NSG 223 MEDICAL-SURGICAL NURSING
2 HESI FINAL REVIEW
1. A patient with a T4 spinal cord injury reports a sudden, throbbing headache and has a
blood pressure of 190/100 mmHg. What is the priority nursing action?
A. Administer an prescribed analgesic for the headache.
B. Perform a neurological assessment including GCS.
C. Lower the head of the bed to a flat position.
D. Check the patient’s bladder for distension.
Answer: D
Conceptual Explanation: The symptoms indicate Autonomic Dysreflexia, a medical
emergency. The priority is to identify and remove the triggering stimulus, most commonly
a distended bladder or impacted bowel.
2. An arterial blood gas (ABG) result shows pH 7.32, PaCO2 50 mmHg, and HCO3 26 mEq/L.
How should the nurse interpret these results?
A. Uncompensated metabolic alkalosis
B. Fully compensated metabolic acidosis
C. Partially compensated respiratory alkalosis
,D. Uncompensated respiratory acidosis
Answer: D
Conceptual Explanation: The pH is low (acidosis), the PaCO2 is high (respiratory cause),
and the HCO3 is within the normal range, indicating no compensation has occurred yet.
3. A client is admitted with Acute Respiratory Distress Syndrome (ARDS). Which oxygenation
finding is pathognomonic for ARDS?
A. Increased PaO2 with high-flow oxygen administration.
B. Increased lung compliance on the ventilator.
C. Refractory hypoxemia despite increasing FiO2.
D. Decreased pulmonary artery wedge pressure (PAWP).
Answer: C
Conceptual Explanation: Refractory hypoxemia, where the oxygen level does not improve
even with supplemental oxygen, is a hallmark sign of ARDS due to significant shunting.
4. When caring for a patient in the emergent phase of a major burn (40% TBSA), which
electrolyte imbalance is the nurse most likely to observe?
A. Hypokalemia
B. Hypernatremia
C. Hyperkalemia
D. Hypocalcemia
, Answer: C
Conceptual Explanation: In the emergent phase of burns, cell destruction releases
potassium into the extracellular fluid, leading to hyperkalemia.
5. A nurse is caring for a patient with Diabetic Ketoacidosis (DKA). Which IV fluid should the
nurse anticipate hanging first?
A. Dextrose 5% in water (D5W)
B. Dextrose 5% in 0.45% Normal Saline
C. 0.45% Normal Saline
D. 0.9% Normal Saline
Answer: D
Conceptual Explanation: The initial goal in DKA treatment is to restore circulatory
volume and perfuse vital organs using isotonic saline (0.9% NS).
6. A patient with cirrhosis has a high ammonia level and is exhibiting confusion. Which
medication should the nurse prepare to administer?
A. Vitamin K
B. Spironolactone
C. Propranolol
D. Lactulose
Answer: D
2 HESI FINAL REVIEW
1. A patient with a T4 spinal cord injury reports a sudden, throbbing headache and has a
blood pressure of 190/100 mmHg. What is the priority nursing action?
A. Administer an prescribed analgesic for the headache.
B. Perform a neurological assessment including GCS.
C. Lower the head of the bed to a flat position.
D. Check the patient’s bladder for distension.
Answer: D
Conceptual Explanation: The symptoms indicate Autonomic Dysreflexia, a medical
emergency. The priority is to identify and remove the triggering stimulus, most commonly
a distended bladder or impacted bowel.
2. An arterial blood gas (ABG) result shows pH 7.32, PaCO2 50 mmHg, and HCO3 26 mEq/L.
How should the nurse interpret these results?
A. Uncompensated metabolic alkalosis
B. Fully compensated metabolic acidosis
C. Partially compensated respiratory alkalosis
,D. Uncompensated respiratory acidosis
Answer: D
Conceptual Explanation: The pH is low (acidosis), the PaCO2 is high (respiratory cause),
and the HCO3 is within the normal range, indicating no compensation has occurred yet.
3. A client is admitted with Acute Respiratory Distress Syndrome (ARDS). Which oxygenation
finding is pathognomonic for ARDS?
A. Increased PaO2 with high-flow oxygen administration.
B. Increased lung compliance on the ventilator.
C. Refractory hypoxemia despite increasing FiO2.
D. Decreased pulmonary artery wedge pressure (PAWP).
Answer: C
Conceptual Explanation: Refractory hypoxemia, where the oxygen level does not improve
even with supplemental oxygen, is a hallmark sign of ARDS due to significant shunting.
4. When caring for a patient in the emergent phase of a major burn (40% TBSA), which
electrolyte imbalance is the nurse most likely to observe?
A. Hypokalemia
B. Hypernatremia
C. Hyperkalemia
D. Hypocalcemia
, Answer: C
Conceptual Explanation: In the emergent phase of burns, cell destruction releases
potassium into the extracellular fluid, leading to hyperkalemia.
5. A nurse is caring for a patient with Diabetic Ketoacidosis (DKA). Which IV fluid should the
nurse anticipate hanging first?
A. Dextrose 5% in water (D5W)
B. Dextrose 5% in 0.45% Normal Saline
C. 0.45% Normal Saline
D. 0.9% Normal Saline
Answer: D
Conceptual Explanation: The initial goal in DKA treatment is to restore circulatory
volume and perfuse vital organs using isotonic saline (0.9% NS).
6. A patient with cirrhosis has a high ammonia level and is exhibiting confusion. Which
medication should the nurse prepare to administer?
A. Vitamin K
B. Spironolactone
C. Propranolol
D. Lactulose
Answer: D
