What are plate guards? and other assistive devices will encour-
age independence in a client with a
self-care deficit.
D) Advanced age.
Which condition is considered a
non-modifiable risk factor for a brain at- Rationale: People over age 55 are a
tack? high-risk group for a brain attack be-
cause the incidence of stroke more than
A) High cholesterol levels. doubles in each successive decade of
B) Obesity. life. Non-modifiable means the client can-
C) History of atrial fibrillation. not do anything to change the risk factor.
D) Advanced age. All the other options are modifiable risk
factors.
B) Place the objects Nancy needs for
A client is experiencing homonymous activities of daily living on the left side of
hemianopsia as the result of a brain at- the table.
tack. Which nursing intervention would
the nurse implement to address this con- Rationale: Homonymous hemianopsia is
dition? loss of the visual field on the same side
as the paralyzed side. This results in the
A) Turn Nancy every two hours and per- client neglecting that side of the body,
form active range of motion exercises. so it is beneficial to place objects on
B) Place the objects Nancy needs for that side. Nancy had a left-hemisphere
activities of daily living on the left side of brain attack so her right side is the
the table. weak side. Speaking slowly and clearly
C) Speak slowly and clearly to assist would address the client's verbal deficits
Nancy in forming sounds to words. due to aphasia. Requesting all liquids to
be thickened would address dysphagia.
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
Turning the client every 2 hours and per-
D) Request that the dietary department
forming active range of motion exercises
thicken all liquids on Nancy's meal and
would address the client's risk for immo-
snack trays.
bility due to paralysis.
A physical therapist (PT) places a gait
belt on a client and is assisting them
with ambulation from the bed to the chair.
As they get up out of the bed, they re-
port being dizzy and begin to fall. The B) PT reported client complained of dizzi-
PT carefully allows them to fall back to ness when getting out of bed, and gait
the bed and notifies the primary nurse. belt was used to allow client to fall back
Which written documentation should the onto the bed.
nurse put in the client's record?
Rationale: This documentation provides
A) Client experienced orthostatic hy- the factual data of the events that oc-
potension when getting out of bed. curred. A)The nurse is making an as-
B) PT reported client complained of sumption that the dizziness was caused
dizziness when getting out of bed, and by orthostatic hypotension. C) Not all the
gait belt was used to allow client to fall pertinent facts are included in this docu-
back onto the bed. mentation.
C) PT notified the primary nurse that the D) A variance report should never be
client could not ambulate at this time be- documented in the client's record.
cause of dizziness.
D) Client had difficulty ambulating from
the bed to the chair when accompanied
by the PT, variance report completed.
A) Encourage the client to use the incen-
A new nurse graduate is caring for a tive spirometer and to cough.
postoperative client with the following
arterial blood gases (ABGs): pH, 7.30; Rationale: Respiratory acidosis is
PCO2, 60 mm Hg; PO2, 80 mm Hg; bi- caused by CO2 retention and impaired
carbonate, 24 mEq/L; and O2 saturation, chest expansion secondary to anesthe-
96%. Which of these actions by the new sia. The nurse takes steps to promote
graduate is indicated? CO2 elimination, including maintaining a
patent airway and expanding the lungs
A) Encourage the client to use the incen- through breathing techniques. O2 is not
tive spirometer and to cough. indicated because Po2 and oxygen satu-
ration are within the normal range. Sodi-
Study online at https://quizlet.com/_f5ztxq
An ER nurse is completing an assess-
A) A carotid bruit.
ment on a patient that is alert but strug-
gles to answer questions. When she at-
Rationale: the carotid artery (artery to
tempts to talk, she slurs her speech and
the brain) is narrowed in clients with
appears very frightened. What addition-
a brain attack. A bruit is an abnormal
al clinical manifestation does the nurse
sound heard on auscultation resulting
expect to find if nacy's sysmptoms have
from interference with normal blood flow.
been caused by a brain attack (stroke)?
Usually the blood pressure is hyperten-
sive. Initially flaccid paralysis occurs, re-
A. A carotid bruit
sulting in hyporefkexic deep tendon re-
B. A hypotensive blood pressure
flexes. Bowel sounds are not indicative of
C. hyperreflexic deep tendon relexes.
a brain attack.
D. Decreased bowel sounds
D) Global aphasia.
Which clinical manifestation further sup-
Rationale: Global aphasia refers to dif-
ports an assessment of a left-sided brain
ficulty speaking, listening, and under-
attack?
standing, as well as difficulty reading and
writing. Symptoms vary from person to
A) Visual field deficit on the left side.
person. Aphasia may occur secondary to
B) Spatial-perceptual deficits.
any brain injury involving the left hemi-
C) Paresthesia of the left side.
sphere. Visual field deficits, spatial-per-
D) Global aphasia.
ceptual deficits, and paresthsia of the left
D) Global aphasia.
side usually occur with right-sided brain
attack.
B) Explain that the client will not be able
When preparing a patient for a noncon-
to move her head throughout the CT
trast computed tomography (CT) scan
scan.
STAT, what nursing intervention should
the nurse implement?
Rationale: Because head motion will dis-
tort the images, Nancy will have to re-
A) Determine if the client has any aller-
main still throughout the procedure. Al-
gies to iodine
lergies to iodine is important if contrast
B) Explain that the client will not be able
dye is being used for the CT scan. Pre-
to move her head throughout the CT
medicating the client to decrease pain
scan.
prior to the procedure is unnecessary be-
C) Premedicate the client to decrease
cause CT scanning is a noninvasive and
pain prior to having the procedure.
painless procedure. Providing an expla-
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
nation of relaxation exercises prior to the
D) Provide an explanation of relaxation procedure is a worthwhile intervention to
exercises prior to the procedure. decrease anxiety but is not of highest
priority.
A neurologist prescribes a magnetic res- C) Right hip replacement.
onance imaging (MRI) of the head STAT
for a patient. Which data warrants imme- The magnetic field generated by the MRI
diate intervention by the nurse concern- is so strong that metal-containing items
ing this diagnostic test? are strongly attracted to the magnet. Be-
cause the hip joint is made of metal,
A) Elevated blood pressure. a lead shield must be used during the
B) Allergy to shell fish. procedure. Elevated blood pressure, an
C) Right hip replacement. allergy to shell fish, and a history of atrial
D) History of atrial fibrillation. fibrillation would not affect the MRI.
A client's daughter is sitting by her moth-
er's bedside who was recently trans-
ferred to the Intermediate Care Unit. She
states "I don't understand what a brain
attack is. The healthcare provider told me
B) "Your mother has had a stroke, and
my mother is in serious condition and
the blood supply to the brain has been
they are going to run several tests. I just
blocked."
don't know what is going on. What hap-
pened to my mother?" What is the best
Rationale: The nurse can discuss what
response by the nurse?
a diagnosis means. Nancy is unable to
make decisions, so the next of kin, her
A) "I am sorry, but according to the
daughter, Gail, needs sufficient informa-
Health Insurance Portability and Ac-
tion to make informed decisions. The
counting Act (HIPAA), I cannot give you
nurse has the knowledge, and the re-
any information."
sponsibility, to explain Nancy's condition
B) "Your mother has had a stroke, and
to Gail. The nurse should give facts first,
the blood supply to the brain has been
and then address her feelings after the
blocked."
information is provided.
C) "How do you feel about what the
healthcare provider said?"
D) "I will call the healthcare provider so
he/she can talk to you about your moth-
er's serious condition."
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
The normal range for cardiac output to
What is the normal range for cardiac out-
ensure cerebral blood flow and oxygen
put?
delivery is 4 to 8 L/min.
A client was admitted with the diagnosis Thrombolytic therapy is contraindicated
of a brain attack. Their symptoms be- in clients with symptom onset longer than
gan 24 hours before being admitted. Why 3 hours prior to admission. This client
would this client not be a candidate for had symptoms for 24 hours before being
for thrombolytic therapy? brought to the medical center
Plate guards prevent food from being
pushed off the plate. Using plate guards
What are plate guards? and other assistive devices will encour-
age independence in a client with a
self-care deficit.
D) Advanced age.
Which condition is considered a
non-modifiable risk factor for a brain at- Rationale: People over age 55 are a
tack? high-risk group for a brain attack be-
cause the incidence of stroke more than
A) High cholesterol levels. doubles in each successive decade of
B) Obesity. life. Non-modifiable means the client can-
C) History of atrial fibrillation. not do anything to change the risk factor.
D) Advanced age. All the other options are modifiable risk
factors.
B) Place the objects Nancy needs for
A client is experiencing homonymous activities of daily living on the left side of
hemianopsia as the result of a brain at- the table.
tack. Which nursing intervention would
the nurse implement to address this con- Rationale: Homonymous hemianopsia is
dition? loss of the visual field on the same side
as the paralyzed side. This results in the
A) Turn Nancy every two hours and per- client neglecting that side of the body,
form active range of motion exercises. so it is beneficial to place objects on
B) Place the objects Nancy needs for that side. Nancy had a left-hemisphere
activities of daily living on the left side of brain attack so her right side is the
the table. weak side. Speaking slowly and clearly
C) Speak slowly and clearly to assist would address the client's verbal deficits
Nancy in forming sounds to words. due to aphasia. Requesting all liquids to
be thickened would address dysphagia.
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
Turning the client every 2 hours and per-
D) Request that the dietary department
forming active range of motion exercises
thicken all liquids on Nancy's meal and
would address the client's risk for immo-
snack trays.
bility due to paralysis.
A physical therapist (PT) places a gait
belt on a client and is assisting them
with ambulation from the bed to the chair.
As they get up out of the bed, they re-
port being dizzy and begin to fall. The B) PT reported client complained of dizzi-
PT carefully allows them to fall back to ness when getting out of bed, and gait
the bed and notifies the primary nurse. belt was used to allow client to fall back
Which written documentation should the onto the bed.
nurse put in the client's record?
Rationale: This documentation provides
A) Client experienced orthostatic hy- the factual data of the events that oc-
potension when getting out of bed. curred. A)The nurse is making an as-
B) PT reported client complained of sumption that the dizziness was caused
dizziness when getting out of bed, and by orthostatic hypotension. C) Not all the
gait belt was used to allow client to fall pertinent facts are included in this docu-
back onto the bed. mentation.
C) PT notified the primary nurse that the D) A variance report should never be
client could not ambulate at this time be- documented in the client's record.
cause of dizziness.
D) Client had difficulty ambulating from
the bed to the chair when accompanied
by the PT, variance report completed.
A) Encourage the client to use the incen-
A new nurse graduate is caring for a tive spirometer and to cough.
postoperative client with the following
arterial blood gases (ABGs): pH, 7.30; Rationale: Respiratory acidosis is
PCO2, 60 mm Hg; PO2, 80 mm Hg; bi- caused by CO2 retention and impaired
carbonate, 24 mEq/L; and O2 saturation, chest expansion secondary to anesthe-
96%. Which of these actions by the new sia. The nurse takes steps to promote
graduate is indicated? CO2 elimination, including maintaining a
patent airway and expanding the lungs
A) Encourage the client to use the incen- through breathing techniques. O2 is not
tive spirometer and to cough. indicated because Po2 and oxygen satu-
ration are within the normal range. Sodi-
