MEDICAL SURGICAL
EVOLVE HESI MEDICAL SURGICAL
INTEGRATED TEST ACTUAL EXAM 4
VERIFIED QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED
RATIONALES) |ALREADY GRADED A+ BEST
DOCUMENT FOR FINAL EXAM
TEST
A nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting
for 2 days. Which of the following laboratory values should the nurse report to the provider?
a) Potassium 4.0 mEq/L
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, MEDICAL SURGICAL
b) Lithium 0.9 mEq/L
c) BUN 12 mg/dL
d) Sodium 132 mEq/L –
D. Sodium 132 mEq/L
Rationale:
The nurse should identify that a sodium level of 132 mEq/L is not within the expected
reference range of 136 to 145 mEq/L. This finding indicates hyponatremia, which can lead to
lithium accumulation and places the client at risk for lithium toxicity. The nurse should report
this finding to the provider.
A patient with a full-thickness burn covering 40% of their body is exhibiting purulent drainage
at the wound site. Before reporting this finding to the healthcare provider, which of the
patient's laboratory values should the nurse review?
A. Blood pH level
B. Hematocrit
C. White blood cell (WBC) count
D. Platelet count
Answer: C. White blood cell (WBC) count
Rationale:
An elevated WBC count can indicate infection, which aligns with purulent drainage at the
wound site.
2|Page
, MEDICAL SURGICAL
Following a transurethral resection of the prostate (TURP), a patient is discharged from the
hospital with an indwelling urinary catheter. Which instruction is most important for the nurse
to include in the discharge teaching plan?
A. Eliminate all spicy foods from your diet
B. Drink 3 liters of water each day
C. Clamp the catheter when taking a shower
D. Avoid driving a car for 2 weeks
Answer: B. Drink 3 liters of water each day
Rationale: Hydration helps prevent complications like urinary infections after procedures like
TURP.
A nurse is collecting data about immunizations for a 65-year-old client who has no identified
risk factors for disease. The nurse should identify the client's need for which of the following
immunizations?
a) Inactivated polio virus
b) Herpes zoster
c) Human papilloma virus
d) Measles, mumps, and rubella –
B. Herpes zoster
Rationale:
Measles, mumps, rubella and inactivated polio vaccines are given to children during routine
immunization of less than 2yrs of age however according to studies this can only be given at
maximum age of 12yrs old. HPV or human papilloma virus vaccine is given to girls at 9 yrs old
until there reproductive age only. Herpes zoster on the other hand, a single dose should be
given to 60 years old and older with no contraindication condition present as per CDC.
3|Page
, MEDICAL SURGICAL
A nurse is caring for a client who is to receive zoster vaccine live due to the risk for herpes
zoster. Which of the following is an appropriate action by the nurse?
a. Withhold an immunization if the white blood cell count is less than 5,000/mm3
b. Administer the immunization IM
c. Repeat the immunization three months after the initial injection
d. Administer Diphenhydramine stat if erythema develops at the site –
A. Withhold an immunization if the white blood cell count is less than 5,000/mm3.
Rationale:
Zoster vaccine live, used for herpes zoster prevention, should be withheld if the client's white
blood cell count is less than 5,000/mm3 due to the risk of disseminated vaccine-related
infection.
A nurse is reinforcing teaching with a client about colorectal cancer. Which of the following
risk factors should the nurse include?
a) Biliary colic
b) Duodenal ulcer
c) Chronic constipation
d) Ulcerative colitis - D. Ulcerative colitis
Rationale:
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EVOLVE HESI MEDICAL SURGICAL
INTEGRATED TEST ACTUAL EXAM 4
VERIFIED QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED
RATIONALES) |ALREADY GRADED A+ BEST
DOCUMENT FOR FINAL EXAM
TEST
A nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting
for 2 days. Which of the following laboratory values should the nurse report to the provider?
a) Potassium 4.0 mEq/L
1|Page
, MEDICAL SURGICAL
b) Lithium 0.9 mEq/L
c) BUN 12 mg/dL
d) Sodium 132 mEq/L –
D. Sodium 132 mEq/L
Rationale:
The nurse should identify that a sodium level of 132 mEq/L is not within the expected
reference range of 136 to 145 mEq/L. This finding indicates hyponatremia, which can lead to
lithium accumulation and places the client at risk for lithium toxicity. The nurse should report
this finding to the provider.
A patient with a full-thickness burn covering 40% of their body is exhibiting purulent drainage
at the wound site. Before reporting this finding to the healthcare provider, which of the
patient's laboratory values should the nurse review?
A. Blood pH level
B. Hematocrit
C. White blood cell (WBC) count
D. Platelet count
Answer: C. White blood cell (WBC) count
Rationale:
An elevated WBC count can indicate infection, which aligns with purulent drainage at the
wound site.
2|Page
, MEDICAL SURGICAL
Following a transurethral resection of the prostate (TURP), a patient is discharged from the
hospital with an indwelling urinary catheter. Which instruction is most important for the nurse
to include in the discharge teaching plan?
A. Eliminate all spicy foods from your diet
B. Drink 3 liters of water each day
C. Clamp the catheter when taking a shower
D. Avoid driving a car for 2 weeks
Answer: B. Drink 3 liters of water each day
Rationale: Hydration helps prevent complications like urinary infections after procedures like
TURP.
A nurse is collecting data about immunizations for a 65-year-old client who has no identified
risk factors for disease. The nurse should identify the client's need for which of the following
immunizations?
a) Inactivated polio virus
b) Herpes zoster
c) Human papilloma virus
d) Measles, mumps, and rubella –
B. Herpes zoster
Rationale:
Measles, mumps, rubella and inactivated polio vaccines are given to children during routine
immunization of less than 2yrs of age however according to studies this can only be given at
maximum age of 12yrs old. HPV or human papilloma virus vaccine is given to girls at 9 yrs old
until there reproductive age only. Herpes zoster on the other hand, a single dose should be
given to 60 years old and older with no contraindication condition present as per CDC.
3|Page
, MEDICAL SURGICAL
A nurse is caring for a client who is to receive zoster vaccine live due to the risk for herpes
zoster. Which of the following is an appropriate action by the nurse?
a. Withhold an immunization if the white blood cell count is less than 5,000/mm3
b. Administer the immunization IM
c. Repeat the immunization three months after the initial injection
d. Administer Diphenhydramine stat if erythema develops at the site –
A. Withhold an immunization if the white blood cell count is less than 5,000/mm3.
Rationale:
Zoster vaccine live, used for herpes zoster prevention, should be withheld if the client's white
blood cell count is less than 5,000/mm3 due to the risk of disseminated vaccine-related
infection.
A nurse is reinforcing teaching with a client about colorectal cancer. Which of the following
risk factors should the nurse include?
a) Biliary colic
b) Duodenal ulcer
c) Chronic constipation
d) Ulcerative colitis - D. Ulcerative colitis
Rationale:
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