MEDICAL SURGICAL
EVOLVE HESI MEDICAL SURGICAL
INTEGRATED TEST ACTUAL EXAM 3
VERIFIED QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED
RATIONALES) |ALREADY GRADED A+ BEST
DOCUMENT FOR FINAL EXAM
A client with cirrhosis develops increasing pedal edema and ascites. Which dietary
modification is most important for the nurse to teach this client?
A.
Avoid high-carbohydrate foods.
B.
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Decrease intake of fat-soluble vitamins.
C.
Decrease caloric intake.
D.
Restrict salt and fluid intake. –
Correct Answer :D
Rationale:
Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as
manifested by edema and ascites. Options A, B, and C will not affect fluid retention.
When educating a client after a total laryngectomy, which instruction would be most
important for the nurse to include in the discharge teaching?
A.
Recommend that the client carry suction equipment at all times.
B.
Instruct the client to carry writing materials at all times.
C.
Tell the client to carry a medical alert card that explains the condition.
D.
Caution the client not to travel outside the United States alone. –
Correct Answer :C
Rationale:
Neck breathers carry a medical alert card that notifies health care personnel of the need to
use mouth to stoma breathing in the event of a cardiac arrest in this client. Mouth-to-mouth
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resuscitation will not establish a patent airway. Options A and D are not necessary. There are
many alternative means of communication for clients who have had a laryngectomy;
dependence on writing messages is probably the least effective.
A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a
continuous pump infusion. The client begins to cough and produces a moderate amount of
white sputum. Which action should the nurse take first?
A.
Auscultate the client's breath sounds.
B.
Turn off the continuous feeding pump.
C.
Check placement of the nasogastric tube.
D.
Measure the amount of residual feeding. –
Correct Answer :B
Rationale:
A productive cough may indicate that the feeding has been aspirated. The nurse should first
stop the feeding to prevent further aspiration. Options A, C, and D should all be performed
before restarting the tube feeding if no evidence of aspiration is present and the tube is in
place.
A client who is receiving an angiotensin-converting enzyme (ACE) inhibitor for hypertension
calls the clinic and reports the recent onset of a cough to the nurse. Which action should the
nurse take first?
A.
Advise the client to come to the clinic immediately for further assessment.
B.
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Instruct the client to discontinue use of the drug and to make an appointment at the clinic.
C.
Suggest that the client learn to accept the cough as a side effect to a necessary prescription.
D.
Encourage the client to keep taking the drug until seen by the health care provider. –
Correct Answer :D
Rationale:
Coughing is a common side effect of ACE inhibitors and is not an indication to discontinue the
medication. Immediate evaluation is not needed. Antihypertensive medications should not be
stopped abruptly because rebound hypertension may occur. Option C is demeaning because
the cough may be very disruptive to the client, and other antihypertensive medications may
produce the desired effect without the adverse effect.
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 –
Correct Answer :D
Rationale:
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EVOLVE HESI MEDICAL SURGICAL
INTEGRATED TEST ACTUAL EXAM 3
VERIFIED QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED
RATIONALES) |ALREADY GRADED A+ BEST
DOCUMENT FOR FINAL EXAM
A client with cirrhosis develops increasing pedal edema and ascites. Which dietary
modification is most important for the nurse to teach this client?
A.
Avoid high-carbohydrate foods.
B.
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, MEDICAL SURGICAL
Decrease intake of fat-soluble vitamins.
C.
Decrease caloric intake.
D.
Restrict salt and fluid intake. –
Correct Answer :D
Rationale:
Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as
manifested by edema and ascites. Options A, B, and C will not affect fluid retention.
When educating a client after a total laryngectomy, which instruction would be most
important for the nurse to include in the discharge teaching?
A.
Recommend that the client carry suction equipment at all times.
B.
Instruct the client to carry writing materials at all times.
C.
Tell the client to carry a medical alert card that explains the condition.
D.
Caution the client not to travel outside the United States alone. –
Correct Answer :C
Rationale:
Neck breathers carry a medical alert card that notifies health care personnel of the need to
use mouth to stoma breathing in the event of a cardiac arrest in this client. Mouth-to-mouth
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resuscitation will not establish a patent airway. Options A and D are not necessary. There are
many alternative means of communication for clients who have had a laryngectomy;
dependence on writing messages is probably the least effective.
A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a
continuous pump infusion. The client begins to cough and produces a moderate amount of
white sputum. Which action should the nurse take first?
A.
Auscultate the client's breath sounds.
B.
Turn off the continuous feeding pump.
C.
Check placement of the nasogastric tube.
D.
Measure the amount of residual feeding. –
Correct Answer :B
Rationale:
A productive cough may indicate that the feeding has been aspirated. The nurse should first
stop the feeding to prevent further aspiration. Options A, C, and D should all be performed
before restarting the tube feeding if no evidence of aspiration is present and the tube is in
place.
A client who is receiving an angiotensin-converting enzyme (ACE) inhibitor for hypertension
calls the clinic and reports the recent onset of a cough to the nurse. Which action should the
nurse take first?
A.
Advise the client to come to the clinic immediately for further assessment.
B.
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Instruct the client to discontinue use of the drug and to make an appointment at the clinic.
C.
Suggest that the client learn to accept the cough as a side effect to a necessary prescription.
D.
Encourage the client to keep taking the drug until seen by the health care provider. –
Correct Answer :D
Rationale:
Coughing is a common side effect of ACE inhibitors and is not an indication to discontinue the
medication. Immediate evaluation is not needed. Antihypertensive medications should not be
stopped abruptly because rebound hypertension may occur. Option C is demeaning because
the cough may be very disruptive to the client, and other antihypertensive medications may
produce the desired effect without the adverse effect.
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 –
Correct Answer :D
Rationale:
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