Medsurg-HESI Test Questions with Verified Answers Graded A+
An ER nurse is completing an assessment on a patient
that is alert but struggles to answer questions. When she A) A carotid bruit.
attempts to talk, she slurs her speech and appears very
frightened. What additional clinical manifestation does Rationale: the carotid artery (artery to the brain) is nar-
the nurse expect to find if nacy's sysmptoms have been rowed in clients with a brain attack. A bruit is an abnormal
caused by a brain attack (stroke)? sound heard on auscultation resulting from interference
with normal blood flow. Usually the blood pressure is
A. A carotid bruit hypertensive. Initially flaccid paralysis occurs, resulting in
B. A hypotensive blood pressure hyporefkexic deep tendon reflexes. Bowel sounds are not
C. hyperreflexic deep tendon relexes. indicative of a brain attack.
D. Decreased bowel sounds
D) Global aphasia.
Which clinical manifestation further supports an assess-
ment of a left-sided brain attack? Rationale: Global aphasia refers to diflculty speaking,
listening, and understanding, as well as diflculty read-
A) Visual field deficit on the left side.
ing and writing. Symptoms vary from person to person.
B) Spatial-perceptual deficits.
Aphasia may occur secondary to any brain injury involving
C) Paresthesia of the left side.
the left hemisphere. Visual field deficits, spatial-perceptual
D) Global aphasia.
deficits, and paresthsia of the left side usually occur with
D) Global aphasia.
right-sided brain attack.
When preparing a patient for a noncontrast computed
B) Explain that the client will not be able to move her head
tomography (CT) scan STAT, what nursing intervention
throughout the CT scan.
should the nurse implement?
Rationale: Because head motion will distort the images,
A) Determine if the client has any allergies to iodine
Nancy will have to remain still throughout the procedure.
B) Explain that the client will not be able to move her head
Allergies to iodine is important if contrast dye is being
throughout the CT scan.
used for the CT scan. Premedicating the client to decrease
C) Premedicate the client to decrease pain prior to having
pain prior to the procedure is unnecessary because CT
the procedure.
scanning is a noninvasive and painless procedure. Pro-
D) Provide an explanation of relaxation exercises prior to
viding an explanation of relaxation exercises prior to the
the procedure.
,Medsurg-HESI Test Questions with Verified Answers Graded A+
procedure is a worthwhile intervention to decrease anxiety
but is not of highest priority.
A neurologist prescribes a magnetic resonance imaging
C) Right hip replacement.
(MRI) of the head STAT for a patient. Which data warrants
immediate intervention by the nurse concerning this di- The magnetic field generated by the MRI is so strong
agnostic test? that metal-containing items are strongly attracted to the
magnet. Because the hip joint is made of metal, a lead
A) Elevated blood pressure.
shield must be used during the procedure. Elevated blood
B) Allergy to shell fish.
pressure, an allergy to shell fish, and a history of atrial
C) Right hip replacement.
fibrillation would not attect the MRI.
D) History of atrial fibrillation.
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 con-
B) "Your mother has had a stroke, and the blood supply to
dition and they are going to run several tests. I just don't
the brain has been blocked."
know what is going on. What happened to my mother?"
What is the best response by the nurse? Rationale: The nurse can discuss what a diagnosis means.
Nancy is unable to make decisions, so the next of kin,
A) "I am sorry, but according to the Health Insurance
her daughter, Gail, needs suflcient information to make
Portability and Accounting Act (HIPAA), I cannot give you
informed decisions. The nurse has the knowledge, and
any information."
the responsibility, to explain Nancy's condition to Gail. The
B) "Your mother has had a stroke, and the blood supply
nurse should give facts first, and then address her feelings
to the brain has been blocked."
after the information is provided.
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."
The normal range for cardiac output to ensure cerebral
What is the normal range for cardiac output?
blood flow and oxygen delivery is 4 to 8 L/min.
,Medsurg-HESI Test Questions with Verified Answers Graded A+
A client was admitted with the diagnosis of a brain attack. Thrombolytic therapy is contraindicated in clients with
Their symptoms began 24 hours before being admitted. symptom onset longer than 3 hours prior to admission.
Why would this client not be a candidate for for throm- This client had symptoms for 24 hours before being
bolytic therapy? brought to the medical center
Plate guards prevent food from being pushed ott the
plate. Using plate guards and other assistive devices
What are plate guards?
will encourage independence in a client with a self-care
deficit.
Which condition is considered a non-modifiable risk fac- D) Advanced age.
tor for a brain attack?
Rationale: People over age 55 are a high-risk group for
A) High cholesterol levels. a brain attack because the incidence of stroke more than
B) Obesity. doubles in each successive decade of life. Non-modifiable
C) History of atrial fibrillation. means the client cannot do anything to change the risk
D) Advanced age. factor. All the other options are modifiable risk factors.
B) Place the objects Nancy needs for activities of daily
A client is experiencing homonymous hemianopsia as the
living on the left side of the table.
result of a brain attack. Which nursing intervention would
the nurse implement to address this condition? Rationale: Homonymous hemianopsia is loss of the visual
field on the same side as the paralyzed side. This results in
A) Turn Nancy every two hours and perform active range
the client neglecting that side of the body, so it is beneficial
of motion exercises.
to place objects on that side. Nancy had a left-hemisphere
B) Place the objects Nancy needs for activities of daily
brain attack so her right side is the weak side. Speaking
living on the left side of the table.
slowly and clearly would address the client's verbal deficits
C) Speak slowly and clearly to assist Nancy in forming
due to aphasia. Requesting all liquids to be thickened
sounds to words.
would address dysphagia. Turning the client every 2 hours
D) Request that the dietary department thicken all liquids
and performing active range of motion exercises would
on Nancy's meal and snack trays.
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
, Medsurg-HESI Test Questions with Verified Answers Graded A+
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 B) PT reported client complained of dizziness when getting
record? out of bed, and gait belt was used to allow client to fall
back onto the bed.
A) Client experienced orthostatic hypotension when get-
ting out of bed. Rationale: This documentation provides the factual data
B) PT reported client complained of dizziness when get- of the events that occurred. A)The nurse is making an
ting out of bed, and gait belt was used to allow client to assumption that the dizziness was caused by orthostatic
fall back onto the bed. hypotension. C) Not all the pertinent facts are included in
C) PT notified the primary nurse that the client could not this documentation.
ambulate at this time because of dizziness. D) A variance report should never be documented in the
D) Client had diflculty ambulating from the bed to the client's record.
chair when accompanied by the PT, variance report com-
pleted.
A) Encourage the client to use the incentive spirometer
A new nurse graduate is caring for a postoperative client and to cough.
with the following arterial blood gases (ABGs): pH, 7.30;
PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 Rationale: Respiratory acidosis is caused by CO2 retention
mEq/L; and O2 saturation, 96%. Which of these actions and impaired chest expansion secondary to anesthesia.
by the new graduate is indicated? The nurse takes steps to promote CO2 elimination, in-
cluding maintaining a patent airway and expanding the
A) Encourage the client to use the incentive spirometer lungs through breathing techniques. O2 is not indicated
and to cough. because Po2 and oxygen saturation are within the nor-
B) Administer oxygen by nasal cannula. mal range. Sodium bicarbonate is not indicated because
C) Request a prescription for sodium bicarbonate from the bicarbonate level is in the normal range; promoting
the health care provider. excretion of respiratory acids is the priority in respiratory
D) Inform the charge nurse that no changes in therapy are acidosis. Post anesthesia, the client will need interventions
needed. as described in A above or may progress to a state of
somnolence and unresponsiveness.
An ER nurse is completing an assessment on a patient
that is alert but struggles to answer questions. When she A) A carotid bruit.
attempts to talk, she slurs her speech and appears very
frightened. What additional clinical manifestation does Rationale: the carotid artery (artery to the brain) is nar-
the nurse expect to find if nacy's sysmptoms have been rowed in clients with a brain attack. A bruit is an abnormal
caused by a brain attack (stroke)? sound heard on auscultation resulting from interference
with normal blood flow. Usually the blood pressure is
A. A carotid bruit hypertensive. Initially flaccid paralysis occurs, resulting in
B. A hypotensive blood pressure hyporefkexic deep tendon reflexes. Bowel sounds are not
C. hyperreflexic deep tendon relexes. indicative of a brain attack.
D. Decreased bowel sounds
D) Global aphasia.
Which clinical manifestation further supports an assess-
ment of a left-sided brain attack? Rationale: Global aphasia refers to diflculty speaking,
listening, and understanding, as well as diflculty read-
A) Visual field deficit on the left side.
ing and writing. Symptoms vary from person to person.
B) Spatial-perceptual deficits.
Aphasia may occur secondary to any brain injury involving
C) Paresthesia of the left side.
the left hemisphere. Visual field deficits, spatial-perceptual
D) Global aphasia.
deficits, and paresthsia of the left side usually occur with
D) Global aphasia.
right-sided brain attack.
When preparing a patient for a noncontrast computed
B) Explain that the client will not be able to move her head
tomography (CT) scan STAT, what nursing intervention
throughout the CT scan.
should the nurse implement?
Rationale: Because head motion will distort the images,
A) Determine if the client has any allergies to iodine
Nancy will have to remain still throughout the procedure.
B) Explain that the client will not be able to move her head
Allergies to iodine is important if contrast dye is being
throughout the CT scan.
used for the CT scan. Premedicating the client to decrease
C) Premedicate the client to decrease pain prior to having
pain prior to the procedure is unnecessary because CT
the procedure.
scanning is a noninvasive and painless procedure. Pro-
D) Provide an explanation of relaxation exercises prior to
viding an explanation of relaxation exercises prior to the
the procedure.
,Medsurg-HESI Test Questions with Verified Answers Graded A+
procedure is a worthwhile intervention to decrease anxiety
but is not of highest priority.
A neurologist prescribes a magnetic resonance imaging
C) Right hip replacement.
(MRI) of the head STAT for a patient. Which data warrants
immediate intervention by the nurse concerning this di- The magnetic field generated by the MRI is so strong
agnostic test? that metal-containing items are strongly attracted to the
magnet. Because the hip joint is made of metal, a lead
A) Elevated blood pressure.
shield must be used during the procedure. Elevated blood
B) Allergy to shell fish.
pressure, an allergy to shell fish, and a history of atrial
C) Right hip replacement.
fibrillation would not attect the MRI.
D) History of atrial fibrillation.
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 con-
B) "Your mother has had a stroke, and the blood supply to
dition and they are going to run several tests. I just don't
the brain has been blocked."
know what is going on. What happened to my mother?"
What is the best response by the nurse? Rationale: The nurse can discuss what a diagnosis means.
Nancy is unable to make decisions, so the next of kin,
A) "I am sorry, but according to the Health Insurance
her daughter, Gail, needs suflcient information to make
Portability and Accounting Act (HIPAA), I cannot give you
informed decisions. The nurse has the knowledge, and
any information."
the responsibility, to explain Nancy's condition to Gail. The
B) "Your mother has had a stroke, and the blood supply
nurse should give facts first, and then address her feelings
to the brain has been blocked."
after the information is provided.
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."
The normal range for cardiac output to ensure cerebral
What is the normal range for cardiac output?
blood flow and oxygen delivery is 4 to 8 L/min.
,Medsurg-HESI Test Questions with Verified Answers Graded A+
A client was admitted with the diagnosis of a brain attack. Thrombolytic therapy is contraindicated in clients with
Their symptoms began 24 hours before being admitted. symptom onset longer than 3 hours prior to admission.
Why would this client not be a candidate for for throm- This client had symptoms for 24 hours before being
bolytic therapy? brought to the medical center
Plate guards prevent food from being pushed ott the
plate. Using plate guards and other assistive devices
What are plate guards?
will encourage independence in a client with a self-care
deficit.
Which condition is considered a non-modifiable risk fac- D) Advanced age.
tor for a brain attack?
Rationale: People over age 55 are a high-risk group for
A) High cholesterol levels. a brain attack because the incidence of stroke more than
B) Obesity. doubles in each successive decade of life. Non-modifiable
C) History of atrial fibrillation. means the client cannot do anything to change the risk
D) Advanced age. factor. All the other options are modifiable risk factors.
B) Place the objects Nancy needs for activities of daily
A client is experiencing homonymous hemianopsia as the
living on the left side of the table.
result of a brain attack. Which nursing intervention would
the nurse implement to address this condition? Rationale: Homonymous hemianopsia is loss of the visual
field on the same side as the paralyzed side. This results in
A) Turn Nancy every two hours and perform active range
the client neglecting that side of the body, so it is beneficial
of motion exercises.
to place objects on that side. Nancy had a left-hemisphere
B) Place the objects Nancy needs for activities of daily
brain attack so her right side is the weak side. Speaking
living on the left side of the table.
slowly and clearly would address the client's verbal deficits
C) Speak slowly and clearly to assist Nancy in forming
due to aphasia. Requesting all liquids to be thickened
sounds to words.
would address dysphagia. Turning the client every 2 hours
D) Request that the dietary department thicken all liquids
and performing active range of motion exercises would
on Nancy's meal and snack trays.
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
, Medsurg-HESI Test Questions with Verified Answers Graded A+
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 B) PT reported client complained of dizziness when getting
record? out of bed, and gait belt was used to allow client to fall
back onto the bed.
A) Client experienced orthostatic hypotension when get-
ting out of bed. Rationale: This documentation provides the factual data
B) PT reported client complained of dizziness when get- of the events that occurred. A)The nurse is making an
ting out of bed, and gait belt was used to allow client to assumption that the dizziness was caused by orthostatic
fall back onto the bed. hypotension. C) Not all the pertinent facts are included in
C) PT notified the primary nurse that the client could not this documentation.
ambulate at this time because of dizziness. D) A variance report should never be documented in the
D) Client had diflculty ambulating from the bed to the client's record.
chair when accompanied by the PT, variance report com-
pleted.
A) Encourage the client to use the incentive spirometer
A new nurse graduate is caring for a postoperative client and to cough.
with the following arterial blood gases (ABGs): pH, 7.30;
PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 Rationale: Respiratory acidosis is caused by CO2 retention
mEq/L; and O2 saturation, 96%. Which of these actions and impaired chest expansion secondary to anesthesia.
by the new graduate is indicated? The nurse takes steps to promote CO2 elimination, in-
cluding maintaining a patent airway and expanding the
A) Encourage the client to use the incentive spirometer lungs through breathing techniques. O2 is not indicated
and to cough. because Po2 and oxygen saturation are within the nor-
B) Administer oxygen by nasal cannula. mal range. Sodium bicarbonate is not indicated because
C) Request a prescription for sodium bicarbonate from the bicarbonate level is in the normal range; promoting
the health care provider. excretion of respiratory acids is the priority in respiratory
D) Inform the charge nurse that no changes in therapy are acidosis. Post anesthesia, the client will need interventions
needed. as described in A above or may progress to a state of
somnolence and unresponsiveness.
