HESI RN MEDICAL SURGICAL EXAM PACK 2024
QUESTIONS AND ANSWERS
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 - <<ANSWER>>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. - <<ANSWER>>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.
,The nurse is assessing a client with a chest tube that is attached to suction and a
closed drainage system. Which finding is most important for the nurse to further
assess?
A) Upper chest subcutaneous emphysema.
B) Tidaling (fluctuation) of fluid in the water-seal chamber.
C) Constant air bubbling in the suction-control chamber.
D) Pain rated 8 (0-10) at the insertion site. - <<ANSWER>>Correct Answer(s): A
* Subcutaneous emphysema (A) is a complication and indicates air is leaking beneath
the skin. Tidaling in the water-seal chamber and constant bubbling with suction in the
suction-control chamber (B and C) are expected findings that indicate the closed
drainage system is working. Pain at the insertion site is an expected finding (D) and the
prescribed analgesia should be given to assist the client to breathe deeply and facilitate
lung expansion.
A couple trying to cope with an infertility problem wants to know what can be done to
preserve emotional equilibrium. What is the best response for the nurse to provide?
A) Tell your friends and family so that they can help you.
B) Get involved with a support group. I will give you some names.
C) Talk only to other friends who are infertile since only they can help.
D) Start adoption proceedings immediately since obtaining an infant is very difficult. -
<<ANSWER>>Correct Answer(s): B
* A support group (B) provides a safe haven for the couple to share experiences and
gain insight from others experiences. Although talking about feelings may unburden the
couple of negative feelings, infertility is a major stressor that affects the couple's
relationships, so discussion with family and friends (A) should be minimal. Limiting
interaction to other infertile couples (C) may address some psychosocial needs, but
depending on where the other couples are in the recovery process, it may not be
helpful. Giving an opinion about adoption (D) is not therapeutic nor supportive of the
psychosocial needs.
The nurse is planning preoperative teaching for a client who will undergo a radical neck
dissection and total laryngectomy. Which information has the greatest priority for this
client?
A) Prognosis after treatment is excellent.
B) Techniques for esophageal speech are relatively easy to learn with practice.
C) The stoma should never be covered after this type of surgery.
D) There is a radical change in appearance as a result of this surgery. -
<<ANSWER>>Correct Answer(s): D
* Radical neck dissection is the removal of lymphatic drainage channels and nodes,
sternocleidomastoid muscle, spinal accessory nerve, jugular vein, and submandibular
,area. The overall outcome of this type of surgery causes the neck to be disfigured, so
(D) should be a priority in the care of this client. (A, B, and C) are included, but the
client's concern for (D) is the priority.
When teaching a client with breast cancer about the prescribed radiation therapy for
treatment, what information is important to include?
A) Dry, itchy skin changes may occur.
B) There is a possibility of long bone pain.
C) Permanent pigment changes to the breast may result.
D) A low-residue diet may be ordered to reduce the likelihood of diarrhea. -
<<ANSWER>>Correct Answer(s): A
* Side effects from radiation to the breast most often include temporary skin changes
such as: dryness, tenderness, redness, swelling, and pruritis (A). (B, C, and D) are not
found in this situation.
Which action should the nurse implement on the scheduled day of surgery for a client
with type 1 diabetes mellitus (DM)?
A) Obtain a prescription for an adjusted dose of insulin.
B) Administer an oral anti-diabetic agent.
C) Give an insulin dose using parameters of a sliding scale.
D) Withhold insulin while the client is NPO. - <<ANSWER>>Correct Answer(s): A
* Stressors, such as surgery, increase serum glucose levels. A client with type 1 DM
who is NPO for scheduled surgery should receive a prescribed adjusted dose of insulin
(A). (B, C, and D) are not indicated.
In planning care for a client with an acute stroke resulting in right-sided hemiplegia,
which positioning should the nurse should use to maintain optimal functioning?
A) Mid-Fowler's with knees supported.
B) Supine with trochanter rolls to the hips.
C) Sim's position alternated with right lateral position q2 hours.
D) Left lateral, supine, brief periods on the right side, and prone. -
<<ANSWER>>Correct Answer(s): D
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. -
<<ANSWER>>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?
A) Elevated blood pressure.
B) Allergy to shell fish.
C) Right hip replacement.
D) History of atrial fibrillation. - <<ANSWER>>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." - <<ANSWER>>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.
QUESTIONS AND ANSWERS
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 - <<ANSWER>>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. - <<ANSWER>>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.
,The nurse is assessing a client with a chest tube that is attached to suction and a
closed drainage system. Which finding is most important for the nurse to further
assess?
A) Upper chest subcutaneous emphysema.
B) Tidaling (fluctuation) of fluid in the water-seal chamber.
C) Constant air bubbling in the suction-control chamber.
D) Pain rated 8 (0-10) at the insertion site. - <<ANSWER>>Correct Answer(s): A
* Subcutaneous emphysema (A) is a complication and indicates air is leaking beneath
the skin. Tidaling in the water-seal chamber and constant bubbling with suction in the
suction-control chamber (B and C) are expected findings that indicate the closed
drainage system is working. Pain at the insertion site is an expected finding (D) and the
prescribed analgesia should be given to assist the client to breathe deeply and facilitate
lung expansion.
A couple trying to cope with an infertility problem wants to know what can be done to
preserve emotional equilibrium. What is the best response for the nurse to provide?
A) Tell your friends and family so that they can help you.
B) Get involved with a support group. I will give you some names.
C) Talk only to other friends who are infertile since only they can help.
D) Start adoption proceedings immediately since obtaining an infant is very difficult. -
<<ANSWER>>Correct Answer(s): B
* A support group (B) provides a safe haven for the couple to share experiences and
gain insight from others experiences. Although talking about feelings may unburden the
couple of negative feelings, infertility is a major stressor that affects the couple's
relationships, so discussion with family and friends (A) should be minimal. Limiting
interaction to other infertile couples (C) may address some psychosocial needs, but
depending on where the other couples are in the recovery process, it may not be
helpful. Giving an opinion about adoption (D) is not therapeutic nor supportive of the
psychosocial needs.
The nurse is planning preoperative teaching for a client who will undergo a radical neck
dissection and total laryngectomy. Which information has the greatest priority for this
client?
A) Prognosis after treatment is excellent.
B) Techniques for esophageal speech are relatively easy to learn with practice.
C) The stoma should never be covered after this type of surgery.
D) There is a radical change in appearance as a result of this surgery. -
<<ANSWER>>Correct Answer(s): D
* Radical neck dissection is the removal of lymphatic drainage channels and nodes,
sternocleidomastoid muscle, spinal accessory nerve, jugular vein, and submandibular
,area. The overall outcome of this type of surgery causes the neck to be disfigured, so
(D) should be a priority in the care of this client. (A, B, and C) are included, but the
client's concern for (D) is the priority.
When teaching a client with breast cancer about the prescribed radiation therapy for
treatment, what information is important to include?
A) Dry, itchy skin changes may occur.
B) There is a possibility of long bone pain.
C) Permanent pigment changes to the breast may result.
D) A low-residue diet may be ordered to reduce the likelihood of diarrhea. -
<<ANSWER>>Correct Answer(s): A
* Side effects from radiation to the breast most often include temporary skin changes
such as: dryness, tenderness, redness, swelling, and pruritis (A). (B, C, and D) are not
found in this situation.
Which action should the nurse implement on the scheduled day of surgery for a client
with type 1 diabetes mellitus (DM)?
A) Obtain a prescription for an adjusted dose of insulin.
B) Administer an oral anti-diabetic agent.
C) Give an insulin dose using parameters of a sliding scale.
D) Withhold insulin while the client is NPO. - <<ANSWER>>Correct Answer(s): A
* Stressors, such as surgery, increase serum glucose levels. A client with type 1 DM
who is NPO for scheduled surgery should receive a prescribed adjusted dose of insulin
(A). (B, C, and D) are not indicated.
In planning care for a client with an acute stroke resulting in right-sided hemiplegia,
which positioning should the nurse should use to maintain optimal functioning?
A) Mid-Fowler's with knees supported.
B) Supine with trochanter rolls to the hips.
C) Sim's position alternated with right lateral position q2 hours.
D) Left lateral, supine, brief periods on the right side, and prone. -
<<ANSWER>>Correct Answer(s): D
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. -
<<ANSWER>>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?
A) Elevated blood pressure.
B) Allergy to shell fish.
C) Right hip replacement.
D) History of atrial fibrillation. - <<ANSWER>>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." - <<ANSWER>>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.
