HESI RN MEDICAL SURGICAL EXAM PACK 2024
QUESTIONS AND ANSWERS
Scenario 1: Assessment of Symptoms and Potential Stroke
Question: What additional clinical manifestation does the nurse expect to find if Nancy's symptoms have
been caused by a brain attack (stroke)?
- Correct Answer: A. A carotid bruit.
Rationale: A bruit can indicate narrowing of the carotid artery, which could contribute to decreased
blood flow to the brain during a stroke. Typically, patients may have hypertension rather than
hypotension, and initially may present with flaccid paralysis leading to hyporeflexic deep tendon
reflexes, not hyperreflexic. Decreased bowel sounds are not indicative of a stroke.
Scenario 2: Left-Sided Brain Attack Symptoms
Question: Which clinical manifestation further supports an assessment of a left-sided brain attack?
- Correct Answer: D. Global aphasia.
Rationale: Global aphasia involves significant difficulties with all forms of communication and is
commonly associated with stroke impacts in the left hemisphere, which controls language. Other
options such as visual field deficits and spatial-perceptual deficits are associated with right-sided brain
attacks.
Scenario 3: Preparing for a CT Scan
Question: When preparing a patient for a noncontrast computed tomography (CT) scan STAT, what
nursing intervention should the nurse implement?
- Correct Answer: B. Explain that the client will not be able to move her head throughout the CT scan.
, Rationale: Keeping the head still is crucial to prevent distortion of the images during a CT scan. While
determining allergies to iodine is relevant for contrast CT scans, this case specifies a non-contrast scan,
and prem medication or relaxation instructions are not priorities for this non-invasive procedure.
Scenario 4: MRI Procedure Considerations
Question: Which data warrants immediate intervention by the nurse concerning an MRI test for a
patient?
- Correct Answer: C. Right hip replacement.
Rationale: The metal in the hip replacement poses a risk due to the strong magnetic field of the MRI,
potentially requiring special precautions. Other options like elevated blood pressure or allergies do not
pose a direct risk to the MRI procedure itself.
Scenario 5: Communicating with Family
Question: What is the best response by the nurse to the client's daughter regarding her mother's
condition?
- Correct Answer: B. "Your mother has had a stroke, and the blood supply to the brain has been
blocked."
Rationale: Providing clear and factual information helps the family understand the situation and
prepares them for any further discussions. It's important to convey what has happened first, with the
responsibility to explain the condition falling on the nurse due to the patient’s inability to make
decisions.
What is the normal range for cardiac output? ✅The normal range for cardiac output to ensure cerebral
blood flow and oxygen delivery is 4 to 8 L/min.
,A client was admitted with the diagnosis of a brain attack. Their symptoms began 24 hours before being
admitted. Why would this client not be a candidate for for thrombolytic therapy? ✅Thrombolytic
therapy is contraindicated in clients with symptom onset longer than 3 hours prior to admission. This
client had symptoms for 24 hours before being brought to the medical center
What are plate guards? ✅Plate guards prevent food from being pushed off the plate. Using plate guards
and other assistive devices will encourage independence in a client with a self-care deficit.
Which condition is considered a non-modifiable risk factor for a brain attack?
A) High cholesterol levels.
B) Obesity.
C) History of atrial fibrillation.
D) Advanced age. ✅D) Advanced age.
Rationale: People over age 55 are a high-risk group for a brain attack because the incidence of stroke
more than doubles in each successive decade of life. Non-modifiable means the client cannot do
anything to change the risk factor. All the other options are modifiable risk factors.
A client is experiencing homonymous hemianopsia as the result of a brain attack. Which nursing
intervention would the nurse implement to address this condition?
A) Turn Nancy every two hours and perform active range of motion exercises.
B) Place the objects Nancy needs for activities of daily living on the left side of the table.
C) Speak slowly and clearly to assist Nancy in forming sounds to words.
D) Request that the dietary department thicken all liquids on Nancy's meal and snack trays. ✅B) Place
the objects Nancy needs for activities of daily living on the left side of the table.
Rationale: Homonymous hemianopsia is loss of the visual field on the same side as the paralyzed side.
This results in the client neglecting that side of the body, so it is beneficial to place objects on that side.
Nancy had a left-hemisphere brain attack so her right side is the weak side. Speaking slowly and clearly
would address the client's verbal deficits due to aphasia. Requesting all liquids to be thickened would
, address dysphagia. Turning the client every 2 hours and performing active range of motion exercises
would address the client's risk for immobility 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 report being dizzy and begin to fall. The PT carefully
allows them to fall back to the bed and notifies the primary nurse. Which written documentation should
the nurse put in the client's record?
A) Client experienced orthostatic hypotension when getting out of bed.
B) PT reported client complained of dizziness when getting out of bed, and gait belt was used to allow
client to fall back onto the bed.
C) PT notified the primary nurse that the client could not ambulate at this time because of dizziness.
D) Client had difficulty ambulating from the bed to the chair when accompanied by the PT, variance
report completed. ✅B) PT reported client complained of dizziness when getting out of bed, and gait belt
was used to allow client to fall back onto the bed.
Rationale: This documentation provides the factual data of the events that occurred. A)The nurse is
making an assumption that the dizziness was caused by orthostatic hypotension. C) Not all the pertinent
facts are included in this documentation.
D) A variance report should never be documented in the client's record.
A new nurse graduate is caring for a postoperative client with the following arterial blood gases (ABGs):
pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation, 96%. Which of
these actions by the new graduate is indicated?
A) Encourage the client to use the incentive spirometer and to cough.
B) Administer oxygen by nasal cannula.
C) Request a prescription for sodium bicarbonate from the health care provider.
D) Inform the charge nurse that no changes in therapy are needed. ✅A) Encourage the client to use the
incentive spirometer and to cough.
Rationale: Respiratory acidosis is caused by CO2 retention and impaired chest expansion secondary to
anesthesia. The nurse takes steps to promote CO2 elimination, including maintaining a patent airway
and expanding the lungs through breathing techniques. O2 is not indicated because Po2 and oxygen
QUESTIONS AND ANSWERS
Scenario 1: Assessment of Symptoms and Potential Stroke
Question: What additional clinical manifestation does the nurse expect to find if Nancy's symptoms have
been caused by a brain attack (stroke)?
- Correct Answer: A. A carotid bruit.
Rationale: A bruit can indicate narrowing of the carotid artery, which could contribute to decreased
blood flow to the brain during a stroke. Typically, patients may have hypertension rather than
hypotension, and initially may present with flaccid paralysis leading to hyporeflexic deep tendon
reflexes, not hyperreflexic. Decreased bowel sounds are not indicative of a stroke.
Scenario 2: Left-Sided Brain Attack Symptoms
Question: Which clinical manifestation further supports an assessment of a left-sided brain attack?
- Correct Answer: D. Global aphasia.
Rationale: Global aphasia involves significant difficulties with all forms of communication and is
commonly associated with stroke impacts in the left hemisphere, which controls language. Other
options such as visual field deficits and spatial-perceptual deficits are associated with right-sided brain
attacks.
Scenario 3: Preparing for a CT Scan
Question: When preparing a patient for a noncontrast computed tomography (CT) scan STAT, what
nursing intervention should the nurse implement?
- Correct Answer: B. Explain that the client will not be able to move her head throughout the CT scan.
, Rationale: Keeping the head still is crucial to prevent distortion of the images during a CT scan. While
determining allergies to iodine is relevant for contrast CT scans, this case specifies a non-contrast scan,
and prem medication or relaxation instructions are not priorities for this non-invasive procedure.
Scenario 4: MRI Procedure Considerations
Question: Which data warrants immediate intervention by the nurse concerning an MRI test for a
patient?
- Correct Answer: C. Right hip replacement.
Rationale: The metal in the hip replacement poses a risk due to the strong magnetic field of the MRI,
potentially requiring special precautions. Other options like elevated blood pressure or allergies do not
pose a direct risk to the MRI procedure itself.
Scenario 5: Communicating with Family
Question: What is the best response by the nurse to the client's daughter regarding her mother's
condition?
- Correct Answer: B. "Your mother has had a stroke, and the blood supply to the brain has been
blocked."
Rationale: Providing clear and factual information helps the family understand the situation and
prepares them for any further discussions. It's important to convey what has happened first, with the
responsibility to explain the condition falling on the nurse due to the patient’s inability to make
decisions.
What is the normal range for cardiac output? ✅The normal range for cardiac output to ensure cerebral
blood flow and oxygen delivery is 4 to 8 L/min.
,A client was admitted with the diagnosis of a brain attack. Their symptoms began 24 hours before being
admitted. Why would this client not be a candidate for for thrombolytic therapy? ✅Thrombolytic
therapy is contraindicated in clients with symptom onset longer than 3 hours prior to admission. This
client had symptoms for 24 hours before being brought to the medical center
What are plate guards? ✅Plate guards prevent food from being pushed off the plate. Using plate guards
and other assistive devices will encourage independence in a client with a self-care deficit.
Which condition is considered a non-modifiable risk factor for a brain attack?
A) High cholesterol levels.
B) Obesity.
C) History of atrial fibrillation.
D) Advanced age. ✅D) Advanced age.
Rationale: People over age 55 are a high-risk group for a brain attack because the incidence of stroke
more than doubles in each successive decade of life. Non-modifiable means the client cannot do
anything to change the risk factor. All the other options are modifiable risk factors.
A client is experiencing homonymous hemianopsia as the result of a brain attack. Which nursing
intervention would the nurse implement to address this condition?
A) Turn Nancy every two hours and perform active range of motion exercises.
B) Place the objects Nancy needs for activities of daily living on the left side of the table.
C) Speak slowly and clearly to assist Nancy in forming sounds to words.
D) Request that the dietary department thicken all liquids on Nancy's meal and snack trays. ✅B) Place
the objects Nancy needs for activities of daily living on the left side of the table.
Rationale: Homonymous hemianopsia is loss of the visual field on the same side as the paralyzed side.
This results in the client neglecting that side of the body, so it is beneficial to place objects on that side.
Nancy had a left-hemisphere brain attack so her right side is the weak side. Speaking slowly and clearly
would address the client's verbal deficits due to aphasia. Requesting all liquids to be thickened would
, address dysphagia. Turning the client every 2 hours and performing active range of motion exercises
would address the client's risk for immobility 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 report being dizzy and begin to fall. The PT carefully
allows them to fall back to the bed and notifies the primary nurse. Which written documentation should
the nurse put in the client's record?
A) Client experienced orthostatic hypotension when getting out of bed.
B) PT reported client complained of dizziness when getting out of bed, and gait belt was used to allow
client to fall back onto the bed.
C) PT notified the primary nurse that the client could not ambulate at this time because of dizziness.
D) Client had difficulty ambulating from the bed to the chair when accompanied by the PT, variance
report completed. ✅B) PT reported client complained of dizziness when getting out of bed, and gait belt
was used to allow client to fall back onto the bed.
Rationale: This documentation provides the factual data of the events that occurred. A)The nurse is
making an assumption that the dizziness was caused by orthostatic hypotension. C) Not all the pertinent
facts are included in this documentation.
D) A variance report should never be documented in the client's record.
A new nurse graduate is caring for a postoperative client with the following arterial blood gases (ABGs):
pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation, 96%. Which of
these actions by the new graduate is indicated?
A) Encourage the client to use the incentive spirometer and to cough.
B) Administer oxygen by nasal cannula.
C) Request a prescription for sodium bicarbonate from the health care provider.
D) Inform the charge nurse that no changes in therapy are needed. ✅A) Encourage the client to use the
incentive spirometer and to cough.
Rationale: Respiratory acidosis is caused by CO2 retention and impaired chest expansion secondary to
anesthesia. The nurse takes steps to promote CO2 elimination, including maintaining a patent airway
and expanding the lungs through breathing techniques. O2 is not indicated because Po2 and oxygen
