EVOLVE ELSEVIER HESI MED SURG ACTUAL
EXAM WITH 150 REAL EXAM QUESTIONS &
ANSWERS
1. Which nursing action would be appropriate for a client who is newly
diagnosed with Cushing syndrome?
A. Monitor blood glucose levels daily.
B. Increase intake of fluids high in potassium.
C. Encourage adequate rest between
activities.
D. Offer the client a sodium-enriched menu.
Answer: A. Monitor blood glucose levels daily.
Rationale: Cushing syndrome results from a hypersecretion of
glucocorticoids in the adrenal cortex. Clients with Cushing syndrome
often develop diabetes mellitus.
Monitoring of serum glucose levels assesses for increased blood
glucose levels so that treatment can begin early. A common finding in
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.
1/
100
,2. During the change of shift report, the charge nurse reviews the
infusions being received by clients on the oncology unit. The client
receiving which infusion should be assessed first?
A. Continuous IV infusion of magnesium
B. One-time infusion of albumin
C. Continuous epidural infusion of
morphine
D. Intermittent infusion of IV vancomycin
Answer: C. Continuous epidural infusion of mor- phine
Rationale: All four of these clients have the potential to have significant
complica- tions. The client with the morphine epidural infusion is at
highest risk for respiratory depression and should be assessed first.
Option A can cause hypotension. The client receiving option B is at
lowest risk for serious complications. Although option D can cause
nephrotoxicity and phlebitis, these problems are not as immediately life
threatening as option C.
3.A client with hypertension has been receiving ramipril, 5 mg PO, daily for
2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's
blood pressure is 120/70 mm Hg. Which action should the nurse take?
A. Administer the prescribed dose at the scheduled time.
B. Hold the dose and contact the health care provider.
C. Hold the dose and recheck the blood pressure in 1 hour.
2/
100
,D. Check the health care provider's prescription to clarify the dose.
Answer: A. Admin- ister the prescribed dose at the scheduled time.
Rationale:
The client's blood pressure is within normal limits, indicating
that the ramipril, an antihypertensive, is having the desired
effect and should be
administered. Options B and C would be appropriate if the client's blood
pressure was excessively low (<100 mm Hg systolic) or if the client were
exhibiting signs
of hypotension such as dizziness. This prescribed dose is within the
normal dosage range, as defined by the manufacturer; therefore, option
D is not necessary
4.The nurse is concerned about infection for a client after an
esophagogas- trostomy for esophageal cancer. Which actions should the
nurse include in the client's plan of care? (Select all that apply.)
A. Frequent oral care every 2 hours while awake.
B. Use incentive spirometer every 2 hours.
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.
Answer: A. Frequent oral care every 2 hours while awake.
B. Use incentive spirometer every 2 hours.
C. Empty contents from NG tube every 8 hours.
3/
100
, Rationale:
One hour post op is too soon to ambulate for this client. Visitors help
support the patient and are encouraged to visit. Oral care is necessary a
the client will be NPO. To decrease the risk of infection post operatively,
implement routine pulmonary exercises. The client will have an NG tube
in place, likely to
intermittent suction, to decompress the stomach post surgery.
5.The client is return demonstrating wrapping of the left limb amputated
above the knee. The nurse evaluates the client is starting the 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
Answer: A. Around the waist
Rationale:
The waist is the anchor point for the bandage for an above the
knee amputation.
6.A nurse is assisting an 82-year-old client with ambulation and is
concerned that the client may fall. Which area contains the older person's
center of gravity?
4/
100
EXAM WITH 150 REAL EXAM QUESTIONS &
ANSWERS
1. Which nursing action would be appropriate for a client who is newly
diagnosed with Cushing syndrome?
A. Monitor blood glucose levels daily.
B. Increase intake of fluids high in potassium.
C. Encourage adequate rest between
activities.
D. Offer the client a sodium-enriched menu.
Answer: A. Monitor blood glucose levels daily.
Rationale: Cushing syndrome results from a hypersecretion of
glucocorticoids in the adrenal cortex. Clients with Cushing syndrome
often develop diabetes mellitus.
Monitoring of serum glucose levels assesses for increased blood
glucose levels so that treatment can begin early. A common finding in
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.
1/
100
,2. During the change of shift report, the charge nurse reviews the
infusions being received by clients on the oncology unit. The client
receiving which infusion should be assessed first?
A. Continuous IV infusion of magnesium
B. One-time infusion of albumin
C. Continuous epidural infusion of
morphine
D. Intermittent infusion of IV vancomycin
Answer: C. Continuous epidural infusion of mor- phine
Rationale: All four of these clients have the potential to have significant
complica- tions. The client with the morphine epidural infusion is at
highest risk for respiratory depression and should be assessed first.
Option A can cause hypotension. The client receiving option B is at
lowest risk for serious complications. Although option D can cause
nephrotoxicity and phlebitis, these problems are not as immediately life
threatening as option C.
3.A client with hypertension has been receiving ramipril, 5 mg PO, daily for
2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's
blood pressure is 120/70 mm Hg. Which action should the nurse take?
A. Administer the prescribed dose at the scheduled time.
B. Hold the dose and contact the health care provider.
C. Hold the dose and recheck the blood pressure in 1 hour.
2/
100
,D. Check the health care provider's prescription to clarify the dose.
Answer: A. Admin- ister the prescribed dose at the scheduled time.
Rationale:
The client's blood pressure is within normal limits, indicating
that the ramipril, an antihypertensive, is having the desired
effect and should be
administered. Options B and C would be appropriate if the client's blood
pressure was excessively low (<100 mm Hg systolic) or if the client were
exhibiting signs
of hypotension such as dizziness. This prescribed dose is within the
normal dosage range, as defined by the manufacturer; therefore, option
D is not necessary
4.The nurse is concerned about infection for a client after an
esophagogas- trostomy for esophageal cancer. Which actions should the
nurse include in the client's plan of care? (Select all that apply.)
A. Frequent oral care every 2 hours while awake.
B. Use incentive spirometer every 2 hours.
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.
Answer: A. Frequent oral care every 2 hours while awake.
B. Use incentive spirometer every 2 hours.
C. Empty contents from NG tube every 8 hours.
3/
100
, Rationale:
One hour post op is too soon to ambulate for this client. Visitors help
support the patient and are encouraged to visit. Oral care is necessary a
the client will be NPO. To decrease the risk of infection post operatively,
implement routine pulmonary exercises. The client will have an NG tube
in place, likely to
intermittent suction, to decompress the stomach post surgery.
5.The client is return demonstrating wrapping of the left limb amputated
above the knee. The nurse evaluates the client is starting the 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
Answer: A. Around the waist
Rationale:
The waist is the anchor point for the bandage for an above the
knee amputation.
6.A nurse is assisting an 82-year-old client with ambulation and is
concerned that the client may fall. Which area contains the older person's
center of gravity?
4/
100
