Evolve HESI Med-Surg 2025|2026 ACTUAL EXAM REVIEW
150 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES GUARANTEE A+GRADE
1. A client post-laryngectomy is being discharged. Which instruction is most important?
☑ A. Carry a medical alert card explaining the condition.
☐ B. Carry suction equipment at all times.
☐ C. Have writing materials with them.
☐ D. Avoid traveling outside the U.S. alone.
Rationale: Neck breathers must notify health personnel that mouth-to-stoma ventilation is required.
Other instructions are less critical.
2. The nurse receives TPN labeled with NPH insulin. What should be done?
☑ A. Return the solution to the pharmacy.
☐ B. Hang solution at current rate.
☐ C. Refrigerate until needed.
☐ D. Prepare with new tubing.
Rationale: Only regular insulin can be given IV. NPH insulin in TPN should not be administered.
3. A post-op client on a Schedule II opioid has a respiratory rate of 12 and O₂ saturation of 85%. What
is the priority action?
☑ A. Intervene immediately for respiratory depression.
☐ B. Monitor bowel sounds.
☐ C. Assess pain level.
☐ D. Treat nausea.
Rationale: Opioid-induced respiratory depression is life-threatening. Other concerns are lower priority.
4. A client on vecuronium for mechanical ventilation. Priority nursing diagnosis?
☑ A. Impaired communication related to paralysis of skeletal muscles.
☐ B. High risk for infection.
☐ C. Potential for injury due to impaired lung expansion.
☐ D. Social isolation.
Rationale: Vecuronium causes paralysis; inability to communicate needs is the priority.
,5. Family member suctioning a tracheostomy. Correct technique?
☑ A. Insert catheter until resistance or coughing occurs.
☐ B. Use continuous suction at 190 mm Hg.
☐ C. Withdraw catheter while maintaining suction.
☐ D. Suction the tracheostomy after the mouth.
Rationale: Suction until resistance or cough; intermittent suction is required; mouth suctioning after
trachea is unsafe.
6. A client with chronic kidney disease has hyperkalemia. Which lab result requires immediate action?
☑ A. Serum potassium 6.5 mEq/L
☐ B. Serum sodium 138 mEq/L
☐ C. BUN 25 mg/dL
☐ D. Creatinine 2.0 mg/dL
Rationale: K⁺ >6 mEq/L can cause life-threatening arrhythmias.
7. A client with a NG tube complains of abdominal bloating. Nursing intervention?
☑ A. Check tube patency and suction as prescribed.
☐ B. Increase feed rate.
☐ C. Clamp tube.
☐ D. Remove tube immediately.
Rationale: NG tube obstruction can cause distention; clearing the tube maintains safety.
8. A client with heart failure reports dyspnea and weight gain. First assessment?
☑ A. Auscultate lung sounds for crackles.
☐ B. Check pedal pulses.
☐ C. Assess bowel sounds.
☐ D. Review hemoglobin.
Rationale: Crackles indicate pulmonary edema; early detection is critical.
9. Which client is at highest risk for developing pressure injuries?
☑ A. Immobile, incontinent client with poor nutrition.
☐ B. Ambulatory client with mild dehydration.
,☐ C. Client with controlled diabetes walking independently.
☐ D. Healthy young adult after minor surgery.
Rationale: Immobility, incontinence, and malnutrition increase pressure injury risk.
10. A client receiving IV heparin has aPTT of 110 seconds. Nursing action?
☑ A. Hold heparin and notify provider.
☐ B. Increase rate.
☐ C. Continue infusion.
☐ D. Check potassium level.
Rationale: aPTT above therapeutic range increases bleeding risk; provider must be notified.
11. A client with COPD on oxygen therapy develops somnolence. What should nurse do first?
☑ A. Lower O₂ flow to maintain target saturation.
☐ B. Encourage coughing.
☐ C. Stop oxygen completely.
☐ D. Increase oxygen.
Rationale: Excess oxygen can suppress respiratory drive in COPD.
12. Postoperative client with PCA pump reports pain not relieved. Nurse should:
☑ A. Assess pain, pump functioning, and ensure patient-controlled use.
⛔ B. Immediately give IV bolus without assessment.
☐ C. Encourage non-pharmacologic measures only.
☐ D. Wait until next scheduled dose.
Rationale: PCA requires assessment of pain, pump settings, and patient understanding.
13. A client with diabetes reports dizziness and sweating. First action?
☑ A. Check blood glucose.
☐ B. Wait 30 minutes.
☐ C. Give insulin.
☐ D. Encourage exercise.
Rationale: Symptoms suggest hypoglycemia; glucose check is priority.
, 14. A client on warfarin reports nosebleed. What is the nurse’s priority action?
☑ A. Hold medication and notify provider.
☐ B. Administer next dose.
☐ C. Encourage rest.
☐ D. Document only.
Rationale: Bleeding indicates elevated INR; medication may need adjustment.
15. A postoperative client reports calf pain and swelling. First action?
☑ A. Assess for DVT and notify provider.
☐ B. Massage calf.
☐ C. Encourage ambulation immediately.
☐ D. Apply heat.
Rationale: Calf pain/swelling may indicate DVT; interventions like massage may dislodge clot.
16. A client with pneumonia has O₂ saturation 88% on 2 L O₂. Next action?
☑ A. Assess lung sounds and notify provider.
☐ B. Reduce oxygen.
☐ C. Send home.
☐ D. Document only.
Rationale: Low O₂ saturation indicates hypoxemia; requires assessment and possible intervention.
17. A client with new colostomy asks about skin care. Correct instruction?
☑ A. Clean skin around stoma gently and change appliance as needed.
☐ B. Use harsh soap to disinfect.
☐ C. Only change appliance once per week.
☐ D. Avoid cleaning the skin.
Rationale: Proper skin care prevents irritation and infection.
18. A client receiving blood transfusion develops chills and fever. First action?
☑ A. Stop transfusion immediately.
☐ B. Slow infusion.
☐ C. Give antihistamine only.
☐ D. Document and continue.
150 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES GUARANTEE A+GRADE
1. A client post-laryngectomy is being discharged. Which instruction is most important?
☑ A. Carry a medical alert card explaining the condition.
☐ B. Carry suction equipment at all times.
☐ C. Have writing materials with them.
☐ D. Avoid traveling outside the U.S. alone.
Rationale: Neck breathers must notify health personnel that mouth-to-stoma ventilation is required.
Other instructions are less critical.
2. The nurse receives TPN labeled with NPH insulin. What should be done?
☑ A. Return the solution to the pharmacy.
☐ B. Hang solution at current rate.
☐ C. Refrigerate until needed.
☐ D. Prepare with new tubing.
Rationale: Only regular insulin can be given IV. NPH insulin in TPN should not be administered.
3. A post-op client on a Schedule II opioid has a respiratory rate of 12 and O₂ saturation of 85%. What
is the priority action?
☑ A. Intervene immediately for respiratory depression.
☐ B. Monitor bowel sounds.
☐ C. Assess pain level.
☐ D. Treat nausea.
Rationale: Opioid-induced respiratory depression is life-threatening. Other concerns are lower priority.
4. A client on vecuronium for mechanical ventilation. Priority nursing diagnosis?
☑ A. Impaired communication related to paralysis of skeletal muscles.
☐ B. High risk for infection.
☐ C. Potential for injury due to impaired lung expansion.
☐ D. Social isolation.
Rationale: Vecuronium causes paralysis; inability to communicate needs is the priority.
,5. Family member suctioning a tracheostomy. Correct technique?
☑ A. Insert catheter until resistance or coughing occurs.
☐ B. Use continuous suction at 190 mm Hg.
☐ C. Withdraw catheter while maintaining suction.
☐ D. Suction the tracheostomy after the mouth.
Rationale: Suction until resistance or cough; intermittent suction is required; mouth suctioning after
trachea is unsafe.
6. A client with chronic kidney disease has hyperkalemia. Which lab result requires immediate action?
☑ A. Serum potassium 6.5 mEq/L
☐ B. Serum sodium 138 mEq/L
☐ C. BUN 25 mg/dL
☐ D. Creatinine 2.0 mg/dL
Rationale: K⁺ >6 mEq/L can cause life-threatening arrhythmias.
7. A client with a NG tube complains of abdominal bloating. Nursing intervention?
☑ A. Check tube patency and suction as prescribed.
☐ B. Increase feed rate.
☐ C. Clamp tube.
☐ D. Remove tube immediately.
Rationale: NG tube obstruction can cause distention; clearing the tube maintains safety.
8. A client with heart failure reports dyspnea and weight gain. First assessment?
☑ A. Auscultate lung sounds for crackles.
☐ B. Check pedal pulses.
☐ C. Assess bowel sounds.
☐ D. Review hemoglobin.
Rationale: Crackles indicate pulmonary edema; early detection is critical.
9. Which client is at highest risk for developing pressure injuries?
☑ A. Immobile, incontinent client with poor nutrition.
☐ B. Ambulatory client with mild dehydration.
,☐ C. Client with controlled diabetes walking independently.
☐ D. Healthy young adult after minor surgery.
Rationale: Immobility, incontinence, and malnutrition increase pressure injury risk.
10. A client receiving IV heparin has aPTT of 110 seconds. Nursing action?
☑ A. Hold heparin and notify provider.
☐ B. Increase rate.
☐ C. Continue infusion.
☐ D. Check potassium level.
Rationale: aPTT above therapeutic range increases bleeding risk; provider must be notified.
11. A client with COPD on oxygen therapy develops somnolence. What should nurse do first?
☑ A. Lower O₂ flow to maintain target saturation.
☐ B. Encourage coughing.
☐ C. Stop oxygen completely.
☐ D. Increase oxygen.
Rationale: Excess oxygen can suppress respiratory drive in COPD.
12. Postoperative client with PCA pump reports pain not relieved. Nurse should:
☑ A. Assess pain, pump functioning, and ensure patient-controlled use.
⛔ B. Immediately give IV bolus without assessment.
☐ C. Encourage non-pharmacologic measures only.
☐ D. Wait until next scheduled dose.
Rationale: PCA requires assessment of pain, pump settings, and patient understanding.
13. A client with diabetes reports dizziness and sweating. First action?
☑ A. Check blood glucose.
☐ B. Wait 30 minutes.
☐ C. Give insulin.
☐ D. Encourage exercise.
Rationale: Symptoms suggest hypoglycemia; glucose check is priority.
, 14. A client on warfarin reports nosebleed. What is the nurse’s priority action?
☑ A. Hold medication and notify provider.
☐ B. Administer next dose.
☐ C. Encourage rest.
☐ D. Document only.
Rationale: Bleeding indicates elevated INR; medication may need adjustment.
15. A postoperative client reports calf pain and swelling. First action?
☑ A. Assess for DVT and notify provider.
☐ B. Massage calf.
☐ C. Encourage ambulation immediately.
☐ D. Apply heat.
Rationale: Calf pain/swelling may indicate DVT; interventions like massage may dislodge clot.
16. A client with pneumonia has O₂ saturation 88% on 2 L O₂. Next action?
☑ A. Assess lung sounds and notify provider.
☐ B. Reduce oxygen.
☐ C. Send home.
☐ D. Document only.
Rationale: Low O₂ saturation indicates hypoxemia; requires assessment and possible intervention.
17. A client with new colostomy asks about skin care. Correct instruction?
☑ A. Clean skin around stoma gently and change appliance as needed.
☐ B. Use harsh soap to disinfect.
☐ C. Only change appliance once per week.
☐ D. Avoid cleaning the skin.
Rationale: Proper skin care prevents irritation and infection.
18. A client receiving blood transfusion develops chills and fever. First action?
☑ A. Stop transfusion immediately.
☐ B. Slow infusion.
☐ C. Give antihistamine only.
☐ D. Document and continue.
