MED-SURG HESI TEST BANK ACTUAL EXAM (5
VERSIONS) QUESTIONS AND CORRECT DETAILED
ANSWERS |AGRADE
When a nurse is caring for a client with acute hypothyroidism, which serum laboratory
value requires immediate intervention?
a. Thyroxine (T4) 4 mcg/dl
b. Serum sodium 122 mEq/L
c. Serum potassium 3.5 mEq/L
d. Triiodothyronine (T3) level 0.8 mcg/dl - ANSWERS-b. serum sodium 122 mEq/L
A potential donor of corneal tissue for the eye bank has just died. The nurse enters the
room with prescribed antibiotic eye drops. What action should the nurse take next?
a. secure eye shields over the closed eyes after instilling the eye drops
b. instill the eyedrops before placing small ice packs over the closed eyes
c. reposition with the head flat and then instill the prescribed eye drops
d. withhold the eyedrops and apply sterile dressing over both closed eyes - ANSWERS-
a. secure eye shields over the closed eyes after instilling the eye drops
* The head of the bed should be elevated (A) to prevent pooling of blood related to the
process of liver mortis, so the nurse should continue with corneal care next, including
instillation of prescribed antibiotic eyedrops and the placement of small ice packs over
the closed eyes (B). (C and D) do not include the measures necessary to protect and
preserve the corneas.
An older female client has been diagnosed with chronic venous insufficiency. To
promote venous return, which action should the nurse encourage the client to take?
a. drink 8 to 10 ounces of water a day.
b. lie down in bed 2 times a day
c. sit at the side of the bed for 15 minutes before standing
d. wear cotton socks and enclosed toe shoes whenever outside. - ANSWERS-b. lie
down in bed 2 times a day
* Elevating the legs by lying down will promote venous return from the legs back to the
heart (B). (A) is important to prevent clot formation, but it does not promote venous
return. (C) helps relieve symptoms of orthostatic hypotension. (D) reduces risk for injury,
especially for diabetics, but is not helpful in promoting venous return.
,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 - ANSWERS-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. - ANSWERS-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. - ANSWERS-
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. - ANSWERS-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." - ANSWERS-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? - ANSWERS-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? - ANSWERS-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? - ANSWERS-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.
B) Obesity.
C) History of atrial fibrillation.
D) Advanced age. - ANSWERS-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. - ANSWERS-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.
VERSIONS) QUESTIONS AND CORRECT DETAILED
ANSWERS |AGRADE
When a nurse is caring for a client with acute hypothyroidism, which serum laboratory
value requires immediate intervention?
a. Thyroxine (T4) 4 mcg/dl
b. Serum sodium 122 mEq/L
c. Serum potassium 3.5 mEq/L
d. Triiodothyronine (T3) level 0.8 mcg/dl - ANSWERS-b. serum sodium 122 mEq/L
A potential donor of corneal tissue for the eye bank has just died. The nurse enters the
room with prescribed antibiotic eye drops. What action should the nurse take next?
a. secure eye shields over the closed eyes after instilling the eye drops
b. instill the eyedrops before placing small ice packs over the closed eyes
c. reposition with the head flat and then instill the prescribed eye drops
d. withhold the eyedrops and apply sterile dressing over both closed eyes - ANSWERS-
a. secure eye shields over the closed eyes after instilling the eye drops
* The head of the bed should be elevated (A) to prevent pooling of blood related to the
process of liver mortis, so the nurse should continue with corneal care next, including
instillation of prescribed antibiotic eyedrops and the placement of small ice packs over
the closed eyes (B). (C and D) do not include the measures necessary to protect and
preserve the corneas.
An older female client has been diagnosed with chronic venous insufficiency. To
promote venous return, which action should the nurse encourage the client to take?
a. drink 8 to 10 ounces of water a day.
b. lie down in bed 2 times a day
c. sit at the side of the bed for 15 minutes before standing
d. wear cotton socks and enclosed toe shoes whenever outside. - ANSWERS-b. lie
down in bed 2 times a day
* Elevating the legs by lying down will promote venous return from the legs back to the
heart (B). (A) is important to prevent clot formation, but it does not promote venous
return. (C) helps relieve symptoms of orthostatic hypotension. (D) reduces risk for injury,
especially for diabetics, but is not helpful in promoting venous return.
,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 - ANSWERS-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. - ANSWERS-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. - ANSWERS-
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. - ANSWERS-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." - ANSWERS-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? - ANSWERS-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? - ANSWERS-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? - ANSWERS-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.
B) Obesity.
C) History of atrial fibrillation.
D) Advanced age. - ANSWERS-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. - ANSWERS-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.
