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RN Evolve Hesi Medical Surgical Exam Versions A & B Each Version with Verified questions and Correct answers with Detailed Rationales/ RN Hesi Med Surg Exam Prep Test Bank 1 / Hesi Medical Surgical Practice Test Bank

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RN Evolve Hesi Medical Surgical Exam Versions A & B Each Version with Verified questions and Correct answers with Detailed Rationales/ RN Hesi Med Surg Exam Prep Test Bank 1 / Hesi Medical Surgical Practice Test Bank A nurse is caring for several clients at risk for overhydration. The nurse assesses the older client with which finding first? A) Has had diabetes mellitus for 12 years B) Had abdominal surgery and has a nasogastric tube C) Just received 3 units of packed red blood cells D) Uses sodium-containing antacids frequently - Correct Answer :C Blood replacement therapy involves intravenous fluid administration, which inherently increases the risk for overhydration. The fact that the fluid consists of packed red blood cells greatly increases the risk, because this fluid increases the colloidal oncotic pressure of the blood, causing fluid to move from interstitial and intracellular spaces into the plasma volume. An older adult may not have sufficient cardiac or renal reserve to manage this extra fluid. The client with a stroke was admitted to a medical-surgical unit. Which tasks does the nurse delegate to the unlicensed assistive personnel? A) Assess level of consciousness. B) Evaluate the pulse oximetry reading. C) Assist the client with meals. RN Evolve Hesi Medical Surgical Exam Versions A & B A+ TEST BANK 2 D) Complete the nursing care plan. - Correct Answer :C The nurse needs to know the five rights of delegation: right task, right circumstances, right person, right communication, and right supervision. Unlicensed assistive personnel can help with feeding, but only the nurse can care plan, assess the level of consciousness, and evaluate the oxygenation of the client. Interrelated concepts to the professional nursing role a nurse manager would consider when addressing concerns about the quality of patient education include: A) adherence. B) developmental level. C) motivation. D) technology. - Correct Answer :D The interrelated concepts to the professional role of a nurse include health promotion, leadership, technology/informatics, quality, collaboration, and communication. Adherence, culture, developmental level, family dynamics, and motivation are considered interrelated concepts to patient attributes and preference. During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? A) Temperature extremes B) Occupational exposure C) Impaired cognition D) Physical agility - Correct Answer :D Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired RN Evolve Hesi Medical Surgical Exam Versions A & B A+ TEST BANK 3 cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes are risk factors for impaired thermoregulation. An older adult client is in physical restraints. Which intervention by the nurse is the priority? A) Assess the client hourly while keeping the restraints in place. B) Assess the client once each shift, releasing the restraints for feeding. C) Assess the client twice each shift while keeping the restraints in place. D) Assess the client every 30 to 60 minutes, releasing restraints every 2 hours. - Correct Answer :D The application of restraints can have serious consequences. Thus, the nurse should check the client every 30 to 60 minutes, releasing the restraints every 2 hours for positioning and toileting. The other answers would not be appropriate because the client would not be assessed frequently enough, and circulation to the limbs could be compromised. Assessing every hour and releasing the restraints every 2 hours is in compliance with federal policy for monitoring clients in restraints. The nurse is assessing a client with a long-term history of arthritic pain. Assessment reveals a heart rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which intervention will the nurse carry out first? A) Administer blood pressure medication. B) Administer a drug to lower the heart rate. C) Continue to assess for possible causes of elevated vital signs. D) Assess whether the client needs anti-arthritis medication. - Correct Answer :C Arthritis is categorized as chronic pain. With chronic pain, the body adapts by blocking the sympathetic nervous system; this normally causes tachycardia and increased blood pressure. Therefore, this client's high blood pressure and heart rate are not caused by chronic pain and may be a result of a more acute type of pain. Therefore, the best intervention is for the nurse to establish whether the client is having pain other than arthritic pain, and then to decide which intervention should be carried out.

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RN Evolve Hesi Medical Surgical
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RN Evolve Hesi Medical Surgical

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RN Evolve Hesi Medical Surgical Exam
Versions A & B

RN Evolve Hesi Medical Surgical Exam
Versions A & B Each Version with Verified
questions and Correct answers with Detailed
Rationales/ RN Hesi Med Surg Exam Prep Test
Bank 1 / Hesi Medical Surgical Practice Test
Bank

A nurse is caring for several clients at risk for overhydration. The nurse assesses the older client with
which finding first?



A) Has had diabetes mellitus for 12 years

B) Had abdominal surgery and has a nasogastric tube

C) Just received 3 units of packed red blood cells

D) Uses sodium-containing antacids frequently - Correct Answer :C



Blood replacement therapy involves intravenous fluid administration, which inherently increases the
risk for overhydration. The fact that the fluid consists of packed red blood cells greatly increases the
risk, because this fluid increases the colloidal oncotic pressure of the blood, causing fluid to move from
interstitial and intracellular spaces into the plasma volume. An older adult may not have sufficient
cardiac or renal reserve to manage this extra fluid.



The client with a stroke was admitted to a medical-surgical unit. Which tasks does the nurse delegate
to the unlicensed assistive personnel?



A) Assess level of consciousness.

B) Evaluate the pulse oximetry reading.

C) Assist the client with meals.


A+ TEST BANK 1

, RN Evolve Hesi Medical Surgical Exam
Versions A & B
D) Complete the nursing care plan. - Correct Answer :C



The nurse needs to know the five rights of delegation: right task, right circumstances, right person,
right communication, and right supervision. Unlicensed assistive personnel can help with feeding, but
only the nurse can care plan, assess the level of consciousness, and evaluate the oxygenation of the
client.



Interrelated concepts to the professional nursing role a nurse manager would consider when
addressing concerns about the quality of patient education include:



A) adherence.

B) developmental level.

C) motivation.

D) technology. - Correct Answer :D



The interrelated concepts to the professional role of a nurse include health promotion, leadership,
technology/informatics, quality, collaboration, and communication. Adherence, culture,
developmental level, family dynamics, and motivation are considered interrelated concepts to patient
attributes and preference.



During orientation to an emergency department, the nurse educator would be concerned if the new
nurse listed which of the following as a risk factor for impaired thermoregulation?

A) Temperature extremes

B) Occupational exposure

C) Impaired cognition

D) Physical agility - Correct Answer :D



Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this
information to plan additional teaching to include medical conditions and gait disturbance as risk
factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired


A+ TEST BANK 2

, RN Evolve Hesi Medical Surgical Exam
Versions A & B
cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes
are risk factors for impaired thermoregulation.



An older adult client is in physical restraints. Which intervention by the nurse is the priority?



A) Assess the client hourly while keeping the restraints in place.

B) Assess the client once each shift, releasing the restraints for feeding.

C) Assess the client twice each shift while keeping the restraints in place.

D) Assess the client every 30 to 60 minutes, releasing restraints every 2 hours. - Correct Answer :D



The application of restraints can have serious consequences. Thus, the nurse should check the client
every 30 to 60 minutes, releasing the restraints every 2 hours for positioning and toileting. The other
answers would not be appropriate because the client would not be assessed frequently enough, and
circulation to the limbs could be compromised. Assessing every hour and releasing the restraints every
2 hours is in compliance with federal policy for monitoring clients in restraints.



The nurse is assessing a client with a long-term history of arthritic pain. Assessment reveals a heart
rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which intervention will the nurse carry out
first?



A) Administer blood pressure medication.

B) Administer a drug to lower the heart rate.

C) Continue to assess for possible causes of elevated vital signs.

D) Assess whether the client needs anti-arthritis medication. - Correct Answer :C



Arthritis is categorized as chronic pain. With chronic pain, the body adapts by blocking the sympathetic
nervous system; this normally causes tachycardia and increased blood pressure. Therefore, this client's
high blood pressure and heart rate are not caused by chronic pain and may be a result of a more acute
type of pain. Therefore, the best intervention is for the nurse to establish whether the client is having
pain other than arthritic pain, and then to decide which intervention should be carried out.



A+ TEST BANK 3

, RN Evolve Hesi Medical Surgical Exam
Versions A & B
The nurse is assigned to care for the following four clients who have the potential for having pain.
Which client is most likely not to be treated adequately for this problem?



A) Middle-aged woman with a fractured arm

B) Client with expressive aphasia

C) Younger adult with metastatic cancer

D) Client who has undergone an appendectomy - Correct Answer :B



Populations at highest risk for inadequate pain treatment include older adults, minorities, and those
with a history of substance abuse. Nonverbal clients are very difficult to assess for pain because self-
report is not possible, and the nurse needs to rely on client behaviors or surrogate reporting.



Before surgery, the nurse observes the client listening to music on the radio. Based on this
observation, the nurse may try which nonpharmacologic intervention for pain relief in the
postoperative setting?



A) Cutaneous skin stimulation

B) Imagery

C) Radiofrequency ablation

D) Hypnosis - Correct Answer :B



Imagery is a form of distraction in which the client is encouraged to visualize about some pleasant or
desirable feeling, sensation, or event. Behaviors that are helpful in assessing a client's capacity for
imagery include being able to listen to music or other auditory stimuli.



What interrelated constructs facilitate a nurse to become culturally competent?



A) Cultural desire, self-awareness, cultural knowledge, and cultural skill

B) Cultural desire, self-awareness, cultural knowledge, and cultural diversity


A+ TEST BANK 4

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Institution
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Uploaded on
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