HESI med surg evolve exam
When educating a client after a total C
laryngectomy, which instruction would be Rationale: Neck breathers carry a medical alert card that
most important for the nurse to include in notifies health care personnel of the need to use mouth
to the discharge teaching? stoma breathing in the event of a cardiac arrest in this
client.
A. Recommend that the client carry suction Mouth to mouth resuscitation will not establish a patent
equipment at all times. airway. Options A and D are not necessary. There are
many
B.Instruct the client to have writing alternative means of communication for clients who have
had materials with him at all times. a laryngectomy; dependence on writing messages is
C. Tell the client to carry a medical alert probably the least effective.
card that explains his condition.
D.Caution the client not to travel
outside the United States alone.
,The nurse receives the client's next D
scheduled bag of TPN labeled with the Rationale: Only regular insulin is administered by the IV route,
additive NPH insulin. Which action should so the TPN solution containing NPH insulin should be
the nurse implement? returned to the pharmacy. Options A, B, and C are not
A. Hang the solution at the current rate. indicated because the solution should not be administered.
B.Refrigerate the solution until needed.
C. Prepare the solution with new tubing.
D. Return the solution to the pharmacy.
A postoperative client receives a Schedule C
II opioid analgesic for pain. Which Rationale: Administration of a Schedule II opioid analgesic
assessment finding requires the most can result in respiratory depression, which requires immediate
immediate intervention by the nurse? intervention by the nurse to prevent respiratory arrest.
A. Hypoactive bowel sounds with Options A, B, and D require action by the nurse but are of
less abdominal distention priority than option C.
B.Client reports continued pain of 8 on a
10-point scale
C. Respiratory rate of 12 breaths/min, with
O2 saturation of 85%
D.Client reports nausea after receiving
the medication
A client is placed on a mechanical ventilator A
following a cerebral hemorrhage, and Rationale:To increase the client's tolerance of
endotracheal vecuronium bromide, 0.04 mg/kg every 12 intubation and/or mechanical ventilation,
a skeletal muscle hours IV, is prescribed. What is the priority relaxant such as vecuronium is usually
prescribed. Option A is nursing diagnosis for this client? a serious outcome because the client
cannot communicate his
A. Impaired communication related to or her needs. Although this client might also
experience paralysis of skeletal muscles option D, it is not a priority when compared with option A.
B.High risk for infection related to increased Infection is not related to increased intracranial
pressure. The intracranial pressure respirator will ensure that the lungs are expanded, so option
C
C. Potential for injury related to impaired is incorrect.
lung expansion
D.Social isolation related to inability
to communicate
A family member was taught to suction a B
client's tracheostomy prior to the client's Rationale:Option B indicates correct technique for
discharge from the hospital. Which performing suctioning. Suction pressure should be between
observation by the nurse indicates that the 80 and 120 mm Hg, not 190 mm Hg. The catheter should
be
family member is capable of correctly withdrawn 1 to 2 cm at a time with intermittent, not continuous,
performing the suctioning technique? suction. Option D introduces pathogens unnecessarily into the
A. Turns on the continuous wall suction to tracheobronchial
tree. 190 mm Hg.
B.Inserts the catheter until resistance or
coughing occurs.
C. Withdraws the catheter while maintaining
suctioning.
D.Reclears the tracheostomy
after suctioning the mouth.
,A client is diagnosed with an acute small A
bowel obstruction. Which assessment Rationale:A sudden increase in temperature is an indicator
of finding requires the most immediate peritonitis. The nurse should notify the health care provider
intervention by the nurse? immediately. Options B, C, and D are also findings that require
A. Fever of 102° F intervention by the nurse but are of less priority than option A.
B.Blood pressure of 150/90 mm Hg Option B may indicate a hypertensive condition but is not as
C. Abdominal cramping acute a condition as peritonitis. Option C is an expected
D.Dry mucous membranes finding in clients with small bowel obstruction and may require
medication. Option D indicates probable fluid volume deficit,
which requires fluid volume replacement.
In assessing a client diagnosed with primary C
aldosteronism, the nurse expects the Rationale: Clients with primary aldosteronism exhibit a
laboratory test results to indicate a profound decline in serum levels of potassium;
hypokalemia; decreased serum level of which substance? hypertension is the most prominent and
universal sign. The
A. Sodium serum sodium level is normal or elevated, depending on the
B.Phosphate amount of water resorbed with the sodium. Option B is
C. Potassium influenced by parathyroid hormone (PTH). Option D is not
D.Glucose affected by primary aldosteronism.
During assessment of a client in the A
intensive care unit, the nurse notes that theRationale: The client is exhibiting symptoms of cardiac
client's breath sounds are clear on tamponade, a collection of fluid in the pericardial sac
that auscultation, but jugular vein distention and results in a reduction in cardiac output, which is a
potentially muffled heart sounds are present. Which fatal complication of pericarditis. Treatment for
tamponade is intervention should the nurse implement? a pericardial tap. Lasix IV is not
indicated for treatment of
A. Prepare the client for a pericardial tap. pericarditis. Because the client's breath sounds are clear,
B. Administer intravenous furosemide (Lasix). option C is not a
priority. Fluids are frequently increased in the
C. Assist the client to cough and breathe initial treatment of tamponade to compensate for the
deeply. decrease in cardiac output, but this is not the same priority as
D.Instruct the client to restrict oral fluid option
A. intake.
A central venous catheter has been inserted D
via a jugular vein, and a radiograph has Rationale:Medication can be administered via a central line
confirmed placement of the catheter. A without additional IV fluids. The line should first be
flushed prescription has been received for a with a normal saline solution to ensure patency. Insufficient
medication STAT, but IV fluids have not yet evidence exists on the effectiveness of flushing catheters
with been started. Which action should the nurse heparin. Option A will not affect the decision to
administer the take prior to administering the prescribed medication and is not a priority.
Administration of the medication? medication STAT is of greater priority than option B.
A. Assess for signs of jugular
venous distention.
B.Obtain the needed intravenous solution.
C. Flush the line with heparinized solution.
D.Flush the line with normal saline.
, Which data would the nurse expect to find C
when reviewing laboratory values of an 80- Rationale: In older adults, the protein found in urine slightly
year-old man who is in good health overall? rises, probably as a result of kidney changes or
subclinical
A. Complete blood count reveals increased urinary tract infections, and clients frequently experience
white blood cell (WBC) and decreased red asymptomatic bacteriuria and pyuria as a result of
incomplete blood cell (RBC) counts. bladder emptying. Laboratory findings in options A, B, and D
B.Chemistries reveal an increased serum are not considered to be normal findings in an older adult.
bilirubin level with slightly increased liver
enzyme levels.
C. Urinalysis reveals slight protein in the
urine and bacteriuria, with pyuria.
D.Serum electrolytes reveal a
decreased sodium level and increased
potassium level.
The nurse witnesses a baseball player D
receive a blunt trauma to the back of the Rationale: The level of consciousness (LOC) should be
head with a softball. What assessment data established immediately when a head injury has occurred.
should the nurse collect immediately? Spontaneous eye opening is a simple measure of
alertness
A. Reactivity of deep tendon reflexes, that indicates that arousal mechanisms are intact. Option A
is comparing upper with lower extremities not the best indicator of LOC. Although option B is important,
B. Vital sign readings, excluding blood vital signs
are not the best indicators of LOC and can be pressure if needed equipment is unavailable
evaluated after the client's LOC has been determined. Option
C. Memory of events that occurred before C can be assessed after LOC has been established by
and after the blow to the head assessing eye opening.
D.Ability to open the eyes spontaneously
before any tactile stimuli are given
A client diagnosed with angina pectoris A
complains of chest pain while ambulating in Rationale: The nurse should safely assist the client to a resting
the hallway. Which action should the nurse position and then perform options C and D. The client
must implement first? cease all activity immediately, which will decrease the
oxygen
A. Support the client to a sitting position. requirement of the myocardial muscle. After these
B. Ask the client to walk slowly back to the
interventions are implemented, the client can be escorted room. back to the room via
wheelchair or stretcher.
C. Administer a sublingual
nitroglycerin tablet.
D.Provide oxygen via nasal cannula.
In assessing a client with an arteriovenous C
(AV) shunt who is scheduled for dialysis Rationale: Absence of a thrill or bruit indicates that the shunt
today, the nurse notes the absence of a thrill may be obstructed. The nurse should notify the
health care or bruit at the shunt site. What action should provider so that intervention can be
initiated to restore
the nurse take? function of the shunt. Option A is incorrect. Option B will not
A. Advise the client that the shunt is intact resolve the obstruction. An AV shunt is internal and cannot
be and ready for dialysis as scheduled. flushed without access using special needles.
B.Encourage the client to keep the shunt
site elevated above the level of the
heart.
C. Notify the health care provider of the
findings immediately.
D.Flush the site at least once with
a heparinized saline solution.
When educating a client after a total C
laryngectomy, which instruction would be Rationale: Neck breathers carry a medical alert card that
most important for the nurse to include in notifies health care personnel of the need to use mouth
to the discharge teaching? stoma breathing in the event of a cardiac arrest in this
client.
A. Recommend that the client carry suction Mouth to mouth resuscitation will not establish a patent
equipment at all times. airway. Options A and D are not necessary. There are
many
B.Instruct the client to have writing alternative means of communication for clients who have
had materials with him at all times. a laryngectomy; dependence on writing messages is
C. Tell the client to carry a medical alert probably the least effective.
card that explains his condition.
D.Caution the client not to travel
outside the United States alone.
,The nurse receives the client's next D
scheduled bag of TPN labeled with the Rationale: Only regular insulin is administered by the IV route,
additive NPH insulin. Which action should so the TPN solution containing NPH insulin should be
the nurse implement? returned to the pharmacy. Options A, B, and C are not
A. Hang the solution at the current rate. indicated because the solution should not be administered.
B.Refrigerate the solution until needed.
C. Prepare the solution with new tubing.
D. Return the solution to the pharmacy.
A postoperative client receives a Schedule C
II opioid analgesic for pain. Which Rationale: Administration of a Schedule II opioid analgesic
assessment finding requires the most can result in respiratory depression, which requires immediate
immediate intervention by the nurse? intervention by the nurse to prevent respiratory arrest.
A. Hypoactive bowel sounds with Options A, B, and D require action by the nurse but are of
less abdominal distention priority than option C.
B.Client reports continued pain of 8 on a
10-point scale
C. Respiratory rate of 12 breaths/min, with
O2 saturation of 85%
D.Client reports nausea after receiving
the medication
A client is placed on a mechanical ventilator A
following a cerebral hemorrhage, and Rationale:To increase the client's tolerance of
endotracheal vecuronium bromide, 0.04 mg/kg every 12 intubation and/or mechanical ventilation,
a skeletal muscle hours IV, is prescribed. What is the priority relaxant such as vecuronium is usually
prescribed. Option A is nursing diagnosis for this client? a serious outcome because the client
cannot communicate his
A. Impaired communication related to or her needs. Although this client might also
experience paralysis of skeletal muscles option D, it is not a priority when compared with option A.
B.High risk for infection related to increased Infection is not related to increased intracranial
pressure. The intracranial pressure respirator will ensure that the lungs are expanded, so option
C
C. Potential for injury related to impaired is incorrect.
lung expansion
D.Social isolation related to inability
to communicate
A family member was taught to suction a B
client's tracheostomy prior to the client's Rationale:Option B indicates correct technique for
discharge from the hospital. Which performing suctioning. Suction pressure should be between
observation by the nurse indicates that the 80 and 120 mm Hg, not 190 mm Hg. The catheter should
be
family member is capable of correctly withdrawn 1 to 2 cm at a time with intermittent, not continuous,
performing the suctioning technique? suction. Option D introduces pathogens unnecessarily into the
A. Turns on the continuous wall suction to tracheobronchial
tree. 190 mm Hg.
B.Inserts the catheter until resistance or
coughing occurs.
C. Withdraws the catheter while maintaining
suctioning.
D.Reclears the tracheostomy
after suctioning the mouth.
,A client is diagnosed with an acute small A
bowel obstruction. Which assessment Rationale:A sudden increase in temperature is an indicator
of finding requires the most immediate peritonitis. The nurse should notify the health care provider
intervention by the nurse? immediately. Options B, C, and D are also findings that require
A. Fever of 102° F intervention by the nurse but are of less priority than option A.
B.Blood pressure of 150/90 mm Hg Option B may indicate a hypertensive condition but is not as
C. Abdominal cramping acute a condition as peritonitis. Option C is an expected
D.Dry mucous membranes finding in clients with small bowel obstruction and may require
medication. Option D indicates probable fluid volume deficit,
which requires fluid volume replacement.
In assessing a client diagnosed with primary C
aldosteronism, the nurse expects the Rationale: Clients with primary aldosteronism exhibit a
laboratory test results to indicate a profound decline in serum levels of potassium;
hypokalemia; decreased serum level of which substance? hypertension is the most prominent and
universal sign. The
A. Sodium serum sodium level is normal or elevated, depending on the
B.Phosphate amount of water resorbed with the sodium. Option B is
C. Potassium influenced by parathyroid hormone (PTH). Option D is not
D.Glucose affected by primary aldosteronism.
During assessment of a client in the A
intensive care unit, the nurse notes that theRationale: The client is exhibiting symptoms of cardiac
client's breath sounds are clear on tamponade, a collection of fluid in the pericardial sac
that auscultation, but jugular vein distention and results in a reduction in cardiac output, which is a
potentially muffled heart sounds are present. Which fatal complication of pericarditis. Treatment for
tamponade is intervention should the nurse implement? a pericardial tap. Lasix IV is not
indicated for treatment of
A. Prepare the client for a pericardial tap. pericarditis. Because the client's breath sounds are clear,
B. Administer intravenous furosemide (Lasix). option C is not a
priority. Fluids are frequently increased in the
C. Assist the client to cough and breathe initial treatment of tamponade to compensate for the
deeply. decrease in cardiac output, but this is not the same priority as
D.Instruct the client to restrict oral fluid option
A. intake.
A central venous catheter has been inserted D
via a jugular vein, and a radiograph has Rationale:Medication can be administered via a central line
confirmed placement of the catheter. A without additional IV fluids. The line should first be
flushed prescription has been received for a with a normal saline solution to ensure patency. Insufficient
medication STAT, but IV fluids have not yet evidence exists on the effectiveness of flushing catheters
with been started. Which action should the nurse heparin. Option A will not affect the decision to
administer the take prior to administering the prescribed medication and is not a priority.
Administration of the medication? medication STAT is of greater priority than option B.
A. Assess for signs of jugular
venous distention.
B.Obtain the needed intravenous solution.
C. Flush the line with heparinized solution.
D.Flush the line with normal saline.
, Which data would the nurse expect to find C
when reviewing laboratory values of an 80- Rationale: In older adults, the protein found in urine slightly
year-old man who is in good health overall? rises, probably as a result of kidney changes or
subclinical
A. Complete blood count reveals increased urinary tract infections, and clients frequently experience
white blood cell (WBC) and decreased red asymptomatic bacteriuria and pyuria as a result of
incomplete blood cell (RBC) counts. bladder emptying. Laboratory findings in options A, B, and D
B.Chemistries reveal an increased serum are not considered to be normal findings in an older adult.
bilirubin level with slightly increased liver
enzyme levels.
C. Urinalysis reveals slight protein in the
urine and bacteriuria, with pyuria.
D.Serum electrolytes reveal a
decreased sodium level and increased
potassium level.
The nurse witnesses a baseball player D
receive a blunt trauma to the back of the Rationale: The level of consciousness (LOC) should be
head with a softball. What assessment data established immediately when a head injury has occurred.
should the nurse collect immediately? Spontaneous eye opening is a simple measure of
alertness
A. Reactivity of deep tendon reflexes, that indicates that arousal mechanisms are intact. Option A
is comparing upper with lower extremities not the best indicator of LOC. Although option B is important,
B. Vital sign readings, excluding blood vital signs
are not the best indicators of LOC and can be pressure if needed equipment is unavailable
evaluated after the client's LOC has been determined. Option
C. Memory of events that occurred before C can be assessed after LOC has been established by
and after the blow to the head assessing eye opening.
D.Ability to open the eyes spontaneously
before any tactile stimuli are given
A client diagnosed with angina pectoris A
complains of chest pain while ambulating in Rationale: The nurse should safely assist the client to a resting
the hallway. Which action should the nurse position and then perform options C and D. The client
must implement first? cease all activity immediately, which will decrease the
oxygen
A. Support the client to a sitting position. requirement of the myocardial muscle. After these
B. Ask the client to walk slowly back to the
interventions are implemented, the client can be escorted room. back to the room via
wheelchair or stretcher.
C. Administer a sublingual
nitroglycerin tablet.
D.Provide oxygen via nasal cannula.
In assessing a client with an arteriovenous C
(AV) shunt who is scheduled for dialysis Rationale: Absence of a thrill or bruit indicates that the shunt
today, the nurse notes the absence of a thrill may be obstructed. The nurse should notify the
health care or bruit at the shunt site. What action should provider so that intervention can be
initiated to restore
the nurse take? function of the shunt. Option A is incorrect. Option B will not
A. Advise the client that the shunt is intact resolve the obstruction. An AV shunt is internal and cannot
be and ready for dialysis as scheduled. flushed without access using special needles.
B.Encourage the client to keep the shunt
site elevated above the level of the
heart.
C. Notify the health care provider of the
findings immediately.
D.Flush the site at least once with
a heparinized saline solution.
