MEDICAL SURGICAL
EVOLVE HESI MEDICAL SURGICAL
INTEGRATED TEST ACTUAL EXAM 2
VERIFIED QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED
RATIONALES) |ALREADY GRADED A+ BEST
DOCUMENT FOR FINAL EXAM
A client with heart failure is prescribed digoxin 0.125 mg PO. The client's apical heart rate
is70 beats per minute, blood pressure is 125/75 mmHg, and respirations are 18 breaths per
minute. Which action should the nurse implement next?
A: Administer the medication.
B: Inform the healthcare provider.
C: Review the vital sign flowsheet.
D: Reassess the apical heart rate.
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, MEDICAL SURGICAL
A: Administer the medication.
Obtaining the apical heart rate is a common parameter prior to administering digoxin, which
may indicate early digoxin toxicity if the heart rate is less than 60 beats per minute, so the
dose should be administered since the client is not demonstrating any signs of toxicity.
A client with a recent history of blood in his stools is scheduled for a proctosigmoidoscopy.
The nurse should implement which protocols to prepare the client for this procedure?
(Select all that apply.)
-Obtain consent for the procedure.
-Initiate preoperative sedation.
-Begin fast the morning of the procedure.
-Administer an enema before the procedure.
-Provide a clear-liquid diet 48 hours before the procedure.
-Obtain consent for the procedure.
-Begin fast the morning of the procedure.
-Administer an enema before the procedure.
-Provide a clear-liquid diet 48 hours before the procedure.
Preoperative preparation for proctosigmoidoscopy includes obtaining the client's consent
for the procedure, a clear-liquid diet for 24 to 48 hours prior to the procedure,
administration of an enema, and fasting on the morning of the procedure.
The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing
action should be included in the plan of care?
A: Perform active range of motion three times daily.
B: Monitor for Battle's sign every four hours.
C: Teach measures to avoid the Valsalva maneuver.
D: Maintain the head of bed in a flat position.
C: Teach measures to avoid the Valsalva maneuver.
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, MEDICAL SURGICAL
The Valsalva maneuver, straining with bowel movements while holding one's breath,
increases intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral
blood vessels.
In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which
positioning should the nurse should use to maintain optimal functioning?
A: Mid-Fowler's with knees supported.
B: Supine with trochanter rolls to the hips.
C: Sim's position alternated with right lateral position q2 hours.
D: Left lateral, supine, brief periods on the right side, and prone.
D: Left lateral, supine, brief periods on the right side, and prone.
After an acute stroke, a positioning and turning schedule that minimizes lying on the
affected side is recommended because it prevents impaired circulation and reduces pain.
The prone position helps prevent flexion contractures of the hips and prepares the client for
optimal functioning and ambulating.
The nurse is planning preoperative teaching for a client who will undergo a radical neck
dissection and total laryngectomy. Which information has the greatest priority for this
client?
A: Prognosis after treatment is excellent.
B: Techniques for esophageal speech are relatively easy to learn with practice.
C: The stoma should never be covered after this type of surgery.
D: There is a radical change in appearance as a result of this surgery.
D: There is a radical change in appearance as a result of this surgery.
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, MEDICAL SURGICAL
Radical neck dissection is the removal of lymphatic drainage channels and nodes,
sternocleidomastoid muscle, spinal accessory nerve, jugular vein, and submandibular area.
The overall outcome of this type of surgery causes the neck to be disfigured, so the radical
change in appearance, "Alteration in body image" will be a priority in the care of this client.
What is the priority nursing action while caring for a client on a ventilator when an electrical
fire occurs in the intensive care unit?
A: Tell another staff member to bring extinguishing equipment to the bedside.
B: Close the doors to the client's area when attempting to extinguish the fire.
C: Use a bag-valve-mask resuscitator while removing the client from the area.
D: Implement an emergency protocol to remove the client from the ventilator.
C: Use a bag-valve-mask resuscitator while removing the client from the area.
A client on a ventilator should have respirations maintained with a manual bag-valve-mask
resuscitator while being moved away from the oxygen wall outlet and fire source.
The nurse is assessing a middle-aged male client for risk factors related to chronic illness.
Which finding should the nurse assess further?
A: Thinning hair and dry scalp.
B: Increase in appetite and taste-bud acuity.
C: Increase in muscle tone but decreased muscle strength.
D: Increase in abdominal fat deposits.
D: Increase in abdominal fat deposits.
An increase in the abdominal girth is a risk factor for the development of metabolic
syndrome. According to the American Heart Association, men with a waist size 40 inches or
larger and women 35 inches or larger double their risk factor of developing CAD and
increase their chances 5Xs of developing DMII.
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EVOLVE HESI MEDICAL SURGICAL
INTEGRATED TEST ACTUAL EXAM 2
VERIFIED QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED
RATIONALES) |ALREADY GRADED A+ BEST
DOCUMENT FOR FINAL EXAM
A client with heart failure is prescribed digoxin 0.125 mg PO. The client's apical heart rate
is70 beats per minute, blood pressure is 125/75 mmHg, and respirations are 18 breaths per
minute. Which action should the nurse implement next?
A: Administer the medication.
B: Inform the healthcare provider.
C: Review the vital sign flowsheet.
D: Reassess the apical heart rate.
1|Page
, MEDICAL SURGICAL
A: Administer the medication.
Obtaining the apical heart rate is a common parameter prior to administering digoxin, which
may indicate early digoxin toxicity if the heart rate is less than 60 beats per minute, so the
dose should be administered since the client is not demonstrating any signs of toxicity.
A client with a recent history of blood in his stools is scheduled for a proctosigmoidoscopy.
The nurse should implement which protocols to prepare the client for this procedure?
(Select all that apply.)
-Obtain consent for the procedure.
-Initiate preoperative sedation.
-Begin fast the morning of the procedure.
-Administer an enema before the procedure.
-Provide a clear-liquid diet 48 hours before the procedure.
-Obtain consent for the procedure.
-Begin fast the morning of the procedure.
-Administer an enema before the procedure.
-Provide a clear-liquid diet 48 hours before the procedure.
Preoperative preparation for proctosigmoidoscopy includes obtaining the client's consent
for the procedure, a clear-liquid diet for 24 to 48 hours prior to the procedure,
administration of an enema, and fasting on the morning of the procedure.
The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing
action should be included in the plan of care?
A: Perform active range of motion three times daily.
B: Monitor for Battle's sign every four hours.
C: Teach measures to avoid the Valsalva maneuver.
D: Maintain the head of bed in a flat position.
C: Teach measures to avoid the Valsalva maneuver.
2|Page
, MEDICAL SURGICAL
The Valsalva maneuver, straining with bowel movements while holding one's breath,
increases intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral
blood vessels.
In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which
positioning should the nurse should use to maintain optimal functioning?
A: Mid-Fowler's with knees supported.
B: Supine with trochanter rolls to the hips.
C: Sim's position alternated with right lateral position q2 hours.
D: Left lateral, supine, brief periods on the right side, and prone.
D: Left lateral, supine, brief periods on the right side, and prone.
After an acute stroke, a positioning and turning schedule that minimizes lying on the
affected side is recommended because it prevents impaired circulation and reduces pain.
The prone position helps prevent flexion contractures of the hips and prepares the client for
optimal functioning and ambulating.
The nurse is planning preoperative teaching for a client who will undergo a radical neck
dissection and total laryngectomy. Which information has the greatest priority for this
client?
A: Prognosis after treatment is excellent.
B: Techniques for esophageal speech are relatively easy to learn with practice.
C: The stoma should never be covered after this type of surgery.
D: There is a radical change in appearance as a result of this surgery.
D: There is a radical change in appearance as a result of this surgery.
3|Page
, MEDICAL SURGICAL
Radical neck dissection is the removal of lymphatic drainage channels and nodes,
sternocleidomastoid muscle, spinal accessory nerve, jugular vein, and submandibular area.
The overall outcome of this type of surgery causes the neck to be disfigured, so the radical
change in appearance, "Alteration in body image" will be a priority in the care of this client.
What is the priority nursing action while caring for a client on a ventilator when an electrical
fire occurs in the intensive care unit?
A: Tell another staff member to bring extinguishing equipment to the bedside.
B: Close the doors to the client's area when attempting to extinguish the fire.
C: Use a bag-valve-mask resuscitator while removing the client from the area.
D: Implement an emergency protocol to remove the client from the ventilator.
C: Use a bag-valve-mask resuscitator while removing the client from the area.
A client on a ventilator should have respirations maintained with a manual bag-valve-mask
resuscitator while being moved away from the oxygen wall outlet and fire source.
The nurse is assessing a middle-aged male client for risk factors related to chronic illness.
Which finding should the nurse assess further?
A: Thinning hair and dry scalp.
B: Increase in appetite and taste-bud acuity.
C: Increase in muscle tone but decreased muscle strength.
D: Increase in abdominal fat deposits.
D: Increase in abdominal fat deposits.
An increase in the abdominal girth is a risk factor for the development of metabolic
syndrome. According to the American Heart Association, men with a waist size 40 inches or
larger and women 35 inches or larger double their risk factor of developing CAD and
increase their chances 5Xs of developing DMII.
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