Evolve HESI Med-Surg 2025|2026 ACTUAL EXAM REVIEW
150 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES GUARANTEE A+GRADE
1. When educating a client after a total laryngectomy, which instruction is most important for
discharge teaching?
☐ A. Recommend carrying suction equipment at all times
☐ B. Instruct to have writing materials at all times
☑ C. Carry a medical alert card that explains the condition
☐ D. Caution not to travel outside the U.S. alone
Rationale: Neck breathers must carry a medical alert card to notify healthcare personnel that mouth-to-
stoma breathing is needed in emergencies. Alternative communication methods are available; options A
and D are unnecessary.
2. The nurse receives a client’s next TPN bag labeled with NPH insulin. Which action should the nurse
implement?
☐ A. Hang the solution at the current rate
☐ B. Refrigerate until needed
☐ C. Prepare with new tubing
☑ D. Return the solution to the pharmacy
Rationale: Only regular insulin is administered IV. NPH in TPN should not be given; the solution must be
returned.
3. A postoperative client receives a Schedule II opioid for pain. Which assessment finding requires the
most immediate intervention?
☐ A. Hypoactive bowel sounds with distention
☐ B. Pain rated 8/10
☑ C. Respiratory rate 12/min, O₂ saturation 85%
☐ D. Nausea
Rationale: Opioids can cause respiratory depression, which is life-threatening. Other issues are
important but not immediately dangerous.
4. A client is on a mechanical ventilator after a cerebral hemorrhage and receives vecuronium
bromide. Priority nursing diagnosis?
,☑ A. Impaired communication related to skeletal muscle paralysis
☐ B. High risk for infection related to increased ICP
☐ C. Potential for injury related to impaired lung expansion
☐ D. Social isolation related to inability to communicate
Rationale: Vecuronium paralyzes muscles, leaving the client unable to communicate needs; this is the
priority concern.
5. A family member is taught tracheostomy suctioning before client discharge. Which observation
indicates correct technique?
☐ A. Turns on continuous wall suction to 190 mm Hg
☑ B. Inserts catheter until resistance or coughing occurs
☐ C. Withdraws catheter while maintaining suction
☐ D. Reclears tracheostomy after suctioning mouth
Rationale: Catheter is inserted until resistance/cough, then withdrawn with intermittent suction.
Suction pressure of 190 mm Hg is too high; continuous suction is incorrect.
6. A client post-MI reports chest pain unrelieved by nitroglycerin. Nursing action?
☑ A. Notify provider immediately
☐ B. Encourage rest only
☐ C. Document only
☐ D. Give a second nitroglycerin without assessment
Rationale: Persistent chest pain may indicate reinfarction; urgent assessment is required.
7. A client with COPD reports increased sputum and SOB. Nursing action?
☑ A. Assess lung sounds and oxygenation
☐ B. Encourage exercise only
☐ C. Increase oxygen without assessment
☐ D. Send home
Rationale: Worsening symptoms may indicate infection or exacerbation; assessment is priority.
8. A client post-thyroidectomy develops tingling around lips/fingers. Nursing action?
☑ A. Assess for hypocalcemia and notify provider
☐ B. Encourage fluids
,☐ C. Document only
☐ D. Administer oral thyroid
Rationale: Tingling may indicate hypocalcemia from parathyroid injury; prompt intervention needed.
9. A client with heart failure has 3+ pitting edema and weight gain. Nursing action?
☑ A. Assess fluid status, monitor daily weights, notify provider
☐ B. Encourage high-sodium diet
☐ C. Document only
☐ D. Restrict fluids without order
Rationale: Monitoring fluid balance prevents worsening heart failure.
10. A client with pneumonia on antibiotics develops rash and wheezing. Nursing action?
☑ A. Stop medication and notify provider
☐ B. Continue antibiotic
☐ C. Give antihistamine only
☐ D. Document
Rationale: Allergic reaction; medication must be stopped and provider notified.
11. A client with hypoglycemia treated with glucose. Nursing action?
☑ A. Recheck blood glucose in 15 minutes
☐ B. Ignore monitoring
☐ C. Give insulin
☐ D. Encourage exercise
Rationale: Ensures hypoglycemia is corrected and prevents recurrence.
12. A client receiving digoxin reports nausea, vomiting, and visual changes. Nursing action?
☑ A. Assess for digoxin toxicity and notify provider
☐ B. Give next dose
☐ C. Encourage fluids only
☐ D. Document only
Rationale: GI and visual symptoms indicate digoxin toxicity.
, 13. A client receiving thrombolytics develops sudden headache. Nursing action?
☑ A. Stop infusion and notify provider immediately
☐ B. Continue infusion
☐ C. Give analgesics only
☐ D. Document
Rationale: Headache may indicate intracranial hemorrhage; urgent action required.
14. A client on opioid analgesic develops respiratory depression. Nursing action?
☑ A. Stop opioid, stimulate client, notify provider
☐ B. Encourage ambulation
☐ C. Document only
☐ D. Give antiemetic
Rationale: Life-threatening; requires immediate action.
15. Client with COPD has SpO₂ 85% on 2 L nasal cannula. Nursing action?
☑ A. Assess and titrate oxygen to maintain target saturation
☐ B. Stop oxygen
☐ C. Increase oxygen to 6 L without assessment
☐ D. Encourage exercise
Rationale: Hypoxemia requires assessment; oxygen should be carefully adjusted.
16. A client post-op develops fever, tachycardia, and hypotension. Nursing action?
☑ A. Assess for sepsis and notify provider
☐ B. Encourage ambulation
☐ C. Document only
☐ D. Give antipyretic only
Rationale: Early detection of sepsis prevents serious postoperative complications.
17. A client on warfarin has INR 6.0. Nursing action?
☑ A. Hold medication and notify provider
☐ B. Continue current dose
☐ C. Encourage vitamin K-rich diet only
☐ D. Document
150 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES GUARANTEE A+GRADE
1. When educating a client after a total laryngectomy, which instruction is most important for
discharge teaching?
☐ A. Recommend carrying suction equipment at all times
☐ B. Instruct to have writing materials at all times
☑ C. Carry a medical alert card that explains the condition
☐ D. Caution not to travel outside the U.S. alone
Rationale: Neck breathers must carry a medical alert card to notify healthcare personnel that mouth-to-
stoma breathing is needed in emergencies. Alternative communication methods are available; options A
and D are unnecessary.
2. The nurse receives a client’s next TPN bag labeled with NPH insulin. Which action should the nurse
implement?
☐ A. Hang the solution at the current rate
☐ B. Refrigerate until needed
☐ C. Prepare with new tubing
☑ D. Return the solution to the pharmacy
Rationale: Only regular insulin is administered IV. NPH in TPN should not be given; the solution must be
returned.
3. A postoperative client receives a Schedule II opioid for pain. Which assessment finding requires the
most immediate intervention?
☐ A. Hypoactive bowel sounds with distention
☐ B. Pain rated 8/10
☑ C. Respiratory rate 12/min, O₂ saturation 85%
☐ D. Nausea
Rationale: Opioids can cause respiratory depression, which is life-threatening. Other issues are
important but not immediately dangerous.
4. A client is on a mechanical ventilator after a cerebral hemorrhage and receives vecuronium
bromide. Priority nursing diagnosis?
,☑ A. Impaired communication related to skeletal muscle paralysis
☐ B. High risk for infection related to increased ICP
☐ C. Potential for injury related to impaired lung expansion
☐ D. Social isolation related to inability to communicate
Rationale: Vecuronium paralyzes muscles, leaving the client unable to communicate needs; this is the
priority concern.
5. A family member is taught tracheostomy suctioning before client discharge. Which observation
indicates correct technique?
☐ A. Turns on continuous wall suction to 190 mm Hg
☑ B. Inserts catheter until resistance or coughing occurs
☐ C. Withdraws catheter while maintaining suction
☐ D. Reclears tracheostomy after suctioning mouth
Rationale: Catheter is inserted until resistance/cough, then withdrawn with intermittent suction.
Suction pressure of 190 mm Hg is too high; continuous suction is incorrect.
6. A client post-MI reports chest pain unrelieved by nitroglycerin. Nursing action?
☑ A. Notify provider immediately
☐ B. Encourage rest only
☐ C. Document only
☐ D. Give a second nitroglycerin without assessment
Rationale: Persistent chest pain may indicate reinfarction; urgent assessment is required.
7. A client with COPD reports increased sputum and SOB. Nursing action?
☑ A. Assess lung sounds and oxygenation
☐ B. Encourage exercise only
☐ C. Increase oxygen without assessment
☐ D. Send home
Rationale: Worsening symptoms may indicate infection or exacerbation; assessment is priority.
8. A client post-thyroidectomy develops tingling around lips/fingers. Nursing action?
☑ A. Assess for hypocalcemia and notify provider
☐ B. Encourage fluids
,☐ C. Document only
☐ D. Administer oral thyroid
Rationale: Tingling may indicate hypocalcemia from parathyroid injury; prompt intervention needed.
9. A client with heart failure has 3+ pitting edema and weight gain. Nursing action?
☑ A. Assess fluid status, monitor daily weights, notify provider
☐ B. Encourage high-sodium diet
☐ C. Document only
☐ D. Restrict fluids without order
Rationale: Monitoring fluid balance prevents worsening heart failure.
10. A client with pneumonia on antibiotics develops rash and wheezing. Nursing action?
☑ A. Stop medication and notify provider
☐ B. Continue antibiotic
☐ C. Give antihistamine only
☐ D. Document
Rationale: Allergic reaction; medication must be stopped and provider notified.
11. A client with hypoglycemia treated with glucose. Nursing action?
☑ A. Recheck blood glucose in 15 minutes
☐ B. Ignore monitoring
☐ C. Give insulin
☐ D. Encourage exercise
Rationale: Ensures hypoglycemia is corrected and prevents recurrence.
12. A client receiving digoxin reports nausea, vomiting, and visual changes. Nursing action?
☑ A. Assess for digoxin toxicity and notify provider
☐ B. Give next dose
☐ C. Encourage fluids only
☐ D. Document only
Rationale: GI and visual symptoms indicate digoxin toxicity.
, 13. A client receiving thrombolytics develops sudden headache. Nursing action?
☑ A. Stop infusion and notify provider immediately
☐ B. Continue infusion
☐ C. Give analgesics only
☐ D. Document
Rationale: Headache may indicate intracranial hemorrhage; urgent action required.
14. A client on opioid analgesic develops respiratory depression. Nursing action?
☑ A. Stop opioid, stimulate client, notify provider
☐ B. Encourage ambulation
☐ C. Document only
☐ D. Give antiemetic
Rationale: Life-threatening; requires immediate action.
15. Client with COPD has SpO₂ 85% on 2 L nasal cannula. Nursing action?
☑ A. Assess and titrate oxygen to maintain target saturation
☐ B. Stop oxygen
☐ C. Increase oxygen to 6 L without assessment
☐ D. Encourage exercise
Rationale: Hypoxemia requires assessment; oxygen should be carefully adjusted.
16. A client post-op develops fever, tachycardia, and hypotension. Nursing action?
☑ A. Assess for sepsis and notify provider
☐ B. Encourage ambulation
☐ C. Document only
☐ D. Give antipyretic only
Rationale: Early detection of sepsis prevents serious postoperative complications.
17. A client on warfarin has INR 6.0. Nursing action?
☑ A. Hold medication and notify provider
☐ B. Continue current dose
☐ C. Encourage vitamin K-rich diet only
☐ D. Document
