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EVOLVE MED SURG HESI PRACTICE EXAM|| ACCURATE AND
FREQUENTLY TESTED QUESTIONS AND 100% CORRECT ANSWERS WITH
RATIONALES|| LATEST AND COMPLETE UPDATE WITH EXPERT
VERIFIED SOLUTIONS
The nurse is caring for a client with a fractured right elbow. Which assessment finding
has the highest priority and requires immediate intervention?
A. Ecchymosis over the right elbow area
B. Deep unrelenting pain in the right arm
C. An edematous right elbow
D. The presence of crepitus in the right elbow - ANSWER: B
Rationale:Compartment syndrome is a condition involving increased pressure and
constriction of the nerves and vessels within an anatomic compartment, causing pain
uncontrolled by opioids and neurovascular compromise. Option A is an expected
finding. Option C related to compartment syndrome cannot be seen, and any visible
edema is an expected finding related to the injury. Option D is an expected finding.
The nurse notes that a client who is scheduled for surgery the next morning has an
elevated blood urea nitrogen (BUN) level. Which condition is most likely to have
contributed to this finding?
A. Myocardial infarction 2 months ago
B. Anorexia and vomiting for the past 2 days
C. Recently diagnosed type 2 diabetes mellitus
D. Skeletal traction for a right hip fracture - ANSWER: B
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Rationale:The blood urea nitrogen (BUN) level indicates the effectiveness of the
kidneys in filtering waste from the blood. Dehydration, which could be caused by
vomiting, would cause an increased BUN level. Option A would affect serum enzyme
levels, not the BUN level. Option C would primarily affect the blood glucose level;
renal failure that could increase the BUN level would be unlikely in a client newly
diagnosed with type 2 diabetes. Effects of option D might affect the complete blood
count (CBC) but would not directly increase the BUN level.
Which instruction is best for the nurse to provide to a client with emphysema and
chronic fatigue?
A."Pace your activities and schedule rest periods." B."Increase the amount of oxygen
you use at night."
C."Obtain medical evaluation for antibiotic therapy."
D."Reduce your intake of fluids containing caffeine." - ANSWER: A
Rationale:Manifestations of emphysema include an increase in AP diameter (referred to
as a barrel chest), nail bed clubbing, and fatigue. The nurse can provide instructions to
promote energy management, such as pacing activities and scheduling rest periods.
Option B may result in a decreased drive to breathe. The client is not exhibiting any
symptoms of infection, so option C is not necessary. Option D is less beneficial than
option A.
Which nursing action would be appropriate for a client who is newly diagnosed with
Cushing syndrome?
A.Monitor blood glucose levels daily.
B.Increase intake of fluids high in potassium. C.Encourage adequate rest between
activities.
D.Offer the client a sodium-enriched menu. - ANSWER: A
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Rationale: Cushing syndrome results from a hypersecretion of glucocorticoids in the
adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus.
Monitoring of serum glucose levels assesses for increased blood glucose levels so that
treatment can begin early. A common finding in Cushing syndrome is generalized
edema. Although potassium is needed, it is generally obtained from food intake, not
by offering potassium-enhanced fluids. Fatigue is usually not an overwhelming factor
in Cushing syndrome, so an emphasis on the need for rest is not indicated. A low-
calorie, low-carbohydrate, low-sodium diet is not recommended.
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 - ANSWER: 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 complications. Although
option D can cause nephrotoxicity and phlebitis, these problems are not as
immediately life threatening as option C.
A client who received a nephrotoxic drug is admitted with acute renal failure and asks
the nurse if dialysis will always be needed. Which pathophysiologic consequence should
the nurse explain that supports the need for temporary dialysis until acute tubular
necrosis subsides?
.
A. Azotemia
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B. Oliguria
C. Hyperkalemia
D. Nephron obstruction - ANSWER: D
Rationale:CKD is characterized by progressive and irreversible destruction of
nephrons, frequently caused by hypertension and diabetes mellitus. Nephrotoxins
cause acute tubular necrosis, a reversible acute renal failure, which creates renal
tubular obstruction from endothelial cells that are sloughed or become edematous.
The obstruction of urine flow will resolve with the return of an adequate glomerular
filtration rate, and when it does, dialysis will no longer be needed.
Options A, B, and C are manifestations seen in the acute and chronic forms of kidney
disease.
The nurse is concerned about infection for a client after an esophagogastrostomy
for esophageal cancer. Which actions should the nurse include in the client's plan of
care? (Select all that apply.)
A. Frequent oral care every 2 hours while awake.
B. Use incentive spirometer every 2 hours.
C. Empty contents from NG tube every 8 hours.
D. Ambulate within 1 hour of return from the PACU.
E. Limit visitors until postoperative day 2. - ANSWER: A,B,C
Rationale:One hour post op is too soon to ambulate for this client. Visitors help
support the patient and are encouraged to visit. Oral care is necessary as the client
will be NPO. To decrease the risk of infection post operatively, implement routine
pulmonary exercises. The client will have an NG tube in place, likely to intermittent
suction, to decompress the stomach post surgery.
EVOLVE MED SURG HESI PRACTICE EXAM|| ACCURATE AND
FREQUENTLY TESTED QUESTIONS AND 100% CORRECT ANSWERS WITH
RATIONALES|| LATEST AND COMPLETE UPDATE WITH EXPERT
VERIFIED SOLUTIONS
The nurse is caring for a client with a fractured right elbow. Which assessment finding
has the highest priority and requires immediate intervention?
A. Ecchymosis over the right elbow area
B. Deep unrelenting pain in the right arm
C. An edematous right elbow
D. The presence of crepitus in the right elbow - ANSWER: B
Rationale:Compartment syndrome is a condition involving increased pressure and
constriction of the nerves and vessels within an anatomic compartment, causing pain
uncontrolled by opioids and neurovascular compromise. Option A is an expected
finding. Option C related to compartment syndrome cannot be seen, and any visible
edema is an expected finding related to the injury. Option D is an expected finding.
The nurse notes that a client who is scheduled for surgery the next morning has an
elevated blood urea nitrogen (BUN) level. Which condition is most likely to have
contributed to this finding?
A. Myocardial infarction 2 months ago
B. Anorexia and vomiting for the past 2 days
C. Recently diagnosed type 2 diabetes mellitus
D. Skeletal traction for a right hip fracture - ANSWER: B
,2|Page
Rationale:The blood urea nitrogen (BUN) level indicates the effectiveness of the
kidneys in filtering waste from the blood. Dehydration, which could be caused by
vomiting, would cause an increased BUN level. Option A would affect serum enzyme
levels, not the BUN level. Option C would primarily affect the blood glucose level;
renal failure that could increase the BUN level would be unlikely in a client newly
diagnosed with type 2 diabetes. Effects of option D might affect the complete blood
count (CBC) but would not directly increase the BUN level.
Which instruction is best for the nurse to provide to a client with emphysema and
chronic fatigue?
A."Pace your activities and schedule rest periods." B."Increase the amount of oxygen
you use at night."
C."Obtain medical evaluation for antibiotic therapy."
D."Reduce your intake of fluids containing caffeine." - ANSWER: A
Rationale:Manifestations of emphysema include an increase in AP diameter (referred to
as a barrel chest), nail bed clubbing, and fatigue. The nurse can provide instructions to
promote energy management, such as pacing activities and scheduling rest periods.
Option B may result in a decreased drive to breathe. The client is not exhibiting any
symptoms of infection, so option C is not necessary. Option D is less beneficial than
option A.
Which nursing action would be appropriate for a client who is newly diagnosed with
Cushing syndrome?
A.Monitor blood glucose levels daily.
B.Increase intake of fluids high in potassium. C.Encourage adequate rest between
activities.
D.Offer the client a sodium-enriched menu. - ANSWER: A
,3|Page
Rationale: Cushing syndrome results from a hypersecretion of glucocorticoids in the
adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus.
Monitoring of serum glucose levels assesses for increased blood glucose levels so that
treatment can begin early. A common finding in Cushing syndrome is generalized
edema. Although potassium is needed, it is generally obtained from food intake, not
by offering potassium-enhanced fluids. Fatigue is usually not an overwhelming factor
in Cushing syndrome, so an emphasis on the need for rest is not indicated. A low-
calorie, low-carbohydrate, low-sodium diet is not recommended.
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 - ANSWER: 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 complications. Although
option D can cause nephrotoxicity and phlebitis, these problems are not as
immediately life threatening as option C.
A client who received a nephrotoxic drug is admitted with acute renal failure and asks
the nurse if dialysis will always be needed. Which pathophysiologic consequence should
the nurse explain that supports the need for temporary dialysis until acute tubular
necrosis subsides?
.
A. Azotemia
, 4|Page
B. Oliguria
C. Hyperkalemia
D. Nephron obstruction - ANSWER: D
Rationale:CKD is characterized by progressive and irreversible destruction of
nephrons, frequently caused by hypertension and diabetes mellitus. Nephrotoxins
cause acute tubular necrosis, a reversible acute renal failure, which creates renal
tubular obstruction from endothelial cells that are sloughed or become edematous.
The obstruction of urine flow will resolve with the return of an adequate glomerular
filtration rate, and when it does, dialysis will no longer be needed.
Options A, B, and C are manifestations seen in the acute and chronic forms of kidney
disease.
The nurse is concerned about infection for a client after an esophagogastrostomy
for esophageal cancer. Which actions should the nurse include in the client's plan of
care? (Select all that apply.)
A. Frequent oral care every 2 hours while awake.
B. Use incentive spirometer every 2 hours.
C. Empty contents from NG tube every 8 hours.
D. Ambulate within 1 hour of return from the PACU.
E. Limit visitors until postoperative day 2. - ANSWER: A,B,C
Rationale:One hour post op is too soon to ambulate for this client. Visitors help
support the patient and are encouraged to visit. Oral care is necessary as the client
will be NPO. To decrease the risk of infection post operatively, implement routine
pulmonary exercises. The client will have an NG tube in place, likely to intermittent
suction, to decompress the stomach post surgery.
