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HESI MED SURG EVOLVE PRACTICE EXAM|| ACCURATE AND
FREQUENTLY TESTED QUESTIONS AND 100% CORRECT
ANSWERS WITH RATIONALES|| LATEST AND COMPLETE
UPDATE WITH EXPERT VERIFIED SOLUTIONS
A home health nurse knows that a 70-year-old male client who is convalescing
at home following a hip replacement is at risk for developing pressure ulcers.
Which physical characteristic of aging puts the client at risk?
A.
16% increase in overall body
fat B.
Reduced melanin production
C.
Thinning of the skin, with loss of
elasticity D.
Calcium loss in the
bones C
Rationale: Thin nonelastic skin is an important factor in pressure formation. The
proportion of body fat to lean mass increases with age and might help decrease
ulcer tendency. Option B causes gray hair. Option D can contribute to broken
bones, but it is probably not a factor in pressure ulcer formation.
A tornado warning alarm has been activated at the local hospital. Which action
should the charge nurse working on a surgical unit implement first?
A.
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Instruct the nursing staff to close all window blinds and curtains in clients'
rooms. B.
Move clients and visitors into the hallways and close all doors to clients'
rooms. C.
Visually confirm the location of the tornado by checking the windows on the
unit. D.
Assist all visitors with evacuation down the stairs in a calm and orderly
manner. B
Rationale: In the event of a tornado, all persons should be moved into the
hallways, away from windows, to prevent flying debris from causing injury.
Although option A may help decrease the amount of flying debris, it is not safe
to leave clients in rooms with closed blinds; option B is a higher priority at this
time. Hospital staff should stay away from windows to avoid injury and should
focus on client evacuation into hallways rather than option C. Option D is not
the first action that should be taken.
An older client is admitted with a diagnosis of bacterial pneumonia. Which
symptom should the nurse report to the health care provider after assessing the
client?
A.
Leukocytosis and febrile
B.
Polycythemia and crackles
C.
Pharyngitis and sputum production
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D.
Confusion and tachycardia
D
Rationale: The onset of pneumonia in the older client may be signaled by
general deterioration, confusion, increased heart rate, and/or increased
respiratory rate.
Options A, B, and C are often absent in the older client with bacterial pneumonia.
During the change of shift report, the charge nurse reviews the infusions
being received by clients on the oncology unit. The client receiving which
infusion should be assessed first?
A.
Continuous IV infusion of magnesium
B.
One-time infusion of
albumin C.
Continuous epidural infusion of morphine
D.
Intermittent infusion of IV vancomycin
C
Rationale: All four of these clients have the potential to have significant
complications. The client with the morphine epidural infusion is at highest risk
for respiratory depression and should be assessed first. Option A can cause
hypotension. The client receiving option B is at lowest risk for serious
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complications. Although option D can cause nephrotoxicity and phlebitis, these
problems are not as immediately life threatening as option C.
The nurse on a medical-surgical unit is receiving a client from the
postanesthesia care unit (PACU) with a Penrose drain. Before choosing a room
for this client, which information is most important for the nurse to obtain?
A.
If suctioning will be needed for drainage of the
wound B.
If the family would prefer a private or semiprivate room
C.
If the client also has a Hemovac in place
D.
If the client's wound is infected
D
Rationale: The fact that the client has a Penrose drain should alert the nurse to
the possibility that the surgical wound is infected. Penrose drains provide a
sinus tract or opening and are often used to provide drainage of an abscess. To
avoid contamination of another postoperative client, it is most important to
place any client with an infected wound in a private room. A Penrose drain does
not require option A. Although option B is helpful information, it does not have
the priority of option D. A Hemovac is used to drain fluid from a dead space
and is not a determinant for the room assignment.
HESI MED SURG EVOLVE PRACTICE EXAM|| ACCURATE AND
FREQUENTLY TESTED QUESTIONS AND 100% CORRECT
ANSWERS WITH RATIONALES|| LATEST AND COMPLETE
UPDATE WITH EXPERT VERIFIED SOLUTIONS
A home health nurse knows that a 70-year-old male client who is convalescing
at home following a hip replacement is at risk for developing pressure ulcers.
Which physical characteristic of aging puts the client at risk?
A.
16% increase in overall body
fat B.
Reduced melanin production
C.
Thinning of the skin, with loss of
elasticity D.
Calcium loss in the
bones C
Rationale: Thin nonelastic skin is an important factor in pressure formation. The
proportion of body fat to lean mass increases with age and might help decrease
ulcer tendency. Option B causes gray hair. Option D can contribute to broken
bones, but it is probably not a factor in pressure ulcer formation.
A tornado warning alarm has been activated at the local hospital. Which action
should the charge nurse working on a surgical unit implement first?
A.
,2|Page
Instruct the nursing staff to close all window blinds and curtains in clients'
rooms. B.
Move clients and visitors into the hallways and close all doors to clients'
rooms. C.
Visually confirm the location of the tornado by checking the windows on the
unit. D.
Assist all visitors with evacuation down the stairs in a calm and orderly
manner. B
Rationale: In the event of a tornado, all persons should be moved into the
hallways, away from windows, to prevent flying debris from causing injury.
Although option A may help decrease the amount of flying debris, it is not safe
to leave clients in rooms with closed blinds; option B is a higher priority at this
time. Hospital staff should stay away from windows to avoid injury and should
focus on client evacuation into hallways rather than option C. Option D is not
the first action that should be taken.
An older client is admitted with a diagnosis of bacterial pneumonia. Which
symptom should the nurse report to the health care provider after assessing the
client?
A.
Leukocytosis and febrile
B.
Polycythemia and crackles
C.
Pharyngitis and sputum production
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D.
Confusion and tachycardia
D
Rationale: The onset of pneumonia in the older client may be signaled by
general deterioration, confusion, increased heart rate, and/or increased
respiratory rate.
Options A, B, and C are often absent in the older client with bacterial pneumonia.
During the change of shift report, the charge nurse reviews the infusions
being received by clients on the oncology unit. The client receiving which
infusion should be assessed first?
A.
Continuous IV infusion of magnesium
B.
One-time infusion of
albumin C.
Continuous epidural infusion of morphine
D.
Intermittent infusion of IV vancomycin
C
Rationale: All four of these clients have the potential to have significant
complications. The client with the morphine epidural infusion is at highest risk
for respiratory depression and should be assessed first. Option A can cause
hypotension. The client receiving option B is at lowest risk for serious
, 4|Page
complications. Although option D can cause nephrotoxicity and phlebitis, these
problems are not as immediately life threatening as option C.
The nurse on a medical-surgical unit is receiving a client from the
postanesthesia care unit (PACU) with a Penrose drain. Before choosing a room
for this client, which information is most important for the nurse to obtain?
A.
If suctioning will be needed for drainage of the
wound B.
If the family would prefer a private or semiprivate room
C.
If the client also has a Hemovac in place
D.
If the client's wound is infected
D
Rationale: The fact that the client has a Penrose drain should alert the nurse to
the possibility that the surgical wound is infected. Penrose drains provide a
sinus tract or opening and are often used to provide drainage of an abscess. To
avoid contamination of another postoperative client, it is most important to
place any client with an infected wound in a private room. A Penrose drain does
not require option A. Although option B is helpful information, it does not have
the priority of option D. A Hemovac is used to drain fluid from a dead space
and is not a determinant for the room assignment.
