HESI med surg evolve
Comprehensive Questions
(Frequently Tested) with
Verified Answers 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
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 - Answer: 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. - Answer: 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. - Answer: 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
Comprehensive Questions
(Frequently Tested) with
Verified Answers 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
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 - Answer: 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. - Answer: 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. - Answer: 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
