EVOLVE HESI MED SURG / HESI MED SURG EVOLVE EXAM
2024-2025 ACTUAL EXAM COMPLETE 100 REAL QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES
(CORRECT VERIFIED ANSWERS) LATEST UPDATED
VERSION |ALREADY GRADED A+
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 have writing materials with him at all times.
C. Tell the client to carry a medical alert card that explains his condition.
D. Caution the client not to travel outside the United States alone.
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 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.
,The nurse receives the client's next scheduled bag of TPN labeled with
the additive NPH insulin. Which action should the nurse implement?
A. Hang the solution at the current rate.
B. Refrigerate the solution until needed.
C.Prepare the solution with new tubing.
D.Return the solution to the pharmacy.
ANSWER-D
Rationale: Only regular insulin is administered by the IV route, so the
TPN solution containing NPH insulin should be returned to the
pharmacy. Options A, B, and C are not indicated because the solution
should not be administered.
A postoperative client receives a Schedule II opioid analgesic for pain.
Which assessment finding requires the most immediate intervention by
the nurse?
A. Hypoactive bowel sounds with abdominal distention
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
ANSWER-C
,Rationale: Administration of a Schedule II opioid analgesic can result in
respiratory depression, which requires immediate intervention by the
nurse to prevent respiratory arrest. Options A, B, and D require action
by the nurse but are of less priority than option C.
A client is placed on a mechanical ventilator following a cerebral
hemorrhage, and vecuronium bromide, 0.04 mg/kg every 12 hours IV, is
prescribed. What is the priority nursing diagnosis for this client?
A. Impaired communication related to paralysis of skeletal muscles
B. High risk for infection related to increased intracranial pressure
C. Potential for injury related to impaired lung expansion
D. Social isolation related to inability to communicate
Answer-A
Rationale:To increase the client's tolerance of endotracheal intubation
and/or mechanical ventilation, a skeletal muscle relaxant such as
vecuronium is usually prescribed. Option A is a serious outcome
because the client cannot communicate his or her needs. Although this
client might also experience option D, it is not a priority when
compared with option A. Infection is not related to increased
intracranial pressure. The respirator will ensure that the lungs are
expanded, so option C is incorrect.
, A family member was taught to suction a client's tracheostomy prior to
the client's discharge from the hospital. Which observation by the nurse
indicates that the family member is capable of correctly performing the
suctioning technique?
A. Turns on the continuous wall suction to 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.
Answer-B
Rationale:Option B indicates correct technique for performing
suctioning. Suction pressure should be between 80 and 120 mm Hg, not
190 mm Hg. The catheter should be withdrawn 1 to 2 cm at a time with
intermittent, not continuous, suction. Option D introduces pathogens
unnecessarily into the tracheobronchial tree.
A client is diagnosed with an acute small bowel obstruction. Which
assessment finding requires the most immediate intervention by the
nurse?
A. Fever of 102° F
B. Blood pressure of 150/90 mm Hg
C. Abdominal cramping
D. Dry mucous membranes
Answer- A
2024-2025 ACTUAL EXAM COMPLETE 100 REAL QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES
(CORRECT VERIFIED ANSWERS) LATEST UPDATED
VERSION |ALREADY GRADED A+
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 have writing materials with him at all times.
C. Tell the client to carry a medical alert card that explains his condition.
D. Caution the client not to travel outside the United States alone.
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 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.
,The nurse receives the client's next scheduled bag of TPN labeled with
the additive NPH insulin. Which action should the nurse implement?
A. Hang the solution at the current rate.
B. Refrigerate the solution until needed.
C.Prepare the solution with new tubing.
D.Return the solution to the pharmacy.
ANSWER-D
Rationale: Only regular insulin is administered by the IV route, so the
TPN solution containing NPH insulin should be returned to the
pharmacy. Options A, B, and C are not indicated because the solution
should not be administered.
A postoperative client receives a Schedule II opioid analgesic for pain.
Which assessment finding requires the most immediate intervention by
the nurse?
A. Hypoactive bowel sounds with abdominal distention
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
ANSWER-C
,Rationale: Administration of a Schedule II opioid analgesic can result in
respiratory depression, which requires immediate intervention by the
nurse to prevent respiratory arrest. Options A, B, and D require action
by the nurse but are of less priority than option C.
A client is placed on a mechanical ventilator following a cerebral
hemorrhage, and vecuronium bromide, 0.04 mg/kg every 12 hours IV, is
prescribed. What is the priority nursing diagnosis for this client?
A. Impaired communication related to paralysis of skeletal muscles
B. High risk for infection related to increased intracranial pressure
C. Potential for injury related to impaired lung expansion
D. Social isolation related to inability to communicate
Answer-A
Rationale:To increase the client's tolerance of endotracheal intubation
and/or mechanical ventilation, a skeletal muscle relaxant such as
vecuronium is usually prescribed. Option A is a serious outcome
because the client cannot communicate his or her needs. Although this
client might also experience option D, it is not a priority when
compared with option A. Infection is not related to increased
intracranial pressure. The respirator will ensure that the lungs are
expanded, so option C is incorrect.
, A family member was taught to suction a client's tracheostomy prior to
the client's discharge from the hospital. Which observation by the nurse
indicates that the family member is capable of correctly performing the
suctioning technique?
A. Turns on the continuous wall suction to 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.
Answer-B
Rationale:Option B indicates correct technique for performing
suctioning. Suction pressure should be between 80 and 120 mm Hg, not
190 mm Hg. The catheter should be withdrawn 1 to 2 cm at a time with
intermittent, not continuous, suction. Option D introduces pathogens
unnecessarily into the tracheobronchial tree.
A client is diagnosed with an acute small bowel obstruction. Which
assessment finding requires the most immediate intervention by the
nurse?
A. Fever of 102° F
B. Blood pressure of 150/90 mm Hg
C. Abdominal cramping
D. Dry mucous membranes
Answer- A
