HESI MED SURG EVOLVE QUESTIONS AND CORRECT ANSWERS
1. When educating a client after a
C
total la- ryngectomy, which
Rationale: Neck breathers carry a
instruction would be most
medical alert card that notifies health
important for the nurse to include
care personnel of the need to use mouth
in the discharge teaching?
to stoma breathing in the event of a
A. Recommend that the client carry
cardiac arrest in this client. Mouth to mouth
suc- tion equipment at all times.
resuscitation will not establish a patent
B. Instruct the client to have
airway. Options A and D are not
writing ma- terials with him at all
necessary.
times.
There are many alternative means of
C. Tell the client to carry a medical
commu- nication for clients who have
alert card that explains his
had a laryngecto- my; dependence on
condition.
writing messages is prob-
D.Caution the client not to travel outside ably the least ettective.
the United States alone.
2. The nurse receives the client's D
next scheduled bag of TPN Rationale: Only regular insulin is
labeled with the additive NPH administered by the IV route, so the TPN
insulin. Which action should the solution containing NPH insulin should be
nurse implement? returned to the phar- macy. Options A,
A. Hang the solution at the B, and C are not indicated because the
current rate.
solution should not be adminis- tered.
B. Refrigerate the solution until
needed.
C. Prepare the solution with new C
tubing.
D. Return the solution to the
pharmacy.
3. A postoperative client receives a
Sched-
, HESI MED SURG EVOLVE QUESTIONS AND CORRECT ANSWERS
ule II opioid analgesic for pain. Which as- Rationale: Administration of a
Schedule II opi-
sessment finding requires the oid analgesic can result in respiratory
most im- mediate intervention depres- sion, which requires immediate
by the nurse? intervention
A.Hypoactive bowel sounds with abdom- by the nurse to prevent respiratory
arrest. Op-
inal distention tions A, B, and D require action by the
nurse
B. Client reports continued pain of 8 on a but are of less priority than option
C.
10-point scale
C. Respiratory rate of 12
breaths/min, with O2 saturation
of 85%
, HESI MED SURG EVOLVE QUESTIONS AND CORRECT ANSWERS
D. Client reports nausea after
receiving the medication
4. A client is placed on a mechanical
ven- tilator following a cerebral Rationale:To increase the client's tolerance of
hemorrhage, and vecuronium endotracheal intubation and/or
bromide, 0.04 mg/kg every 12 mechanical ventilation, a skeletal muscle
hours IV, is prescribed. What relaxant such as vecuronium is usually
is the priority nursing diagnosis for this prescribed. Option A is a serious
client? outcome because the client cannot
A. Impaired communication communicate his or her needs.
related to paralysis of skeletal Although this client might also experience
muscles option D, it is not a priority when
B. High risk for infection related compared with option A. In- fection is
to in- creased intracranial not related to increased intracranial
pressure
C.Potential for injury related to impaired pressure. The respirator will ensure
that the
lung expansion lungs are expanded, so option C is incorrect.
D. Social isolation related to
inability to communicate
5. A family member was taught to suction a B
client's tracheostomy prior to the client's Rationale:Option B indicates
correct technique
discharge from the hospital. Which ob- for performing suctioning.
Suction pressure
servation by the nurse indicates that the should be between 80 and 120
mm Hg, not
family member is capable of suction to 190 mm Hg.
correctly performing the
suctioning technique?
A. Turns on the continuous wall
, HESI MED SURG EVOLVE QUESTIONS AND CORRECT ANSWERS
190 mm Hg. The catheter should be with- drawn 1 pathogens unnecessarily into the tra-
to 2 cm at a time with intermit-
tent, not continuous, suction. Option D intro- duces
B. Inserts the catheter until resistance or cheobronchial tree.
coughing occurs.
C. Withdraws the catheter while
main- taining suctioning.
D. Reclears the tracheostomy after
suc- tioning the mouth.
1. When educating a client after a
C
total la- ryngectomy, which
Rationale: Neck breathers carry a
instruction would be most
medical alert card that notifies health
important for the nurse to include
care personnel of the need to use mouth
in the discharge teaching?
to stoma breathing in the event of a
A. Recommend that the client carry
cardiac arrest in this client. Mouth to mouth
suc- tion equipment at all times.
resuscitation will not establish a patent
B. Instruct the client to have
airway. Options A and D are not
writing ma- terials with him at all
necessary.
times.
There are many alternative means of
C. Tell the client to carry a medical
commu- nication for clients who have
alert card that explains his
had a laryngecto- my; dependence on
condition.
writing messages is prob-
D.Caution the client not to travel outside ably the least ettective.
the United States alone.
2. The nurse receives the client's D
next scheduled bag of TPN Rationale: Only regular insulin is
labeled with the additive NPH administered by the IV route, so the TPN
insulin. Which action should the solution containing NPH insulin should be
nurse implement? returned to the phar- macy. Options A,
A. Hang the solution at the B, and C are not indicated because the
current rate.
solution should not be adminis- tered.
B. Refrigerate the solution until
needed.
C. Prepare the solution with new C
tubing.
D. Return the solution to the
pharmacy.
3. A postoperative client receives a
Sched-
, HESI MED SURG EVOLVE QUESTIONS AND CORRECT ANSWERS
ule II opioid analgesic for pain. Which as- Rationale: Administration of a
Schedule II opi-
sessment finding requires the oid analgesic can result in respiratory
most im- mediate intervention depres- sion, which requires immediate
by the nurse? intervention
A.Hypoactive bowel sounds with abdom- by the nurse to prevent respiratory
arrest. Op-
inal distention tions A, B, and D require action by the
nurse
B. Client reports continued pain of 8 on a but are of less priority than option
C.
10-point scale
C. Respiratory rate of 12
breaths/min, with O2 saturation
of 85%
, HESI MED SURG EVOLVE QUESTIONS AND CORRECT ANSWERS
D. Client reports nausea after
receiving the medication
4. A client is placed on a mechanical
ven- tilator following a cerebral Rationale:To increase the client's tolerance of
hemorrhage, and vecuronium endotracheal intubation and/or
bromide, 0.04 mg/kg every 12 mechanical ventilation, a skeletal muscle
hours IV, is prescribed. What relaxant such as vecuronium is usually
is the priority nursing diagnosis for this prescribed. Option A is a serious
client? outcome because the client cannot
A. Impaired communication communicate his or her needs.
related to paralysis of skeletal Although this client might also experience
muscles option D, it is not a priority when
B. High risk for infection related compared with option A. In- fection is
to in- creased intracranial not related to increased intracranial
pressure
C.Potential for injury related to impaired pressure. The respirator will ensure
that the
lung expansion lungs are expanded, so option C is incorrect.
D. Social isolation related to
inability to communicate
5. A family member was taught to suction a B
client's tracheostomy prior to the client's Rationale:Option B indicates
correct technique
discharge from the hospital. Which ob- for performing suctioning.
Suction pressure
servation by the nurse indicates that the should be between 80 and 120
mm Hg, not
family member is capable of suction to 190 mm Hg.
correctly performing the
suctioning technique?
A. Turns on the continuous wall
, HESI MED SURG EVOLVE QUESTIONS AND CORRECT ANSWERS
190 mm Hg. The catheter should be with- drawn 1 pathogens unnecessarily into the tra-
to 2 cm at a time with intermit-
tent, not continuous, suction. Option D intro- duces
B. Inserts the catheter until resistance or cheobronchial tree.
coughing occurs.
C. Withdraws the catheter while
main- taining suctioning.
D. Reclears the tracheostomy after
suc- tioning the mouth.
