HESI MED-SURG EVOLVE EXAM QUESTIONS AND
CORRECT ANSWERS WITH RATIONALES RATED A+
2025
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.: C
Rationale: Neck breathers carry a medical alert card that notifies health
care per- sonnel 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.: 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: C
Rationale: Administration of a Schedule II opioid analgesic can result in
respiratory depression, which requires immediate intervention by the nurse
to prevent respira- tory 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
hemor- rhage, 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: A
Rationale:To increase the client's tolerance of endotracheal intubation
and/or me- chanical 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.: 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
assess- ment 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: A
Rationale:A sudden increase in temperature is an indicator of peritonitis.
The nurse should notify the health care provider immediately. Options B, C,
and D are also findings that require intervention by the nurse but are of less
priority than option A. Option B may indicate a hypertensive condition but is
not as acute a condition as peritonitis. Option C is an expected 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 aldosteronism, the nurse
expects the laboratory test results to indicate a decreased serum level
of which substance?
a. Sodium
b. Phosphate
c. Potassium
d. Glucose: C
Rationale: Clients with primary aldosteronism exhibit a profound decline in
serum levels of potassium; hypokalemia; hypertension is the most prominent
and universal sign. The serum sodium level is normal or elevated,
depending on the amount of water resorbed with the sodium. Option B is
influenced by parathyroid hormone (PTH). Option D is not affected by
primary aldosteronism.
During assessment of a client in the intensive care unit, the nurse notes
that the client's breath sounds are clear on auscultation, but jugular vein
, distention and muffled heart sounds are present. Which intervention
should the nurse implement?
a. Prepare the client for a pericardial tap.
b. Administer intravenous furosemide (Lasix).
c. Assist the client to cough and breathe deeply.
d. Instruct the client to restrict oral fluid intake.: A
Rationale: The client is exhibiting symptoms of cardiac tamponade, a
collection of fluid in the pericardial sac that results in a reduction in cardiac
output, which is a potentially fatal complication of pericarditis. Treatment for
tamponade is a pericardial tap. Lasix IV is not indicated for treatment of
pericarditis. Because the client's breath sounds are clear, option C is not a
priority. Fluids are frequently increased in the initial treatment of tamponade
to compensate for the decrease in cardiac output, but this is not the same
priority as option A.
A central venous catheter has been inserted via a jugular vein, and a
radiograph has confirmed placement of the catheter. A prescription
has been received for a medication STAT, but IV fluids have not yet
been started. Which action should the nurse take prior to
administering the prescribed medication?
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.: D
Rationale:Medication can be administered via a central line without
additional IV fluids. The line should first be flushed with a normal saline
solution to ensure patency. Insufficient evidence exists on the effectiveness
of flushing catheters with heparin. Option A will not affect the decision to
administer the medication and is not a priority. Administration of the
medication STAT is of greater priority than option B.
Which data would the nurse expect to find when reviewing laboratory
values of an 80-year-old man who is in good health overall?
a. Complete blood count reveals increased white blood cell (WBC) and
de- creased red blood cell (RBC) counts.
CORRECT ANSWERS WITH RATIONALES RATED A+
2025
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.: C
Rationale: Neck breathers carry a medical alert card that notifies health
care per- sonnel 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.: 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: C
Rationale: Administration of a Schedule II opioid analgesic can result in
respiratory depression, which requires immediate intervention by the nurse
to prevent respira- tory 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
hemor- rhage, 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: A
Rationale:To increase the client's tolerance of endotracheal intubation
and/or me- chanical 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.: 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
assess- ment 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: A
Rationale:A sudden increase in temperature is an indicator of peritonitis.
The nurse should notify the health care provider immediately. Options B, C,
and D are also findings that require intervention by the nurse but are of less
priority than option A. Option B may indicate a hypertensive condition but is
not as acute a condition as peritonitis. Option C is an expected 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 aldosteronism, the nurse
expects the laboratory test results to indicate a decreased serum level
of which substance?
a. Sodium
b. Phosphate
c. Potassium
d. Glucose: C
Rationale: Clients with primary aldosteronism exhibit a profound decline in
serum levels of potassium; hypokalemia; hypertension is the most prominent
and universal sign. The serum sodium level is normal or elevated,
depending on the amount of water resorbed with the sodium. Option B is
influenced by parathyroid hormone (PTH). Option D is not affected by
primary aldosteronism.
During assessment of a client in the intensive care unit, the nurse notes
that the client's breath sounds are clear on auscultation, but jugular vein
, distention and muffled heart sounds are present. Which intervention
should the nurse implement?
a. Prepare the client for a pericardial tap.
b. Administer intravenous furosemide (Lasix).
c. Assist the client to cough and breathe deeply.
d. Instruct the client to restrict oral fluid intake.: A
Rationale: The client is exhibiting symptoms of cardiac tamponade, a
collection of fluid in the pericardial sac that results in a reduction in cardiac
output, which is a potentially fatal complication of pericarditis. Treatment for
tamponade is a pericardial tap. Lasix IV is not indicated for treatment of
pericarditis. Because the client's breath sounds are clear, option C is not a
priority. Fluids are frequently increased in the initial treatment of tamponade
to compensate for the decrease in cardiac output, but this is not the same
priority as option A.
A central venous catheter has been inserted via a jugular vein, and a
radiograph has confirmed placement of the catheter. A prescription
has been received for a medication STAT, but IV fluids have not yet
been started. Which action should the nurse take prior to
administering the prescribed medication?
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.: D
Rationale:Medication can be administered via a central line without
additional IV fluids. The line should first be flushed with a normal saline
solution to ensure patency. Insufficient evidence exists on the effectiveness
of flushing catheters with heparin. Option A will not affect the decision to
administer the medication and is not a priority. Administration of the
medication STAT is of greater priority than option B.
Which data would the nurse expect to find when reviewing laboratory
values of an 80-year-old man who is in good health overall?
a. Complete blood count reveals increased white blood cell (WBC) and
de- creased red blood cell (RBC) counts.
