NSG 223 MEDICAL-SURGICAL NURSING
2 HESI PREPARATION
1. A patient with a head injury presents with a blood pressure of 180/60, a heart rate of 45,
and irregular respirations. Which condition does the nurse suspect?
A. Cushing’s triad due to increased ICP
B. Hypovolemic shock
C. Septic shock
D. Autonomic dysreflexia
Answer: A
Conceptual Explanation: Cushing’s triad consists of bradycardia, hypertension with a
widening pulse pressure, and irregular respirations, signaling increased intracranial
pressure.
2. Which arterial blood gas (ABG) result would the nurse expect in a patient with acute
respiratory distress syndrome (ARDS)?
A. pH 7.30, PaO2 55, PaCO2 50
B. pH 7.48, PaO2 80, PaCO2 30
C. pH 7.35, PaO2 95, PaCO2 40
,D. pH 7.50, PaO2 60, PaCO2 35
Answer: A
Conceptual Explanation: ARDS is characterized by respiratory acidosis and severe
hypoxemia refractory to oxygen therapy.
3. A patient is admitted with Diabetic Ketoacidosis (DKA). Which IV fluid should the nurse
expect to administer first?
A. 5% Dextrose in 0.45% Saline
B. Lactated Ringer’s
C. 0.9% Normal Saline
D. 0.45% Normal Saline
Answer: C
Conceptual Explanation: Initial treatment for DKA involves aggressive fluid resuscitation
with isotonic saline (0.9% NS) to restore volume.
4. In a patient with chronic kidney disease (CKD), which electrolyte imbalance is most likely to
cause life-threatening cardiac arrhythmias?
A. Hyperkalemia
B. Hypermagnesemia
C. Hypocalcemia
D. Hyponatremia
, Answer: A
Conceptual Explanation: Hyperkalemia is the most dangerous electrolyte imbalance in
CKD because it can lead to fatal arrhythmias like V-fib.
5. A patient with a T6 spinal cord injury reports a severe headache and nasal congestion. The
blood pressure is 210/110. What is the priority nursing action?
A. Administer PRN antihypertensives
B. Place the patient in a supine position
C. Notify the healthcare provider immediately
D. Check the patient’s bladder for distension
Answer: D
Conceptual Explanation: These are signs of Autonomic Dysreflexia. The priority is to
remove the stimulus, most commonly a distended bladder.
6. Which assessment finding is a classic sign of Cardiac Tamponade?
A. Crackles in the lungs
B. Muffled heart sounds
C. Flattened neck veins
D. Widened pulse pressure
Answer: B
2 HESI PREPARATION
1. A patient with a head injury presents with a blood pressure of 180/60, a heart rate of 45,
and irregular respirations. Which condition does the nurse suspect?
A. Cushing’s triad due to increased ICP
B. Hypovolemic shock
C. Septic shock
D. Autonomic dysreflexia
Answer: A
Conceptual Explanation: Cushing’s triad consists of bradycardia, hypertension with a
widening pulse pressure, and irregular respirations, signaling increased intracranial
pressure.
2. Which arterial blood gas (ABG) result would the nurse expect in a patient with acute
respiratory distress syndrome (ARDS)?
A. pH 7.30, PaO2 55, PaCO2 50
B. pH 7.48, PaO2 80, PaCO2 30
C. pH 7.35, PaO2 95, PaCO2 40
,D. pH 7.50, PaO2 60, PaCO2 35
Answer: A
Conceptual Explanation: ARDS is characterized by respiratory acidosis and severe
hypoxemia refractory to oxygen therapy.
3. A patient is admitted with Diabetic Ketoacidosis (DKA). Which IV fluid should the nurse
expect to administer first?
A. 5% Dextrose in 0.45% Saline
B. Lactated Ringer’s
C. 0.9% Normal Saline
D. 0.45% Normal Saline
Answer: C
Conceptual Explanation: Initial treatment for DKA involves aggressive fluid resuscitation
with isotonic saline (0.9% NS) to restore volume.
4. In a patient with chronic kidney disease (CKD), which electrolyte imbalance is most likely to
cause life-threatening cardiac arrhythmias?
A. Hyperkalemia
B. Hypermagnesemia
C. Hypocalcemia
D. Hyponatremia
, Answer: A
Conceptual Explanation: Hyperkalemia is the most dangerous electrolyte imbalance in
CKD because it can lead to fatal arrhythmias like V-fib.
5. A patient with a T6 spinal cord injury reports a severe headache and nasal congestion. The
blood pressure is 210/110. What is the priority nursing action?
A. Administer PRN antihypertensives
B. Place the patient in a supine position
C. Notify the healthcare provider immediately
D. Check the patient’s bladder for distension
Answer: D
Conceptual Explanation: These are signs of Autonomic Dysreflexia. The priority is to
remove the stimulus, most commonly a distended bladder.
6. Which assessment finding is a classic sign of Cardiac Tamponade?
A. Crackles in the lungs
B. Muffled heart sounds
C. Flattened neck veins
D. Widened pulse pressure
Answer: B
