MED-SURG HESI PRACTICE TEST: KEY
CONCEPTS & CLINICAL SCENARIOS
Small bowel obstruction is a condition characterized by which finding?
Severe fluid and electrolyte imbalances.
Metabolic acidosis.
Ribbon-like stools.
Intermittent lower abdominal cramping.
Rationale
Among the findings characteristic of a small bowel obstruction is the presence of
severe fluid and electrolyte imbalances.
How should the nurse position the electrodes for modified chest lead one (MCL I)
telemetry monitoring?
Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple
line.
Positive polarity left shoulder, negative polarity right chest nipple line, ground left chest
nipple line.
Positive polarity right chest nipple line, negative polarity left chest nipple line, ground left
shoulder.
Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest
nipple line.
Rationale
In MCL I monitoring, the positive electrode is placed on the client's mid-chest to
the right of the sternum, and the negative electrode is placed on the upper left
part of the chest. The ground may be placed anywhere, but is usually placed on
the lower left portion of the chest.
Which description of symptoms is characteristic of a client diagnosed with
trigeminal neuralgia (tic douloureux)?
Tinnitus, vertigo, and hearing difficulties.
Sudden, stabbing, severe pain over the lip and chin.
Facial weakness and paralysis.
Difficulty in chewing, talking, and swallowing.
Rationale
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric
shock, in the area innervated by one or more branches of the trigeminal nerve
(5th cranial). Women are more often afflicted with this condition and generally
occurs in clients over the age of 50 years old.
A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg.
Which action should the nurse implement?
Position the head of the bed (HOB) flat.
Withhold intravenous fluids.
Administer a bolus of IV fluids.
Give an antihypertensive medication.
Rationale
Most ischemic strokes occur during sleep when baseline blood pressure declines
or blood viscosity increases due to minimal fluid intake. Completed strokes
,usually produce neurologic deficits within an hour, and the client's current
, elevated blood pressure requires antihypertensive medication.
The nurse is assessing a client who has a history of Parkinson's disease for the
past 5 years. What symptoms would this client most likely exhibit?
Loss of short-term memory, facial tics and grimaces, and constant writhing movements.
Shuffling gait, masklike facial expression, and tremors of the head.
Extreme muscular weakness, easy fatigability, and ptosis.
Numbness of the extremities, loss of balance, and visual disturbances.
Rationale
Parkinson's Disease is one of the most common neurologic progressive disorder
of the older client. Shuffling gait, masklike facial expression, and tremors of the
head and hands are common clinical features of Parkinsonism.
Healthcare workers must protect themselves against becoming infected with HIV.
The Center for Disease Control has issued guidelines for healthcare workers in
relation to protection from HIV. These guidelines include which recommendation?
Place HIV positive clients in strict isolation and limit visitors.
Wear gloves when coming in contact with the blood or body fluids of any client.
Conduct mandatory HIV testing of those who work with AIDS clients.
Freeze HIV blood specimens at -70 F to kill the virus.
Rationale
The CDC guidelines recommend that healthcare workers use gloves when
coming in contact with blood or body fluids from any client since HIV is
infectious before the client becomes aware of their exposure and/or symptomatic.
The nurse is assisting a client out of bed for the first time after surgery. What
action should the nurse do first?
Place a chair at a right angle to the bedside.
Encourage deep breathing prior to standing.
Help the client to sit and dangle legs on the side of the bed.
Allow the client to sit with the bed in a high Fowler's position.
Rationale
The first step is to raise the head of the bed to a high Fowler's position, which
allow venous return to compensate from lying flat and the vasodilation effects of
perioperative drugs. This helps prevent the client from becoming light-headed
and decreases the chance of a client fall.
What is the correct procedure for performing an opthalmoscopic examination on
a client's right retina?
Instruct the client to look at examiner's nose and not move his/her eyes during the
exam.
Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right
eye.
From a distance of 12 to 15 inches and slightly to the side, shine the light into the
client's pupil.
CONCEPTS & CLINICAL SCENARIOS
Small bowel obstruction is a condition characterized by which finding?
Severe fluid and electrolyte imbalances.
Metabolic acidosis.
Ribbon-like stools.
Intermittent lower abdominal cramping.
Rationale
Among the findings characteristic of a small bowel obstruction is the presence of
severe fluid and electrolyte imbalances.
How should the nurse position the electrodes for modified chest lead one (MCL I)
telemetry monitoring?
Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple
line.
Positive polarity left shoulder, negative polarity right chest nipple line, ground left chest
nipple line.
Positive polarity right chest nipple line, negative polarity left chest nipple line, ground left
shoulder.
Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest
nipple line.
Rationale
In MCL I monitoring, the positive electrode is placed on the client's mid-chest to
the right of the sternum, and the negative electrode is placed on the upper left
part of the chest. The ground may be placed anywhere, but is usually placed on
the lower left portion of the chest.
Which description of symptoms is characteristic of a client diagnosed with
trigeminal neuralgia (tic douloureux)?
Tinnitus, vertigo, and hearing difficulties.
Sudden, stabbing, severe pain over the lip and chin.
Facial weakness and paralysis.
Difficulty in chewing, talking, and swallowing.
Rationale
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric
shock, in the area innervated by one or more branches of the trigeminal nerve
(5th cranial). Women are more often afflicted with this condition and generally
occurs in clients over the age of 50 years old.
A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg.
Which action should the nurse implement?
Position the head of the bed (HOB) flat.
Withhold intravenous fluids.
Administer a bolus of IV fluids.
Give an antihypertensive medication.
Rationale
Most ischemic strokes occur during sleep when baseline blood pressure declines
or blood viscosity increases due to minimal fluid intake. Completed strokes
,usually produce neurologic deficits within an hour, and the client's current
, elevated blood pressure requires antihypertensive medication.
The nurse is assessing a client who has a history of Parkinson's disease for the
past 5 years. What symptoms would this client most likely exhibit?
Loss of short-term memory, facial tics and grimaces, and constant writhing movements.
Shuffling gait, masklike facial expression, and tremors of the head.
Extreme muscular weakness, easy fatigability, and ptosis.
Numbness of the extremities, loss of balance, and visual disturbances.
Rationale
Parkinson's Disease is one of the most common neurologic progressive disorder
of the older client. Shuffling gait, masklike facial expression, and tremors of the
head and hands are common clinical features of Parkinsonism.
Healthcare workers must protect themselves against becoming infected with HIV.
The Center for Disease Control has issued guidelines for healthcare workers in
relation to protection from HIV. These guidelines include which recommendation?
Place HIV positive clients in strict isolation and limit visitors.
Wear gloves when coming in contact with the blood or body fluids of any client.
Conduct mandatory HIV testing of those who work with AIDS clients.
Freeze HIV blood specimens at -70 F to kill the virus.
Rationale
The CDC guidelines recommend that healthcare workers use gloves when
coming in contact with blood or body fluids from any client since HIV is
infectious before the client becomes aware of their exposure and/or symptomatic.
The nurse is assisting a client out of bed for the first time after surgery. What
action should the nurse do first?
Place a chair at a right angle to the bedside.
Encourage deep breathing prior to standing.
Help the client to sit and dangle legs on the side of the bed.
Allow the client to sit with the bed in a high Fowler's position.
Rationale
The first step is to raise the head of the bed to a high Fowler's position, which
allow venous return to compensate from lying flat and the vasodilation effects of
perioperative drugs. This helps prevent the client from becoming light-headed
and decreases the chance of a client fall.
What is the correct procedure for performing an opthalmoscopic examination on
a client's right retina?
Instruct the client to look at examiner's nose and not move his/her eyes during the
exam.
Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right
eye.
From a distance of 12 to 15 inches and slightly to the side, shine the light into the
client's pupil.
