Evolve Elsevier Hesi Med Surg Actual Exam With 100 Real Exam Questions And Correct Answers With Rationales/ Evolve Hesi Medical Surgical Latest Exam 2024/2025 ||Complete A+ Guide

Evolve Elsevier Hesi Med Surg Actual Exam With 100 Real

Exam Questions And Correct Answers With Rationales/

Evolve Hesi Medical Surgical Latest Exam 2024/2025

||Complete A+ Guide




1. When educating a client after a total laryngectomy, which instruction would
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m be most important for the nurse to include in the discharge teaching?
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A. Recommend that the client carry suction equipment at all times.
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B. Instruct the client to have writing materials with him at all times.
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C. Tell the client to carry a medical alert card that explains his condition.
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D. Caution the client not to travel outside the United States alone.
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…Ans>> C mmm m




Rationale: Neck breathers carry a medical alert card that notifies health care per- sonnel
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of the need to use mouth to stoma breathing in the event of a cardiac arrest in this client.
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Mouth to mouth resuscitation will not establish a patent airway. Options A and D are not
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,necessary. There are many alternative means of communication for clients who have had a
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laryngectomy; dependence on writing messages is probably the least effective.
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2. The nurse receives the client's next scheduled bag of TPN labeled with the
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m additive NPH insulin. Which action should the nurse implement?
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A. Hang the solution at the current rate.
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B. Refrigerate the solution until needed. m m m m




C. Prepare the solution with new tubing.
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D. Return the solution to the pharmacy.
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…Ans>> D mm




Rationale: Only regular insulin is administered by the IV route, so the TPN solution
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m containing NPH insulin should be returned to the pharmacy. Options A, B, and C are not
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m indicated because the solution should not be administered.
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3. A postoperative client receives a Schedule II opioid analgesic for pain.
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m Which assessment finding requires the most immediate intervention by the
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m nurse?
A. Hypoactive bowel sounds with abdominal distention m m m m m




B. Client reports continued pain of 8 on a 10-point scale
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C. Respiratory rate of 12 breaths/min, with O2 saturation of 85%
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D. Client reports nausea after receiving the medication
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…Ans>> C mm




Rationale: Administration of a Schedule II opioid analgesic can result in respiratory
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m depression, which requires immediate intervention by the nurse to prevent respira- tory
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,m arrest. Options A, B, and D require action by the nurse but are of less priority than option
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m C.


4. A client is placed on a mechanical ventilator following a cerebral hemor-
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m rhage, and vecuronium bromide, 0.04 mg/kg every 12 hours IV, is
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prescribed. What is the priority nursing diagnosis for this client?
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A. Impaired communication related to paralysis of skeletal muscles
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B. High risk for infection related to increased intracranial pressure
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C. Potential for injury related to impaired lung expansion
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D. Social isolation related to inability to communicate
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…Ans>> A mm




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, Rationale: To increase the client's tolerance of endotracheal intubation and/or me-
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m chanical ventilation, a skeletal muscle relaxant such as vecuronium is usually prescribed.
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m Option A is a serious outcome because the client cannot communicate his or her needs.
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m Although this client might also experience option D, it is not a priority when compared
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m with option A. Infection is not related to increased intracranial pressure. The respirator will
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m ensure that the lungs are expanded, so option C is incorrect.
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5. A family member was taught to suction a client's tracheostomy prior to the
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m client's discharge from the hospital. Which observation by the nurse indicates
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m that the family member is capable of correctly performing the suctioning
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m technique?
A. Turns on the continuous wall suction to 190 mm Hg.
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B. Inserts the catheter until resistance or coughing occurs.
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C. Withdraws the catheter while maintaining suctioning. m m m m m




D. Reclears the tracheostomy after suctioning the mouth.
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…Ans>> B mm m




Rationale: Option B indicates correct technique for performing suctioning. Suction
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m pressure should be between 80 and 120 mm Hg, not 190 mm Hg. The catheter should be
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m withdrawn 1 to 2 cm at a time with intermittent, not continuous, suction. Option D
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m introduces pathogens unnecessarily into the tracheobronchial tree.
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6. A client is diagnosed with an acute small bowel obstruction. Which assess-
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m ment finding requires the most immediate intervention by the nurse?
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A. Fever of 102° F m m m



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