EVOLVE MED SURG HESI EXAM 2025|
Test Bank | Real Exam Prep Questions
And Correct Answers With Detailed
Rationales
The nurse is concerned about infection for a client after an esophagogastrostomy 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. - ✓✓-Correct Answer: A,B,C
Rationale:One bhour bpost bop bis btoo bsoon bto bambulate bfor bthis bclient. bVisitors bhelp
bsupport bthe bpatient band bare bencouraged bto bvisit. bOral bcare bis bnecessary bas bthe
bclient bwill bbe bNPO. bTo bdecrease bthe brisk bof binfection bpost boperatively, bimplement
broutine bpulmonary bexercises. bThe bclient bwill bhave ban bNG btube bin bplace, blikely bto
bintermittent bsuction, bto bdecompress bthe bstomach bpost bsurgery.
The bclient bis breturn bdemonstrating bwrapping bof bthe bleft blimb bamputated babove bthe
bknee. bThe bnurse bevaluates bthe bclient bis bstarting bthe bwrapping bmethod bcorrectly
bwhen bthe bclient bplaces bthe bend bof bthe bbandage bat bwhich bpoint?
A. Around bthe bwaist
B. At bthe binner baspect bof bthe bleft bstump
C. At bthe bouter baspect bof bthe bleft bstump
D. At bthe bleft bgroin barea b- b✓✓-Correct bAnswer: bA
Rationale:The bwaist bis bthe banchor bpoint bfor bthe bbandage bfor ban babove bthe bknee
bamputation.
A bnurse bis bassisting ban b82-year-old bclient bwith bambulation band bis bconcerned bthat
bthe bclient bmay bfall. bWhich barea bcontains bthe bolder bperson's bcenter bof bgravity?
A. Head band bneck
B. Upper btorso
,C. Bilateral barms
D. Feet band blegs b- b✓✓-Correct bAnswer: bB
Rationale:Stooped bposture bresults bin bthe bupper btorso bbecoming bthe bcenter bof
bgravity bfor bolder bpersons. bThe bcenter bof bgravity bfor badults bis bthe bhips. bHowever,
bas ba bperson bgrows bolder, ba bstooped bposture bis bcommon bbecause bof bchanges
bcaused bby bosteoporosis band bnormal bbone bdegeneration. bFurthermore, bthe bknees,
bhips, band belbows bflex. bThe bhead band bneck band bfeet band blegs bare bnot bthe
bcenter bof bgravity bin bthe bolder badult. bAlthough bthe barms bcomprise ba bpart bof bthe
bupper btorso, bthey bdo bnot breflect bthe bbest band bmost bcomplete banswer.
A bclient bwith bhypertension bhas bbeen breceiving bramipril, b5 bmg bPO, bdaily bfor b2
bweeks band bis bscheduled bto breceive ba bdose bat b0900. bAt b0830, bthe bclient's
bblood bpressure bis b120/70 bmm bHg. bWhich baction bshould bthe bnurse btake?
A. Administer bthe bprescribed bdose bat bthe bscheduled btime.
B. Hold bthe bdose band bcontact bthe bhealth bcare bprovider.
C. Hold bthe bdose band b recheck bthe bblood bpressure bin b1 bhour.
D. Check bthe bhealth bcare bprovider's bprescription bto bclarify bthe bdose. b- b✓✓-
Correct bAnswer: bA
Rationale:The bclient's bblood bpressure bis bwithin bnormal blimits, bindicating bthat bthe
bramipril, ban bantihypertensive, bis bhaving bthe bdesired beffect band bshould bbe
badministered. bOptions bB band bC bwould bbe bappropriate bif bthe bclient's bblood
bpressure bwas bexcessively blow b(<100 bmm bHg bsystolic) bor bif bthe bclient bwere
bexhibiting bsigns bof bhypotension bsuch bas bdizziness. bThis bprescribed bdose bis bwithin
bthe bnormal bdosage brange, bas bdefined bby bthe bmanufacturer; btherefore, boption bD bis
bnot bnecessary
The bnurse bis bproviding bcare bfor ba bclient bdiagnosed bwith btrigeminal bneuralgia b(tic
bdouloureux). bWhich bsymptoms bwill bthe bnurse bbe blooking bfor bin bthe bfocused
bassessment brelated bto bthis bcondition? b(Select ball bthat bapply.)
A. Facial bmuscle bspasms
B. Sudden bfacial bpain
C. Unilateral bfacial bweakness
D. Difficulty bin
bchewing bE.Tinnitus
F.Hearing bdifficulties b- b✓✓-Correct bAnswer: bA,B
Rationale:Trigeminal bneuralgia bis bcharacterized bby bparoxysms bof bpain, bsimilar bto
ban belectric bshock, bin bthe barea binnervated bby bone bor bmore bbranches bof bthe
btrigeminal bnerve b(cranial bV). bThe bremaining bsymptoms bare bnot brelated bto
btrigeminal bneuralgia.
In bcaring bfor ba bclient bwith bacute bdiverticulitis, bwhich bassessment bdata bwarrants ban
bimmediate bnursing baction?
,A. bThe bclient bhas ba brigid bhard babdomen band b elevated bWBC.
B. bThe bclient bhas bleft blower bquadrant bpain band ban belevated btemperature.
C.The bclient bis brefusing bto beat bany bof bthe bmeal band bis bcomplaining bof bnausea.
D. bThe bclient bhas bnot bhad ba bbowel bmovement bin b2 bdays band bhas ba bsoft
babdomen. b- b✓✓- bCorrect bAnswer: bA
Rationale: bA bhard brigid babdomen band belevated bWBC bis bindicative bof bperitonitis,
bwhich bis ba bmedical bemergency band bshould bbe breported bto bthe bhealth bcare
bprovider bimmediately. bOptions bB band bC bare bexpected bclinical bmanifestations bof
bdiverticulitis. bOption bD bdoes bnot bwarrant bimmediate bintervention.
The bnurse bis bcaring bfor ba bclient bwith ba bfractured bright belbow. bWhich bassessment
bfinding bhas bthe bhighest bpriority band brequires bimmediate bintervention?
A. bEcchymosis bover bthe bright belbow barea
B. bDeep bunrelenting bpain bin bthe bright barm
C. bAn bedematous bright belbow
D. bThe bpresence bof bcrepitus bin bthe bright belbow b- b✓✓-Correct bAnswer: bB
Rationale:Compartment bsyndrome bis ba bcondition binvolving bincreased bpressure band
bconstriction bof bthe bnerves band bvessels bwithin ban banatomic bcompartment, bcausing
bpain buncontrolled bby bopioids band bneurovascular bcompromise. bOption bA bis ban
bexpected bfinding. bOption bC brelated bto bcompartment bsyndrome bcannot bbe bseen,
band bany bvisible bedema bis ban bexpected bfinding brelated bto bthe binjury. bOption bD bis
ban bexpected bfinding.
The bnurse bnotes bthat ba bclient bwho bis bscheduled bfor bsurgery bthe bnext bmorning bhas
ban belevated bblood burea bnitrogen b(BUN) blevel. bWhich bcondition bis bmost blikely bto
bhave bcontributed bto bthis bfinding?
A. bMyocardial binfarction b2 bmonths bago
B. bAnorexia band bvomiting bfor bthe bpast b2 bdays
C.Recently bdiagnosed btype b2 bdiabetes bmellitus
D. bSkeletal btraction bfor ba bright bhip bfracture b- b✓✓-Correct bAnswer: bB
Rationale:The bblood burea bnitrogen b(BUN) blevel bindicates bthe beffectiveness bof bthe
bkidneys bin bfiltering bwaste bfrom bthe bblood. bDehydration, bwhich bcould bbe bcaused bby
bvomiting, bwould bcause ban b increased b BUN blevel. bOption bA bwould baffect bserum
benzyme blevels, bnot bthe bBUN blevel. bOption bC bwould bprimarily baffect bthe bblood
bglucose blevel; brenal bfailure bthat bcould bincrease bthe bBUN blevel bwould bbe bunlikely
bin ba bclient bnewly bdiagnosed bwith btype b2 bdiabetes. bEffects bof boption bD bmight
baffect bthe bcomplete bblood bcount b(CBC) bbut bwould bnot bdirectly bincrease bthe bBUN
blevel.
, Which binstruction bis bbest bfor bthe bnurse bto bprovide bto ba bclient bwith bemphysema
band bchronic bfatigue?
A."Pace byour bactivities band bschedule brest
bperiods." bB."Increase bthe bamount bof boxygen byou
buse bat bnight."
C."Obtain bmedical bevaluation bfor bantibiotic btherapy."
D."Reduce byour bintake bof bfluids bcontaining bcaffeine." b- b✓✓-Correct bAnswer: bA
Rationale:Manifestations bof bemphysema binclude ban bincrease bin bAP bdiameter
b(referred bto bas ba bbarrel bchest), bnail bbed bclubbing, band bfatigue. bThe bnurse bcan
bprovide binstructions bto bpromote benergy bmanagement, bsuch bas bpacing bactivities
band bscheduling brest bperiods.
Option bB bmay bresult bin ba bdecreased bdrive bto bbreathe. bThe bclient bis bnot
bexhibiting bany bsymptoms bof binfection, bso boption bC bis bnot bnecessary. bOption bD
bis bless bbeneficial bthan boption bA.
Which bnursing baction bwould bbe bappropriate bfor ba bclient bwho bis bnewly bdiagnosed
bwith bCushing bsyndrome?
A.Monitor bblood bglucose blevels bdaily.
B.Increase bintake bof bfluids bhigh bin bpotassium.
bC.Encourage badequate brest bbetween bactivities.
D.Offer bthe bclient ba bsodium-enriched bmenu. b- b✓✓-Correct bAnswer: bA
Rationale: bCushing bsyndrome bresults bfrom ba bhypersecretion bof bglucocorticoids bin
bthe badrenal bcortex. bClients bwith bCushing bsyndrome boften bdevelop bdiabetes
bmellitus.
Monitoring bof bserum bglucose blevels bassesses bfor bincreased bblood bglucose blevels
bso bthat btreatment bcan bbegin bearly. bA bcommon bfinding bin bCushing bsyndrome bis
bgeneralized bedema. bAlthough bpotassium bis bneeded, bit bis bgenerally bobtained bfrom
bfood bintake, bnot bby boffering bpotassium-enhanced bfluids. bFatigue bis busually bnot
ban boverwhelming bfactor bin bCushing bsyndrome, bso ban bemphasis bon bthe bneed bfor
brest bis bnot bindicated. bA blow-calorie, blow-carbohydrate, blow-sodium bdiet bis bnot
brecommended.
During bthe bchange bof bshift breport, bthe bcharge bnurse breviews bthe binfusions bbeing
breceived bby bclients bon bthe boncology bunit. bThe bclient breceiving bwhich binfusion
bshould bbe bassessed bfirst?
A.Continuous bIV binfusion bof bmagnesium
bB.One-time binfusion bof balbumin
bC.Continuous bepidural binfusion bof
bmorphine
D.Intermittent binfusion bof bIV bvancomycin b- b✓✓-Correct bAnswer: bC
Test Bank | Real Exam Prep Questions
And Correct Answers With Detailed
Rationales
The nurse is concerned about infection for a client after an esophagogastrostomy 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. - ✓✓-Correct Answer: A,B,C
Rationale:One bhour bpost bop bis btoo bsoon bto bambulate bfor bthis bclient. bVisitors bhelp
bsupport bthe bpatient band bare bencouraged bto bvisit. bOral bcare bis bnecessary bas bthe
bclient bwill bbe bNPO. bTo bdecrease bthe brisk bof binfection bpost boperatively, bimplement
broutine bpulmonary bexercises. bThe bclient bwill bhave ban bNG btube bin bplace, blikely bto
bintermittent bsuction, bto bdecompress bthe bstomach bpost bsurgery.
The bclient bis breturn bdemonstrating bwrapping bof bthe bleft blimb bamputated babove bthe
bknee. bThe bnurse bevaluates bthe bclient bis bstarting bthe bwrapping bmethod bcorrectly
bwhen bthe bclient bplaces bthe bend bof bthe bbandage bat bwhich bpoint?
A. Around bthe bwaist
B. At bthe binner baspect bof bthe bleft bstump
C. At bthe bouter baspect bof bthe bleft bstump
D. At bthe bleft bgroin barea b- b✓✓-Correct bAnswer: bA
Rationale:The bwaist bis bthe banchor bpoint bfor bthe bbandage bfor ban babove bthe bknee
bamputation.
A bnurse bis bassisting ban b82-year-old bclient bwith bambulation band bis bconcerned bthat
bthe bclient bmay bfall. bWhich barea bcontains bthe bolder bperson's bcenter bof bgravity?
A. Head band bneck
B. Upper btorso
,C. Bilateral barms
D. Feet band blegs b- b✓✓-Correct bAnswer: bB
Rationale:Stooped bposture bresults bin bthe bupper btorso bbecoming bthe bcenter bof
bgravity bfor bolder bpersons. bThe bcenter bof bgravity bfor badults bis bthe bhips. bHowever,
bas ba bperson bgrows bolder, ba bstooped bposture bis bcommon bbecause bof bchanges
bcaused bby bosteoporosis band bnormal bbone bdegeneration. bFurthermore, bthe bknees,
bhips, band belbows bflex. bThe bhead band bneck band bfeet band blegs bare bnot bthe
bcenter bof bgravity bin bthe bolder badult. bAlthough bthe barms bcomprise ba bpart bof bthe
bupper btorso, bthey bdo bnot breflect bthe bbest band bmost bcomplete banswer.
A bclient bwith bhypertension bhas bbeen breceiving bramipril, b5 bmg bPO, bdaily bfor b2
bweeks band bis bscheduled bto breceive ba bdose bat b0900. bAt b0830, bthe bclient's
bblood bpressure bis b120/70 bmm bHg. bWhich baction bshould bthe bnurse btake?
A. Administer bthe bprescribed bdose bat bthe bscheduled btime.
B. Hold bthe bdose band bcontact bthe bhealth bcare bprovider.
C. Hold bthe bdose band b recheck bthe bblood bpressure bin b1 bhour.
D. Check bthe bhealth bcare bprovider's bprescription bto bclarify bthe bdose. b- b✓✓-
Correct bAnswer: bA
Rationale:The bclient's bblood bpressure bis bwithin bnormal blimits, bindicating bthat bthe
bramipril, ban bantihypertensive, bis bhaving bthe bdesired beffect band bshould bbe
badministered. bOptions bB band bC bwould bbe bappropriate bif bthe bclient's bblood
bpressure bwas bexcessively blow b(<100 bmm bHg bsystolic) bor bif bthe bclient bwere
bexhibiting bsigns bof bhypotension bsuch bas bdizziness. bThis bprescribed bdose bis bwithin
bthe bnormal bdosage brange, bas bdefined bby bthe bmanufacturer; btherefore, boption bD bis
bnot bnecessary
The bnurse bis bproviding bcare bfor ba bclient bdiagnosed bwith btrigeminal bneuralgia b(tic
bdouloureux). bWhich bsymptoms bwill bthe bnurse bbe blooking bfor bin bthe bfocused
bassessment brelated bto bthis bcondition? b(Select ball bthat bapply.)
A. Facial bmuscle bspasms
B. Sudden bfacial bpain
C. Unilateral bfacial bweakness
D. Difficulty bin
bchewing bE.Tinnitus
F.Hearing bdifficulties b- b✓✓-Correct bAnswer: bA,B
Rationale:Trigeminal bneuralgia bis bcharacterized bby bparoxysms bof bpain, bsimilar bto
ban belectric bshock, bin bthe barea binnervated bby bone bor bmore bbranches bof bthe
btrigeminal bnerve b(cranial bV). bThe bremaining bsymptoms bare bnot brelated bto
btrigeminal bneuralgia.
In bcaring bfor ba bclient bwith bacute bdiverticulitis, bwhich bassessment bdata bwarrants ban
bimmediate bnursing baction?
,A. bThe bclient bhas ba brigid bhard babdomen band b elevated bWBC.
B. bThe bclient bhas bleft blower bquadrant bpain band ban belevated btemperature.
C.The bclient bis brefusing bto beat bany bof bthe bmeal band bis bcomplaining bof bnausea.
D. bThe bclient bhas bnot bhad ba bbowel bmovement bin b2 bdays band bhas ba bsoft
babdomen. b- b✓✓- bCorrect bAnswer: bA
Rationale: bA bhard brigid babdomen band belevated bWBC bis bindicative bof bperitonitis,
bwhich bis ba bmedical bemergency band bshould bbe breported bto bthe bhealth bcare
bprovider bimmediately. bOptions bB band bC bare bexpected bclinical bmanifestations bof
bdiverticulitis. bOption bD bdoes bnot bwarrant bimmediate bintervention.
The bnurse bis bcaring bfor ba bclient bwith ba bfractured bright belbow. bWhich bassessment
bfinding bhas bthe bhighest bpriority band brequires bimmediate bintervention?
A. bEcchymosis bover bthe bright belbow barea
B. bDeep bunrelenting bpain bin bthe bright barm
C. bAn bedematous bright belbow
D. bThe bpresence bof bcrepitus bin bthe bright belbow b- b✓✓-Correct bAnswer: bB
Rationale:Compartment bsyndrome bis ba bcondition binvolving bincreased bpressure band
bconstriction bof bthe bnerves band bvessels bwithin ban banatomic bcompartment, bcausing
bpain buncontrolled bby bopioids band bneurovascular bcompromise. bOption bA bis ban
bexpected bfinding. bOption bC brelated bto bcompartment bsyndrome bcannot bbe bseen,
band bany bvisible bedema bis ban bexpected bfinding brelated bto bthe binjury. bOption bD bis
ban bexpected bfinding.
The bnurse bnotes bthat ba bclient bwho bis bscheduled bfor bsurgery bthe bnext bmorning bhas
ban belevated bblood burea bnitrogen b(BUN) blevel. bWhich bcondition bis bmost blikely bto
bhave bcontributed bto bthis bfinding?
A. bMyocardial binfarction b2 bmonths bago
B. bAnorexia band bvomiting bfor bthe bpast b2 bdays
C.Recently bdiagnosed btype b2 bdiabetes bmellitus
D. bSkeletal btraction bfor ba bright bhip bfracture b- b✓✓-Correct bAnswer: bB
Rationale:The bblood burea bnitrogen b(BUN) blevel bindicates bthe beffectiveness bof bthe
bkidneys bin bfiltering bwaste bfrom bthe bblood. bDehydration, bwhich bcould bbe bcaused bby
bvomiting, bwould bcause ban b increased b BUN blevel. bOption bA bwould baffect bserum
benzyme blevels, bnot bthe bBUN blevel. bOption bC bwould bprimarily baffect bthe bblood
bglucose blevel; brenal bfailure bthat bcould bincrease bthe bBUN blevel bwould bbe bunlikely
bin ba bclient bnewly bdiagnosed bwith btype b2 bdiabetes. bEffects bof boption bD bmight
baffect bthe bcomplete bblood bcount b(CBC) bbut bwould bnot bdirectly bincrease bthe bBUN
blevel.
, Which binstruction bis bbest bfor bthe bnurse bto bprovide bto ba bclient bwith bemphysema
band bchronic bfatigue?
A."Pace byour bactivities band bschedule brest
bperiods." bB."Increase bthe bamount bof boxygen byou
buse bat bnight."
C."Obtain bmedical bevaluation bfor bantibiotic btherapy."
D."Reduce byour bintake bof bfluids bcontaining bcaffeine." b- b✓✓-Correct bAnswer: bA
Rationale:Manifestations bof bemphysema binclude ban bincrease bin bAP bdiameter
b(referred bto bas ba bbarrel bchest), bnail bbed bclubbing, band bfatigue. bThe bnurse bcan
bprovide binstructions bto bpromote benergy bmanagement, bsuch bas bpacing bactivities
band bscheduling brest bperiods.
Option bB bmay bresult bin ba bdecreased bdrive bto bbreathe. bThe bclient bis bnot
bexhibiting bany bsymptoms bof binfection, bso boption bC bis bnot bnecessary. bOption bD
bis bless bbeneficial bthan boption bA.
Which bnursing baction bwould bbe bappropriate bfor ba bclient bwho bis bnewly bdiagnosed
bwith bCushing bsyndrome?
A.Monitor bblood bglucose blevels bdaily.
B.Increase bintake bof bfluids bhigh bin bpotassium.
bC.Encourage badequate brest bbetween bactivities.
D.Offer bthe bclient ba bsodium-enriched bmenu. b- b✓✓-Correct bAnswer: bA
Rationale: bCushing bsyndrome bresults bfrom ba bhypersecretion bof bglucocorticoids bin
bthe badrenal bcortex. bClients bwith bCushing bsyndrome boften bdevelop bdiabetes
bmellitus.
Monitoring bof bserum bglucose blevels bassesses bfor bincreased bblood bglucose blevels
bso bthat btreatment bcan bbegin bearly. bA bcommon bfinding bin bCushing bsyndrome bis
bgeneralized bedema. bAlthough bpotassium bis bneeded, bit bis bgenerally bobtained bfrom
bfood bintake, bnot bby boffering bpotassium-enhanced bfluids. bFatigue bis busually bnot
ban boverwhelming bfactor bin bCushing bsyndrome, bso ban bemphasis bon bthe bneed bfor
brest bis bnot bindicated. bA blow-calorie, blow-carbohydrate, blow-sodium bdiet bis bnot
brecommended.
During bthe bchange bof bshift breport, bthe bcharge bnurse breviews bthe binfusions bbeing
breceived bby bclients bon bthe boncology bunit. bThe bclient breceiving bwhich binfusion
bshould bbe bassessed bfirst?
A.Continuous bIV binfusion bof bmagnesium
bB.One-time binfusion bof balbumin
bC.Continuous bepidural binfusion bof
bmorphine
D.Intermittent binfusion bof bIV bvancomycin b- b✓✓-Correct bAnswer: bC
