HESI RN MEDICAL SURGICAL NEWEST 2024 -2025 ACTUAL
EXAM TEST BANK COMPLETE 320 MOST TESTED QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |
ALREADY GRADED A+||BRAND NEW
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.
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.
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.
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.
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?
,HESI RN MEDICAL SURGICAL NEWEST 2024 -2025 ACTUAL
EXAM TEST BANK COMPLETE 320 MOST TESTED QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |
ALREADY GRADED A+||BRAND NEW
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.
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 Accounting 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 Nancy's condition
to Gail. The nurse should give facts first, and then address her feelings after the information
is provided.
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.
,HESI RN MEDICAL SURGICAL NEWEST 2024 -2025 ACTUAL
EXAM TEST BANK COMPLETE 320 MOST TESTED QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |
ALREADY GRADED A+||BRAND NEW
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.
, HESI RN MEDICAL SURGICAL NEWEST 2024 -2025 ACTUAL
EXAM TEST BANK COMPLETE 320 MOST TESTED QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |
ALREADY GRADED A+||BRAND NEW
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 saturation are within the normal range. Sodium
bicarbonate is not indicated because the bicarbonate level is in the normal range; promoting
excretion of respiratory acids is the priority in respiratory acidosis. Post anesthesia, the client
will need interventions as described in A above or may progress to a state of somnolence
and unresponsiveness.
The nurse is providing dietary instructions to a 68-year-old client who is at high risk for
development of coronary heart disease (CHD). Which information should the nurse include?
A) Limit dietary selection of cholesterol to 300 mg per day
B) Increase intake of soluble fiber to 10 to 25 grams per day.
C) Decrease plant stanols and sterols to less than 2 grams/day.
D) Ensure saturated fat is less than 30% of total caloric intake. - B) Increase intake of soluble
fiber to 10 to 25 grams per day.
Rationale: To reduce risk factors associated with coronary heart disease, the daily intake of
soluble fiber (B) should be increased to between 10 and 25 gm. Cholesterol intake (A) should
be limited to 180 mg/day or less. Intake of plant stanols and sterols is recommended at 2
g/day (C). Saturated fat (D) intake should be limited to 7% of total daily calories.
A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which
statement by the nurse provides the most accurate explanation for use of the splints?
A) Prevention of deformities.
B) Avoidance of joint trauma.
C) Relief of joint inflammation.
D) Improvement in joint strength. - A) Prevention of deformities.
Rationale: Splints may be used at night by clients with rheumatoid arthritis to prevent
deformities (A) caused by muscle spasms and contractures. Splints are not used for (B). (C) is
usually treated with medications, particularly those classified as non-steroidal
antiinflammatory drugs (NSAIDs). For (D), a prescribed exercise program is indicated.
EXAM TEST BANK COMPLETE 320 MOST TESTED QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |
ALREADY GRADED A+||BRAND NEW
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.
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.
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.
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.
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?
,HESI RN MEDICAL SURGICAL NEWEST 2024 -2025 ACTUAL
EXAM TEST BANK COMPLETE 320 MOST TESTED QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |
ALREADY GRADED A+||BRAND NEW
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.
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 Accounting 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 Nancy's condition
to Gail. The nurse should give facts first, and then address her feelings after the information
is provided.
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.
,HESI RN MEDICAL SURGICAL NEWEST 2024 -2025 ACTUAL
EXAM TEST BANK COMPLETE 320 MOST TESTED QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |
ALREADY GRADED A+||BRAND NEW
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.
, HESI RN MEDICAL SURGICAL NEWEST 2024 -2025 ACTUAL
EXAM TEST BANK COMPLETE 320 MOST TESTED QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |
ALREADY GRADED A+||BRAND NEW
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 saturation are within the normal range. Sodium
bicarbonate is not indicated because the bicarbonate level is in the normal range; promoting
excretion of respiratory acids is the priority in respiratory acidosis. Post anesthesia, the client
will need interventions as described in A above or may progress to a state of somnolence
and unresponsiveness.
The nurse is providing dietary instructions to a 68-year-old client who is at high risk for
development of coronary heart disease (CHD). Which information should the nurse include?
A) Limit dietary selection of cholesterol to 300 mg per day
B) Increase intake of soluble fiber to 10 to 25 grams per day.
C) Decrease plant stanols and sterols to less than 2 grams/day.
D) Ensure saturated fat is less than 30% of total caloric intake. - B) Increase intake of soluble
fiber to 10 to 25 grams per day.
Rationale: To reduce risk factors associated with coronary heart disease, the daily intake of
soluble fiber (B) should be increased to between 10 and 25 gm. Cholesterol intake (A) should
be limited to 180 mg/day or less. Intake of plant stanols and sterols is recommended at 2
g/day (C). Saturated fat (D) intake should be limited to 7% of total daily calories.
A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which
statement by the nurse provides the most accurate explanation for use of the splints?
A) Prevention of deformities.
B) Avoidance of joint trauma.
C) Relief of joint inflammation.
D) Improvement in joint strength. - A) Prevention of deformities.
Rationale: Splints may be used at night by clients with rheumatoid arthritis to prevent
deformities (A) caused by muscle spasms and contractures. Splints are not used for (B). (C) is
usually treated with medications, particularly those classified as non-steroidal
antiinflammatory drugs (NSAIDs). For (D), a prescribed exercise program is indicated.
