Florida State University NUR 4445
EVOLVE MED SURG HESI EXAM QUESTIONS AND
CORRECT ANSWERS WITH WELL-ELABORATED
RATIONALES/ GRADED A+| EVOLVE HESI MEDICAL
SURGICAL LATEST EXAM (BRAND NEW!
Students also studied
Flashcard sets Study guides
C
Terms in this set (125)
The nurse is concerned about infection for a Correct
Answer: A,B,C client after an esophagogastrostomy for
esophageal cancer. Which actions should Rationale:One hour post op is too soon to ambulate for
this the nurse include in the client's plan of care? client. Visitors help support the patient and are
encouraged to (Select all that apply.) visit. Oral care is necessary as the client will be NPO. To
decrease the risk of infection post operatively, implement
A. Frequent oral care every 2 hours while routine pulmonary exercises. The client will have an NG
tube awake. in place, likely to intermittent suction, to decompress the
B.Use incentive spirometer every 2 hours. stomach post surgery.
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.
The client is return demonstrating wrapping Correct Answer: A
of the left limb amputated above the knee. Rationale:The waist is the anchor point for the bandage for
an The nurse evaluates the client is starting the above the knee amputation.
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
,A nurse is assisting an 82-year-old client Correct Answer: B
with ambulation and is concerned that the Rationale:Stooped posture results in the upper torso
client may fall. Which area contains the becoming the center of gravity for older persons. The center
older person's center of gravity? of gravity for adults is the hips. However, as a person grows
A. Head and neck older, a stooped posture is common because of changes
B. Upper torso caused by osteoporosis and normal bone degeneration.
C. Bilateral arms Furthermore, the knees, hips, and elbows flex. The head and
D. Feet and legs 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 Correct Answer: A
receiving ramipril, 5 mg PO, daily for 2 Rationale:The client's blood pressure is within normal limits,
weeks and is scheduled to receive a dose at indicating that the ramipril, an antihypertensive, is
having the 0900. At 0830, the client's blood pressure is desired effect and should be
administered. Options B and C 120/70 mm Hg. Which action should the would be appropriate if the
client's blood pressure was nurse take? excessively low (<100 mm Hg systolic) or if the client were
A. Administer the prescribed dose at the exhibiting signs of hypotension such as dizziness. This
scheduled time. prescribed dose is within the normal dosage range, as defined
B. Hold the dose and contact the health by the manufacturer; therefore, option D is not
necessary 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.
The nurse is providing care for a client Correct Answer: A,B
diagnosed with trigeminal neuralgia (tic Rationale:Trigeminal neuralgia is characterized by paroxysms
douloureux). Which symptoms will the nurse of pain, similar to an electric shock, in the area
innervated by be looking for in the focused assessment one or more branches of the trigeminal
nerve (cranial V). The related to this condition? (Select all that remaining symptoms are not related to
trigeminal neuralgia. apply.)
A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in chewing
E.Tinnitus
F.Hearing difficulties
In caring for a client with acute diverticulitis, Correct
Answer: A which assessment data warrants an
immediate nursing action? Rationale: A hard rigid abdomen and elevated WBC is
A. The client has a rigid hard abdomen and indicative of peritonitis, which is a medical emergency and
elevated WBC. should be reported to the health care provider immediately.
B. The client has left lower quadrant pain Options B and C are expected clinical manifestations of
and an elevated temperature. diverticulitis. Option D does not warrant immediate
C.The client is refusing to eat any of the intervention.
meal and is complaining of nausea.
D. The client has not had a bowel
movement in 2 days and has a soft
abdomen.
,The nurse is caring for a client with a Correct Answer: B
fractured right elbow. Which assessment
finding has the highest priority and requiresRationale:Compartment syndrome is a condition involving
immediate intervention? increased pressure and constriction of the nerves and
vessels
A. Ecchymosis over the right elbow area within an anatomic compartment, causing pain uncontrolled
B.Deep unrelenting pain in the right arm by opioids and neurovascular compromise. Option A is an
C. An edematous right elbow expected finding. Option C related to compartment syndrome
D.The presence of crepitus in the right cannot be seen, and any visible edema is an expected
finding elbow related to the injury. Option D is an expected finding.
The nurse notes that a client who is Correct Answer: B
scheduled for surgery the next morning has
an elevated blood urea nitrogen (BUN) Rationale:The blood urea nitrogen (BUN) level indicates the
level. Which condition is most likely to have effectiveness of the kidneys in filtering waste from the
blood. contributed to this finding? Dehydration, which could be caused by vomiting, would
cause an increased BUN level. Option A would affect serum
A. Myocardial infarction 2 months ago enzyme levels, not the BUN level. Option C would primarily
B. Anorexia and vomiting for the past 2 days affect the blood
glucose level; renal failure that could
C. Recently diagnosed type 2 diabetes increase
the BUN level would be unlikely in a client newly mellitus diagnosed with type 2 diabetes.
Effects of option D might
D.Skeletal traction for a right hip fracture affect the complete blood count (CBC) but would not directly
increase the BUN level.
Which instruction is best for the nurse to Correct Answer:
A provide to a client with emphysema and
chronic fatigue? Rationale:Manifestations of emphysema include an increase
in A."Pace your activities and schedule rest AP diameter (referred to as a barrel chest), nail bed clubbing,
periods." and fatigue. The nurse can provide instructions to promote
B."Increase the amount of oxygen you use at energy management, such as pacing activities and
scheduling night." rest periods. Option B may result in a decreased drive to
C."Obtain medical evaluation for antibiotic breathe. The client is not exhibiting any symptoms of infection,
therapy." so option C is not necessary. Option D is less beneficial
than D."Reduce your intake of fluids containing option A.
caffeine."
Which nursing action would be appropriate Correct Answer:
A for a client who is newly diagnosed with
Cushing syndrome? Rationale: Cushing syndrome results from a hypersecretion of
A. Monitor blood glucose levels daily. glucocorticoids in the adrenal cortex. Clients with Cushing
B. Increase intake of fluids high in potassium. syndrome
often develop diabetes mellitus. Monitoring of C.Encourage adequate rest between serum
glucose levels assesses for increased blood glucose activities. levels so that treatment can begin early. A
common finding in D.Offer the client a sodium-enriched menu. 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 Correct Answer: C
charge nurse reviews the infusions being
received by clients on the oncology unit. Rationale: All four of these clients have the potential to
The client receiving which infusion should have significant complications. The client with the morphine
be assessed first? epidural infusion is at highest risk for respiratory
A.Continuous IV infusion of magnesium depression and should be assessed first. Option A can cause
B.One-time infusion of albumin hypotension. The client receiving option B is at lowest risk
C.Continuous epidural infusion of morphine for serious complications. Although option D can cause
D.Intermittent infusion of IV vancomycin nephrotoxicity and phlebitis, these problems are not as
immediately life threatening as option C.
A client who received a nephrotoxic drug is Correct Answer: D
admitted with acute renal failure and asks
the nurse if dialysis will always be Rationale:CKD is characterized by progressive and irreversible
needed. Which pathophysiologic destruction of nephrons, frequently caused by hypertension
consequence should the nurse explain and diabetes mellitus. Nephrotoxins cause acute tubular
that supports the need for temporary necrosis, a reversible acute renal failure, which creates
dialysis until acute tubular necrosis renal tubular obstruction from endothelial cells that are
subsides? 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
A. Azotemia needed.
B.Oliguria Options A, B, and C are manifestations seen in the acute and
C. Hyperkalemia chronic forms of kidney disease.
D. Nephron obstruction
The client returns to the unit after Correct Answer: B
abdominal surgery with a 5″ × 9″ absorbent
dressing in place to the mid abdomen. The Rationale:By circling the existing stain upon admission to the
nurse notes a spot of red staining unit, the nurse can then assess any increase, though subtle, in
centrally on the dressing. What is the the amount of drainage over time. The size of the stain will
nurse's next action? need to be noted in the chart, but it is not the first action. The
A. Note the size of the stain in the chart. nurse removes the dressing under the prescription of the
B.Circle the stain with an ink pen. health care provider or in an emergency. Neither of those
C. Remove the dressing to assess the conditions exist in the question. The dressing in place is an
source of the bleeding. absorbent dressing. There is no need for a further
D.Place a pressure dressing on the dressing until the existing dressing becomes saturated.
existing dressing.
EVOLVE MED SURG HESI EXAM QUESTIONS AND
CORRECT ANSWERS WITH WELL-ELABORATED
RATIONALES/ GRADED A+| EVOLVE HESI MEDICAL
SURGICAL LATEST EXAM (BRAND NEW!
Students also studied
Flashcard sets Study guides
C
Terms in this set (125)
The nurse is concerned about infection for a Correct
Answer: A,B,C client after an esophagogastrostomy for
esophageal cancer. Which actions should Rationale:One hour post op is too soon to ambulate for
this the nurse include in the client's plan of care? client. Visitors help support the patient and are
encouraged to (Select all that apply.) visit. Oral care is necessary as the client will be NPO. To
decrease the risk of infection post operatively, implement
A. Frequent oral care every 2 hours while routine pulmonary exercises. The client will have an NG
tube awake. in place, likely to intermittent suction, to decompress the
B.Use incentive spirometer every 2 hours. stomach post surgery.
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.
The client is return demonstrating wrapping Correct Answer: A
of the left limb amputated above the knee. Rationale:The waist is the anchor point for the bandage for
an The nurse evaluates the client is starting the above the knee amputation.
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
,A nurse is assisting an 82-year-old client Correct Answer: B
with ambulation and is concerned that the Rationale:Stooped posture results in the upper torso
client may fall. Which area contains the becoming the center of gravity for older persons. The center
older person's center of gravity? of gravity for adults is the hips. However, as a person grows
A. Head and neck older, a stooped posture is common because of changes
B. Upper torso caused by osteoporosis and normal bone degeneration.
C. Bilateral arms Furthermore, the knees, hips, and elbows flex. The head and
D. Feet and legs 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 Correct Answer: A
receiving ramipril, 5 mg PO, daily for 2 Rationale:The client's blood pressure is within normal limits,
weeks and is scheduled to receive a dose at indicating that the ramipril, an antihypertensive, is
having the 0900. At 0830, the client's blood pressure is desired effect and should be
administered. Options B and C 120/70 mm Hg. Which action should the would be appropriate if the
client's blood pressure was nurse take? excessively low (<100 mm Hg systolic) or if the client were
A. Administer the prescribed dose at the exhibiting signs of hypotension such as dizziness. This
scheduled time. prescribed dose is within the normal dosage range, as defined
B. Hold the dose and contact the health by the manufacturer; therefore, option D is not
necessary 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.
The nurse is providing care for a client Correct Answer: A,B
diagnosed with trigeminal neuralgia (tic Rationale:Trigeminal neuralgia is characterized by paroxysms
douloureux). Which symptoms will the nurse of pain, similar to an electric shock, in the area
innervated by be looking for in the focused assessment one or more branches of the trigeminal
nerve (cranial V). The related to this condition? (Select all that remaining symptoms are not related to
trigeminal neuralgia. apply.)
A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in chewing
E.Tinnitus
F.Hearing difficulties
In caring for a client with acute diverticulitis, Correct
Answer: A which assessment data warrants an
immediate nursing action? Rationale: A hard rigid abdomen and elevated WBC is
A. The client has a rigid hard abdomen and indicative of peritonitis, which is a medical emergency and
elevated WBC. should be reported to the health care provider immediately.
B. The client has left lower quadrant pain Options B and C are expected clinical manifestations of
and an elevated temperature. diverticulitis. Option D does not warrant immediate
C.The client is refusing to eat any of the intervention.
meal and is complaining of nausea.
D. The client has not had a bowel
movement in 2 days and has a soft
abdomen.
,The nurse is caring for a client with a Correct Answer: B
fractured right elbow. Which assessment
finding has the highest priority and requiresRationale:Compartment syndrome is a condition involving
immediate intervention? increased pressure and constriction of the nerves and
vessels
A. Ecchymosis over the right elbow area within an anatomic compartment, causing pain uncontrolled
B.Deep unrelenting pain in the right arm by opioids and neurovascular compromise. Option A is an
C. An edematous right elbow expected finding. Option C related to compartment syndrome
D.The presence of crepitus in the right cannot be seen, and any visible edema is an expected
finding elbow related to the injury. Option D is an expected finding.
The nurse notes that a client who is Correct Answer: B
scheduled for surgery the next morning has
an elevated blood urea nitrogen (BUN) Rationale:The blood urea nitrogen (BUN) level indicates the
level. Which condition is most likely to have effectiveness of the kidneys in filtering waste from the
blood. contributed to this finding? Dehydration, which could be caused by vomiting, would
cause an increased BUN level. Option A would affect serum
A. Myocardial infarction 2 months ago enzyme levels, not the BUN level. Option C would primarily
B. Anorexia and vomiting for the past 2 days affect the blood
glucose level; renal failure that could
C. Recently diagnosed type 2 diabetes increase
the BUN level would be unlikely in a client newly mellitus diagnosed with type 2 diabetes.
Effects of option D might
D.Skeletal traction for a right hip fracture affect the complete blood count (CBC) but would not directly
increase the BUN level.
Which instruction is best for the nurse to Correct Answer:
A provide to a client with emphysema and
chronic fatigue? Rationale:Manifestations of emphysema include an increase
in A."Pace your activities and schedule rest AP diameter (referred to as a barrel chest), nail bed clubbing,
periods." and fatigue. The nurse can provide instructions to promote
B."Increase the amount of oxygen you use at energy management, such as pacing activities and
scheduling night." rest periods. Option B may result in a decreased drive to
C."Obtain medical evaluation for antibiotic breathe. The client is not exhibiting any symptoms of infection,
therapy." so option C is not necessary. Option D is less beneficial
than D."Reduce your intake of fluids containing option A.
caffeine."
Which nursing action would be appropriate Correct Answer:
A for a client who is newly diagnosed with
Cushing syndrome? Rationale: Cushing syndrome results from a hypersecretion of
A. Monitor blood glucose levels daily. glucocorticoids in the adrenal cortex. Clients with Cushing
B. Increase intake of fluids high in potassium. syndrome
often develop diabetes mellitus. Monitoring of C.Encourage adequate rest between serum
glucose levels assesses for increased blood glucose activities. levels so that treatment can begin early. A
common finding in D.Offer the client a sodium-enriched menu. 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 Correct Answer: C
charge nurse reviews the infusions being
received by clients on the oncology unit. Rationale: All four of these clients have the potential to
The client receiving which infusion should have significant complications. The client with the morphine
be assessed first? epidural infusion is at highest risk for respiratory
A.Continuous IV infusion of magnesium depression and should be assessed first. Option A can cause
B.One-time infusion of albumin hypotension. The client receiving option B is at lowest risk
C.Continuous epidural infusion of morphine for serious complications. Although option D can cause
D.Intermittent infusion of IV vancomycin nephrotoxicity and phlebitis, these problems are not as
immediately life threatening as option C.
A client who received a nephrotoxic drug is Correct Answer: D
admitted with acute renal failure and asks
the nurse if dialysis will always be Rationale:CKD is characterized by progressive and irreversible
needed. Which pathophysiologic destruction of nephrons, frequently caused by hypertension
consequence should the nurse explain and diabetes mellitus. Nephrotoxins cause acute tubular
that supports the need for temporary necrosis, a reversible acute renal failure, which creates
dialysis until acute tubular necrosis renal tubular obstruction from endothelial cells that are
subsides? 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
A. Azotemia needed.
B.Oliguria Options A, B, and C are manifestations seen in the acute and
C. Hyperkalemia chronic forms of kidney disease.
D. Nephron obstruction
The client returns to the unit after Correct Answer: B
abdominal surgery with a 5″ × 9″ absorbent
dressing in place to the mid abdomen. The Rationale:By circling the existing stain upon admission to the
nurse notes a spot of red staining unit, the nurse can then assess any increase, though subtle, in
centrally on the dressing. What is the the amount of drainage over time. The size of the stain will
nurse's next action? need to be noted in the chart, but it is not the first action. The
A. Note the size of the stain in the chart. nurse removes the dressing under the prescription of the
B.Circle the stain with an ink pen. health care provider or in an emergency. Neither of those
C. Remove the dressing to assess the conditions exist in the question. The dressing in place is an
source of the bleeding. absorbent dressing. There is no need for a further
D.Place a pressure dressing on the dressing until the existing dressing becomes saturated.
existing dressing.
