1|Pa ge
EVOLVE ELSEVIER HESI MED SURG EXAM||
ACCURATE AND FREQUENTLY TESTED QUESTIONS
AND 100% CORRECT ANSWERS WITH RATIONALES||
LATEST AND COMPLETE UPDATE WITH EXPERT
VERIFIED SOLUTIONS|GUARANTEED PASS!
The nurse is providing care to a client admitted to the emergency room with a
blood glucose level of 40 mg/dL and is semiconscious. What are the nurse's next
actions? (Select all that apply.)
-Start an IV of Normal Saline.
-Obtain a 50% dextrose solution.
-Administer glucagon as per the standing order.
-Turn the client to the side.
Rationale:
Oral carbohydrates, such as sugar and honey, should never be given to the
semiconscious or unconscious clients with low blood sugar levels, for concern for
aspiration. Glucagon can be administered immediately, followed by starting an IV.
Await the orders for the 50% dextrose solution. Place the client in a side lying
position as there is a risk for vomiting and aspiration with these clients.
An 81-year-old client has emphysema. The client lives at home with a cat and
manages self-care with no difficulty. When making a home visit, the nurse notices
that this client's tongue is somewhat cracked and his eyeballs appear sunken.
Which nursing action is indicated?
Help the client determine ways to increase fluid intake.
Rationale:
Clients with COPD should ingest 3 L of fluids daily but may experience a fluid
deficit because of shortness of breath. The nurse should suggest creative methods
,2|Pa ge
to increase the intake of fluids, such as having fruit juices in disposable containers
readily available.
A 58-year-old client who has no health problems asks the nurse about receiving the
pneumococcal vaccine. Which statement given by the nurse would offer the client
accurate information about this vaccine?
The immunization is administered once to older adults or those at risk for illness.
Rationale:
It is usually recommended that persons older than 65 years and those with a history
of chronic illness should receive the vaccine once in their lifetime. Some
recommend receiving the vaccine at 50 years of age. The influenza vaccine is
given once a year. Although the vaccine might be given to a person traveling
overseas, that is not the main rationale for administering the vaccine. The vaccine
is usually given once in a lifetime, but with immunosuppressed clients or clients
with a history of pneumonia, revaccination is sometimes required.
The clinic nurse is teaching a client with osteoarthritis to the knees bilaterally
about self-care. Which teaching points will the nurse include in the client's plan of
care? (Select all that apply.)
-Apply heat packs to your knees as needed for pain.
-Support your knees while you are in bed with a pillow or a rolled towel.
-Get 7 to 8 hours of sleep every night.
-Eat a balanced diet, including fish with Omega-3 fatty acids.
Rationale:
The maximum daily dose of acetaminophen is 4 g, the instruction includes up to 6
g/per day. The best type of exercise does not place additional stress on the knee
joints, such as biking or swimming. Apply heat to increase circulation and ice
packs to decrease swelling. Support to the knees can take the strain off of the joint.
,3|Pa ge
Getting rest will help with coping with the pain of the disease. Eating a balanced
diet may help with weight loss; additional weight places strain on the
joint.
The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12
hours after chest tube insertion for hemothorax. What is the best initial action for
the nurse to take?
Assess for kinks or dependent loops in the tubing.
Rationale:
The least invasive nursing action should be performed first to determine why the
drainage has diminished.
During report, the nurse learns that a client with tumor lysis syndrome is receiving
an IV infusion containing insulin. Which action should the nurse complete first?
Monitor the client's serum potassium and blood glucose levels.
Rationale:
Clients with tumor lysis syndrome may experience hyperkalemia, requiring the
addition of insulin to the IV solution to reduce the serum potassium level. It is
most important for the nurse to monitor the client's serum potassium and blood
glucose levels to ensure that they are not at dangerous levels.
For the client undergoing hemodialysis, the nurse suspects the client has an air
embolism. What symptoms lead the nurse to this conclusion? (Select all that
apply.)
-Dyspnea
, 4|Pa ge
-Chest pain
-Anxiety
-Blue nail beds
Rationale:
For the client experiencing an air embolism, the nurse will see hypotension and not
hypertension. The O2 saturation will also fall with an air embolism. The remaining
are signs of an air embolism.
A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid
ventricular response. Based on this finding, the nurse anticipates assisting the
physician with which treatment?
Perform synchronized cardioversion.
Rationale:
With uncontrolled atrial fibrillation, the treatment of choice is synchronized
cardioversion to convert the cardiac rhythm back to normal sinus rhythm.
The post-operative client states to the nurse, "I hate the feeling of those
compression stockings as they inflate and deflate all the time. It keeps me awake."
What is the nurse's best response?
"Tell me what you know about the intermittent compression stockings."
Rationale:
The purpose of the intermittent compression stockings is to decrease the risk of
blood clots forming in the legs. By assessing the client's knowledge about the
devise, the nurse can determine if the client is aware of the potential for blood clots
and the sequela that clots have.
EVOLVE ELSEVIER HESI MED SURG EXAM||
ACCURATE AND FREQUENTLY TESTED QUESTIONS
AND 100% CORRECT ANSWERS WITH RATIONALES||
LATEST AND COMPLETE UPDATE WITH EXPERT
VERIFIED SOLUTIONS|GUARANTEED PASS!
The nurse is providing care to a client admitted to the emergency room with a
blood glucose level of 40 mg/dL and is semiconscious. What are the nurse's next
actions? (Select all that apply.)
-Start an IV of Normal Saline.
-Obtain a 50% dextrose solution.
-Administer glucagon as per the standing order.
-Turn the client to the side.
Rationale:
Oral carbohydrates, such as sugar and honey, should never be given to the
semiconscious or unconscious clients with low blood sugar levels, for concern for
aspiration. Glucagon can be administered immediately, followed by starting an IV.
Await the orders for the 50% dextrose solution. Place the client in a side lying
position as there is a risk for vomiting and aspiration with these clients.
An 81-year-old client has emphysema. The client lives at home with a cat and
manages self-care with no difficulty. When making a home visit, the nurse notices
that this client's tongue is somewhat cracked and his eyeballs appear sunken.
Which nursing action is indicated?
Help the client determine ways to increase fluid intake.
Rationale:
Clients with COPD should ingest 3 L of fluids daily but may experience a fluid
deficit because of shortness of breath. The nurse should suggest creative methods
,2|Pa ge
to increase the intake of fluids, such as having fruit juices in disposable containers
readily available.
A 58-year-old client who has no health problems asks the nurse about receiving the
pneumococcal vaccine. Which statement given by the nurse would offer the client
accurate information about this vaccine?
The immunization is administered once to older adults or those at risk for illness.
Rationale:
It is usually recommended that persons older than 65 years and those with a history
of chronic illness should receive the vaccine once in their lifetime. Some
recommend receiving the vaccine at 50 years of age. The influenza vaccine is
given once a year. Although the vaccine might be given to a person traveling
overseas, that is not the main rationale for administering the vaccine. The vaccine
is usually given once in a lifetime, but with immunosuppressed clients or clients
with a history of pneumonia, revaccination is sometimes required.
The clinic nurse is teaching a client with osteoarthritis to the knees bilaterally
about self-care. Which teaching points will the nurse include in the client's plan of
care? (Select all that apply.)
-Apply heat packs to your knees as needed for pain.
-Support your knees while you are in bed with a pillow or a rolled towel.
-Get 7 to 8 hours of sleep every night.
-Eat a balanced diet, including fish with Omega-3 fatty acids.
Rationale:
The maximum daily dose of acetaminophen is 4 g, the instruction includes up to 6
g/per day. The best type of exercise does not place additional stress on the knee
joints, such as biking or swimming. Apply heat to increase circulation and ice
packs to decrease swelling. Support to the knees can take the strain off of the joint.
,3|Pa ge
Getting rest will help with coping with the pain of the disease. Eating a balanced
diet may help with weight loss; additional weight places strain on the
joint.
The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12
hours after chest tube insertion for hemothorax. What is the best initial action for
the nurse to take?
Assess for kinks or dependent loops in the tubing.
Rationale:
The least invasive nursing action should be performed first to determine why the
drainage has diminished.
During report, the nurse learns that a client with tumor lysis syndrome is receiving
an IV infusion containing insulin. Which action should the nurse complete first?
Monitor the client's serum potassium and blood glucose levels.
Rationale:
Clients with tumor lysis syndrome may experience hyperkalemia, requiring the
addition of insulin to the IV solution to reduce the serum potassium level. It is
most important for the nurse to monitor the client's serum potassium and blood
glucose levels to ensure that they are not at dangerous levels.
For the client undergoing hemodialysis, the nurse suspects the client has an air
embolism. What symptoms lead the nurse to this conclusion? (Select all that
apply.)
-Dyspnea
, 4|Pa ge
-Chest pain
-Anxiety
-Blue nail beds
Rationale:
For the client experiencing an air embolism, the nurse will see hypotension and not
hypertension. The O2 saturation will also fall with an air embolism. The remaining
are signs of an air embolism.
A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid
ventricular response. Based on this finding, the nurse anticipates assisting the
physician with which treatment?
Perform synchronized cardioversion.
Rationale:
With uncontrolled atrial fibrillation, the treatment of choice is synchronized
cardioversion to convert the cardiac rhythm back to normal sinus rhythm.
The post-operative client states to the nurse, "I hate the feeling of those
compression stockings as they inflate and deflate all the time. It keeps me awake."
What is the nurse's best response?
"Tell me what you know about the intermittent compression stockings."
Rationale:
The purpose of the intermittent compression stockings is to decrease the risk of
blood clots forming in the legs. By assessing the client's knowledge about the
devise, the nurse can determine if the client is aware of the potential for blood clots
and the sequela that clots have.
