HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
1. An ER nurse is completing an assessment on a patient that is alert but
struggles to answer questions. When she attempts to talk, she slurs her
speech and appears very frightened. What additional clinical manifestation
does the nurse expect to find if nacy's sysmptoms have been caused by a
brain attack (stroke)?
A. A carotid bruit
B. A hypotensive blood pressure
C. hyperreflexic deep tendon relexes.
D. Decreased bowel sounds: A) A carotid bruit.
Rationale: the carotid artery (artery to the brain) is narrowed in clients with a
brain attack. A bruit is an abnormal sound heard on auscultation resulting from
interference with normal blood flow. Usually the blood pressure is hypertensive.
Initially flaccid paralysis occurs, resulting in hyporefkexic deep tendon reflexes.
Bowel sounds are not indicative of a brain attack.
2. Which clinical manifestation further supports an assessment of a left-sided
brain attack?
A) Visual field deficit on the left side.
B) Spatial-perceptual deficits.
C) Paresthesia of the left side.
D) Global aphasia.
D) Global aphasia.: D) Global aphasia.
Rationale: Global aphasia refers to difficulty speaking, listening, and understanding,
as well as difficulty reading and writing. Symptoms vary from person to person.
Aphasia may occur secondary to any brain injury involving the left hemisphere.
Visual field deficits, spatial-perceptual deficits, and paresthsia of the left side usually
occur with right-sided brain attack.
3. When preparing a patient for a noncontrast computed tomography (CT)
scan STAT, what nursing intervention should the nurse implement?
A) Determine if the client has any allergies to iodine
B) Explain that the client will not be able to move her head throughout the CT
scan.
C) Premedicate the client to decrease pain prior to having the procedure.
D) Provide an explanation of relaxation exercises prior to the procedure.: B)
Explain that the client will not be able to move her head throughout the CT scan.
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
Rationale: Because head motion will distort the images, Nancy will have to remain
still throughout the procedure. Allergies to iodine is important if contrast dye is
being used for the CT scan. Premedicating the client to decrease pain prior to
the procedure is unnecessary because CT scanning is a noninvasive and painless
procedure. Providing an explanation of relaxation exercises prior to the procedure
is a worthwhile intervention to decrease anxiety but is not of highest priority.
4. A neurologist prescribes a magnetic resonance imaging (MRI) of the head
STAT for a patient. Which data warrants immediate intervention by the nurse
concerning this diagnostic test?
A) Elevated blood pressure.
B) Allergy to shell fish.
C) Right hip replacement.
D) History of atrial fibrillation.: C) Right hip replacement.
The magnetic field generated by the MRI is so strong that metal-containing items
are strongly attracted to the magnet. Because the hip joint is made of metal, a lead
shield must be used during the procedure. Elevated blood pressure, an allergy to
shell fish, and a history of atrial fibrillation would not affect the MRI.
5. A client's daughter is sitting by her mother's bedside who was recently
transferred to the Intermediate Care Unit. She states "I don't understand what
a brain attack is. The healthcare provider told me my mother is in serious
condition and they are going to run several tests. I just don't know what is
going on. What happened to my mother?" What is the best response by the
nurse?
A) "I am sorry, but according to the Health Insurance Portability and Account-
ing Act (HIPAA), I cannot give you any information."
B) "Your mother has had a stroke, and the blood supply to the brain has been
blocked."
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
mother's serious condition.": B) "Your mother has had a stroke, and the blood
supply to the brain has been blocked."
Rationale: The nurse can discuss what a diagnosis means. Nancy is unable to make
decisions, so the next of kin, her daughter, Gail, needs sufficient information to make
informed decisions. The nurse has the knowledge, and the responsibility, to explain
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
Nancy's condition to Gail. The nurse should give facts first, and then address her
feelings after the information is provided.
6. 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.
7. 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 can-
didate 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
8. 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.
9. 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.
10. 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
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
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.
11. 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 accompa-
nied 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.
12. 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) Encour-
age 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 elimina-
tion, including maintaining a patent airway and expanding the lungs through breath-
Study online at https://quizlet.com/_f5ztxq
1. An ER nurse is completing an assessment on a patient that is alert but
struggles to answer questions. When she attempts to talk, she slurs her
speech and appears very frightened. What additional clinical manifestation
does the nurse expect to find if nacy's sysmptoms have been caused by a
brain attack (stroke)?
A. A carotid bruit
B. A hypotensive blood pressure
C. hyperreflexic deep tendon relexes.
D. Decreased bowel sounds: A) A carotid bruit.
Rationale: the carotid artery (artery to the brain) is narrowed in clients with a
brain attack. A bruit is an abnormal sound heard on auscultation resulting from
interference with normal blood flow. Usually the blood pressure is hypertensive.
Initially flaccid paralysis occurs, resulting in hyporefkexic deep tendon reflexes.
Bowel sounds are not indicative of a brain attack.
2. Which clinical manifestation further supports an assessment of a left-sided
brain attack?
A) Visual field deficit on the left side.
B) Spatial-perceptual deficits.
C) Paresthesia of the left side.
D) Global aphasia.
D) Global aphasia.: D) Global aphasia.
Rationale: Global aphasia refers to difficulty speaking, listening, and understanding,
as well as difficulty reading and writing. Symptoms vary from person to person.
Aphasia may occur secondary to any brain injury involving the left hemisphere.
Visual field deficits, spatial-perceptual deficits, and paresthsia of the left side usually
occur with right-sided brain attack.
3. When preparing a patient for a noncontrast computed tomography (CT)
scan STAT, what nursing intervention should the nurse implement?
A) Determine if the client has any allergies to iodine
B) Explain that the client will not be able to move her head throughout the CT
scan.
C) Premedicate the client to decrease pain prior to having the procedure.
D) Provide an explanation of relaxation exercises prior to the procedure.: B)
Explain that the client will not be able to move her head throughout the CT scan.
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
Rationale: Because head motion will distort the images, Nancy will have to remain
still throughout the procedure. Allergies to iodine is important if contrast dye is
being used for the CT scan. Premedicating the client to decrease pain prior to
the procedure is unnecessary because CT scanning is a noninvasive and painless
procedure. Providing an explanation of relaxation exercises prior to the procedure
is a worthwhile intervention to decrease anxiety but is not of highest priority.
4. A neurologist prescribes a magnetic resonance imaging (MRI) of the head
STAT for a patient. Which data warrants immediate intervention by the nurse
concerning this diagnostic test?
A) Elevated blood pressure.
B) Allergy to shell fish.
C) Right hip replacement.
D) History of atrial fibrillation.: C) Right hip replacement.
The magnetic field generated by the MRI is so strong that metal-containing items
are strongly attracted to the magnet. Because the hip joint is made of metal, a lead
shield must be used during the procedure. Elevated blood pressure, an allergy to
shell fish, and a history of atrial fibrillation would not affect the MRI.
5. A client's daughter is sitting by her mother's bedside who was recently
transferred to the Intermediate Care Unit. She states "I don't understand what
a brain attack is. The healthcare provider told me my mother is in serious
condition and they are going to run several tests. I just don't know what is
going on. What happened to my mother?" What is the best response by the
nurse?
A) "I am sorry, but according to the Health Insurance Portability and Account-
ing Act (HIPAA), I cannot give you any information."
B) "Your mother has had a stroke, and the blood supply to the brain has been
blocked."
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
mother's serious condition.": B) "Your mother has had a stroke, and the blood
supply to the brain has been blocked."
Rationale: The nurse can discuss what a diagnosis means. Nancy is unable to make
decisions, so the next of kin, her daughter, Gail, needs sufficient information to make
informed decisions. The nurse has the knowledge, and the responsibility, to explain
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
Nancy's condition to Gail. The nurse should give facts first, and then address her
feelings after the information is provided.
6. 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.
7. 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 can-
didate 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
8. 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.
9. 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.
10. 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
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
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.
11. 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 accompa-
nied 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.
12. 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) Encour-
age 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 elimina-
tion, including maintaining a patent airway and expanding the lungs through breath-
