EVOLVE HESI MED SURG ACTUAL EXAM
WITH QUESTIONS AND VERIFIED ANSWERS
WITH RATIONALES Graded A+/BRAND NEW!!
,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-Correct
Answer: A,B,C
Rationale:One hour post op is too soon to ambulate for this client. Visitors help
support the patient and are encouraged to visit. Oral care is necessary as the client
will be NPO. To decrease the risk of infection post operatively, implement routine
pulmonary exercises. The client will have an NG tube in place, likely to
intermittent suction, to decompress the stomach post surgery.
The client is return demonstrating wrapping of the left limb amputated above the
knee. The nurse evaluates the client is starting the wrapping method correctly when
the client places the end of the bandage at which point?
A. Around the waist
B. At the inner aspect of the left stump
C. At the outer aspect of the left stump
D. At the left groin area - CORRECT ANSWER-Correct Answer: A
Rationale: The waist is the anchor point for the bandage for an above the knee
amputation.
A nurse is assisting an 82-year-old client with ambulation and is concerned that the
client may fall. Which area contains the older person's center of gravity?
A. Head and neck
B. Upper torso
C. Bilateral arms
D. Feet and legs - CORRECT ANSWER-Correct Answer: B
,Rationale: Stooped posture results in the upper torso becoming the center of
gravity for older persons. The center of gravity for adults is the hips. However, as a
person grows older, a stooped posture is common because of changes caused by
osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and
elbows flex. The head and neck and feet and legs are not the center of gravity in
the older adult. Although the arms comprise a part of the upper torso, they do not
reflect the best and most complete answer.
A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks
and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is
120/70 mm Hg. Which action should the nurse take?
A. Administer the prescribed dose at the scheduled time.
B. Hold the dose and contact the health care provider.
C. Hold the dose and recheck the blood pressure in 1 hour.
D. Check the health care provider's prescription to clarify the dose. - CORRECT
ANSWER: A
Rationale: The client's blood pressure is within normal limits, indicating that the
ramipril, an antihypertensive, is having the desired effect and should be
administered. Options B and C would be appropriate if the client's blood pressure
was excessively low (<100 mm Hg systolic) or if the client were exhibiting signs
of hypotension, such as dizziness. This prescribed dose is within the normal dosage
range, as defined by the manufacturer; therefore, option D is not necessary
The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic
douloureux). Which symptoms will the nurse be looking for in the focused
assessment related to this condition? (Select all that apply.)
A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in chewing
E.Tinnitus
F. Hearing difficulties - CORRECT ANSWER-Correct Answer: A,B
Rationale: Trigeminal neuralgia is characterized by paroxysms of pain, similar to
an electric shock, in the area innervated by one or more branches of the trigeminal
nerve (cranial V). The remaining symptoms are not related to trigeminal neuralgia.
In caring for a client with acute diverticulitis, which assessment data warrants an
immediate nursing action?
, A. The client has a rigid hard abdomen and elevated WBC.
B. The client has left lower quadrant pain and an elevated temperature.
C.The client is refusing to eat any of the meal and is complaining of nausea.
D. The client has not had a bowel movement in 2 days and has a soft abdomen. -
CORRECT ANSWER: A
Rationale: A hard rigid abdomen and elevated WBC is indicative of peritonitis,
which is a medical emergency and should be reported to the health care provider
immediately. Options B and C are expected clinical manifestations of diverticulitis.
Option D does not warrant immediate intervention.
The nurse is caring for a client with a fractured right elbow. Which assessment
finding has the highest priority and requires immediate intervention?
A. Ecchymosis over the right elbow area
B. Deep, unrelenting pain in the right arm
C. An edematous right elbow
D. The presence of crepitus in the right elbow - CORRECT ANSWER-Correct
Answer: B
Rationale: Compartment syndrome is a condition involving increased pressure and
constriction of the nerves and vessels within an anatomic compartment, causing
pain uncontrolled by opioids and neurovascular compromise. Option A is an
expected finding. Option C related to compartment syndrome cannot be seen, and
any visible edema is an expected finding related to the injury. Option D is an
expected finding.
The nurse notes that a client who is scheduled for surgery the next morning has an
elevated blood urea nitrogen (BUN) level. Which condition is most likely to have
contributed to this finding?
A. Myocardial infarction 2 months ago
B. Anorexia and vomiting for the past 2 days
C. Recently diagnosed type 2 diabetes mellitus
D. Skeletal traction for a right hip fracture - CORRECT ANSWER-Correct
Answer: B
Rationale: The blood urea nitrogen (BUN) level indicates the effectiveness of the
kidneys in filtering waste from the blood. Dehydration, which could be caused by
vomiting, would cause an increased BUN level. Option A would affect serum
enzyme levels, not the BUN level. Option C would primarily affect the blood
WITH QUESTIONS AND VERIFIED ANSWERS
WITH RATIONALES Graded A+/BRAND NEW!!
,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-Correct
Answer: A,B,C
Rationale:One hour post op is too soon to ambulate for this client. Visitors help
support the patient and are encouraged to visit. Oral care is necessary as the client
will be NPO. To decrease the risk of infection post operatively, implement routine
pulmonary exercises. The client will have an NG tube in place, likely to
intermittent suction, to decompress the stomach post surgery.
The client is return demonstrating wrapping of the left limb amputated above the
knee. The nurse evaluates the client is starting the wrapping method correctly when
the client places the end of the bandage at which point?
A. Around the waist
B. At the inner aspect of the left stump
C. At the outer aspect of the left stump
D. At the left groin area - CORRECT ANSWER-Correct Answer: A
Rationale: The waist is the anchor point for the bandage for an above the knee
amputation.
A nurse is assisting an 82-year-old client with ambulation and is concerned that the
client may fall. Which area contains the older person's center of gravity?
A. Head and neck
B. Upper torso
C. Bilateral arms
D. Feet and legs - CORRECT ANSWER-Correct Answer: B
,Rationale: Stooped posture results in the upper torso becoming the center of
gravity for older persons. The center of gravity for adults is the hips. However, as a
person grows older, a stooped posture is common because of changes caused by
osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and
elbows flex. The head and neck and feet and legs are not the center of gravity in
the older adult. Although the arms comprise a part of the upper torso, they do not
reflect the best and most complete answer.
A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks
and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is
120/70 mm Hg. Which action should the nurse take?
A. Administer the prescribed dose at the scheduled time.
B. Hold the dose and contact the health care provider.
C. Hold the dose and recheck the blood pressure in 1 hour.
D. Check the health care provider's prescription to clarify the dose. - CORRECT
ANSWER: A
Rationale: The client's blood pressure is within normal limits, indicating that the
ramipril, an antihypertensive, is having the desired effect and should be
administered. Options B and C would be appropriate if the client's blood pressure
was excessively low (<100 mm Hg systolic) or if the client were exhibiting signs
of hypotension, such as dizziness. This prescribed dose is within the normal dosage
range, as defined by the manufacturer; therefore, option D is not necessary
The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic
douloureux). Which symptoms will the nurse be looking for in the focused
assessment related to this condition? (Select all that apply.)
A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in chewing
E.Tinnitus
F. Hearing difficulties - CORRECT ANSWER-Correct Answer: A,B
Rationale: Trigeminal neuralgia is characterized by paroxysms of pain, similar to
an electric shock, in the area innervated by one or more branches of the trigeminal
nerve (cranial V). The remaining symptoms are not related to trigeminal neuralgia.
In caring for a client with acute diverticulitis, which assessment data warrants an
immediate nursing action?
, A. The client has a rigid hard abdomen and elevated WBC.
B. The client has left lower quadrant pain and an elevated temperature.
C.The client is refusing to eat any of the meal and is complaining of nausea.
D. The client has not had a bowel movement in 2 days and has a soft abdomen. -
CORRECT ANSWER: A
Rationale: A hard rigid abdomen and elevated WBC is indicative of peritonitis,
which is a medical emergency and should be reported to the health care provider
immediately. Options B and C are expected clinical manifestations of diverticulitis.
Option D does not warrant immediate intervention.
The nurse is caring for a client with a fractured right elbow. Which assessment
finding has the highest priority and requires immediate intervention?
A. Ecchymosis over the right elbow area
B. Deep, unrelenting pain in the right arm
C. An edematous right elbow
D. The presence of crepitus in the right elbow - CORRECT ANSWER-Correct
Answer: B
Rationale: Compartment syndrome is a condition involving increased pressure and
constriction of the nerves and vessels within an anatomic compartment, causing
pain uncontrolled by opioids and neurovascular compromise. Option A is an
expected finding. Option C related to compartment syndrome cannot be seen, and
any visible edema is an expected finding related to the injury. Option D is an
expected finding.
The nurse notes that a client who is scheduled for surgery the next morning has an
elevated blood urea nitrogen (BUN) level. Which condition is most likely to have
contributed to this finding?
A. Myocardial infarction 2 months ago
B. Anorexia and vomiting for the past 2 days
C. Recently diagnosed type 2 diabetes mellitus
D. Skeletal traction for a right hip fracture - CORRECT ANSWER-Correct
Answer: B
Rationale: The blood urea nitrogen (BUN) level indicates the effectiveness of the
kidneys in filtering waste from the blood. Dehydration, which could be caused by
vomiting, would cause an increased BUN level. Option A would affect serum
enzyme levels, not the BUN level. Option C would primarily affect the blood
