EVOLVE MED SURG HESI LATEST 2026 PRACTICE
QUESTIONS AND ANSWERS WITH FULL RATIONALES
| INSTANT DOWNLOAD PDF
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. - correct answer -Correct 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.
The client is return demonstrating wrapping of the left limb amputated above the knee. The
nurse evaluates the client is starting the wrapping method correctly when the client places the
end of the bandage at which point?
A.Around the waist
B.At the inner aspect of the left stump
C.At the outer aspect of the left stump
D.At the left groin area - correct answer -Correct Answer: A
Rationale:The waist is the anchor point for the bandage for an above the knee amputation.
,A nurse is assisting an 82-year-old client with ambulation and is concerned that the client may
fall. Which area contains the older person's center of gravity?
A. Head and neck
B. Upper torso
C. Bilateral arms
D. Feet and legs - correct answer -Correct Answer: B
Rationale:Stooped posture results in the upper torso becoming the center of gravity for older
persons. The center of gravity for adults is the hips. However, as a person grows older, a stooped
posture is common because of changes caused by osteoporosis and normal bone degeneration.
Furthermore, the knees, hips, and elbows flex. The head and neck and feet and legs are not the
center of gravity in the older adult. Although the arms comprise a part of the upper torso, they
do not reflect the best and most complete answer.
A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks and is
scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg.
Which action should the nurse take?
A. Administer the prescribed dose at the scheduled time.
B. Hold the dose and contact the health care provider.
C. Hold the dose and recheck the blood pressure in 1 hour.
D. Check the health care provider's prescription to clarify the dose. - correct answer -Correct
Answer: A
Rationale:The client's blood pressure is within normal limits, indicating that the ramipril, an
antihypertensive, is having the desired effect and should be administered. Options B and C
would be appropriate if the client's blood pressure was excessively low (<100 mm Hg systolic) or
if the client were exhibiting signs of hypotension such as dizziness. This prescribed dose is
within the normal dosage range, as defined by the manufacturer; therefore, option D is not
necessary
,The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic douloureux).
Which symptoms will the nurse be looking for in the focused assessment related to this
condition? (Select all that apply.)
A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in chewing
E.Tinnitus
F.Hearing difficulties - correct answer -Correct Answer: A,B
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 (cranial V). The
remaining symptoms are not related to trigeminal neuralgia.
In caring for a client with acute diverticulitis, which assessment data warrants an immediate
nursing action?
A. The client has a rigid hard abdomen and elevated WBC.
B. The client has left lower quadrant pain and an elevated temperature.
C.The client is refusing to eat any of the meal and is complaining of nausea.
D. The client has not had a bowel movement in 2 days and has a soft abdomen. - correct
answer -Correct Answer: A
Rationale: A hard rigid abdomen and elevated WBC is indicative of peritonitis, which is a
medical emergency and should be reported to the health care provider immediately. Options B
and C are expected clinical manifestations of diverticulitis. Option D does not warrant
immediate intervention.
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 - correct answer -Correct 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 - correct answer -Correct Answer: B
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."
QUESTIONS AND ANSWERS WITH FULL RATIONALES
| INSTANT DOWNLOAD PDF
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. - correct answer -Correct 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.
The client is return demonstrating wrapping of the left limb amputated above the knee. The
nurse evaluates the client is starting the wrapping method correctly when the client places the
end of the bandage at which point?
A.Around the waist
B.At the inner aspect of the left stump
C.At the outer aspect of the left stump
D.At the left groin area - correct answer -Correct Answer: A
Rationale:The waist is the anchor point for the bandage for an above the knee amputation.
,A nurse is assisting an 82-year-old client with ambulation and is concerned that the client may
fall. Which area contains the older person's center of gravity?
A. Head and neck
B. Upper torso
C. Bilateral arms
D. Feet and legs - correct answer -Correct Answer: B
Rationale:Stooped posture results in the upper torso becoming the center of gravity for older
persons. The center of gravity for adults is the hips. However, as a person grows older, a stooped
posture is common because of changes caused by osteoporosis and normal bone degeneration.
Furthermore, the knees, hips, and elbows flex. The head and neck and feet and legs are not the
center of gravity in the older adult. Although the arms comprise a part of the upper torso, they
do not reflect the best and most complete answer.
A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks and is
scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg.
Which action should the nurse take?
A. Administer the prescribed dose at the scheduled time.
B. Hold the dose and contact the health care provider.
C. Hold the dose and recheck the blood pressure in 1 hour.
D. Check the health care provider's prescription to clarify the dose. - correct answer -Correct
Answer: A
Rationale:The client's blood pressure is within normal limits, indicating that the ramipril, an
antihypertensive, is having the desired effect and should be administered. Options B and C
would be appropriate if the client's blood pressure was excessively low (<100 mm Hg systolic) or
if the client were exhibiting signs of hypotension such as dizziness. This prescribed dose is
within the normal dosage range, as defined by the manufacturer; therefore, option D is not
necessary
,The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic douloureux).
Which symptoms will the nurse be looking for in the focused assessment related to this
condition? (Select all that apply.)
A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in chewing
E.Tinnitus
F.Hearing difficulties - correct answer -Correct Answer: A,B
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 (cranial V). The
remaining symptoms are not related to trigeminal neuralgia.
In caring for a client with acute diverticulitis, which assessment data warrants an immediate
nursing action?
A. The client has a rigid hard abdomen and elevated WBC.
B. The client has left lower quadrant pain and an elevated temperature.
C.The client is refusing to eat any of the meal and is complaining of nausea.
D. The client has not had a bowel movement in 2 days and has a soft abdomen. - correct
answer -Correct Answer: A
Rationale: A hard rigid abdomen and elevated WBC is indicative of peritonitis, which is a
medical emergency and should be reported to the health care provider immediately. Options B
and C are expected clinical manifestations of diverticulitis. Option D does not warrant
immediate intervention.
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 - correct answer -Correct 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 - correct answer -Correct Answer: B
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."
