EVOLVE ELSEVIER HESI MED SURG TEST BANK| COMPLETE 350 REAL
EXAM QUESTIONS AND CORRECT ANSWERS WITH WELL-ELABORATED
RATIONALES/ GRADED A+| EVOLVE HESI MEDICAL SURGICAL LATEST
EXAM
A client is diagnosed with an acute small bowel obstruction and suddenly spikes a temperature
of 102°F/38.9°C. What other assessments should the nurse include in the client's focused
assessment? (Select all that apply.)
A. Nausea and vomiting
B. Loss of appetite
C. Abdominal cramping
D. Guarding with abdominal palpation
E. Low urine output
F. Cool, clammy skin
Answer: A,B,C,D
Rationale: The client is showing signs of peritonitis with the sudden spike in temperature. Low
urine output and cool clammy skin are not seen with peritonitis. Peritonitis is a medical
emergency and the health care provider must be notified immediately.
In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory
test results to indicate a decreased serum level of which substance?
A.Sodium
B. Phosphate
C. Potassium
D. Glucose
Answer: C
,Rationale:
Clients with primary aldosteronism exhibit a profound decline in serum levels of potassium;
hypokalemia; hypertension is the most prominent and universal sign. The serum sodium level is
normal or elevated, depending on the amount of water resorbed with the sodium. Option B is
influenced by parathyroid hormone (PTH). Option D is not affected by primary aldosteronism
During assessment of a client in the intensive care unit, the nurse notes that the client's breath
sounds are clear on auscultation, but jugular vein distention and muffled heart sounds are
present. Which action should the nurse take first?
A.Prepare the client for a pericardial tap.
B.Administer intravenous furosemide.
C.Assist the client to cough and breathe deeply.
D.Instruct the client to restrict oral fluid intake.
Answer: A
Rationale:The client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the
pericardial sac that results in a reduction in cardiac output, which is a potentially fatal
complication of pericarditis. Treatment for tamponade is a pericardial tap. Lasix IV is not
indicated for treatment of pericarditis. Because the client's breath sounds are clear, option C is
not a priority. Fluids are frequently increased in the initial treatment of tamponade to
compensate for the decrease in cardiac output, but this is not the same priority as option A.
What is the most important nursing priority for a client who has been admitted for a possible
kidney stone?
A. Reducing dairy products in the diet
B. Straining all urine
C. Measuring intake and output
D. Increasing fluid intake
Answer: B
,Rationale: Straining all urine is the most important nursing action to take in this case.
Encouraging fluid intake is important for any client who may have a kidney stone, but it is even
more important to strain all urine. Straining urine will enable the nurse to determine when the
kidney stone has been passed and may prevent the need for surgery. Option C is not the highest
priority action. Option A is usually not recommended until the stone is obtained and the
content of the stone is determined. Even then, dietary restrictions are controversial.
The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which
food items chosen by the client indicate understanding of the teaching? (Select all that apply.)
A. White bread
B. Salmon
C. Broccoli
D. Whole milk
E. Banana
Answer: B,C,E
Rationale:Options B, C, and E provide fresh fruits, lean meats and fish, vegetables, whole grains,
and low-fat dairy products. All are recommended by the American Diabetes Association (ADA)
and are a part of the My Plate guidelines recommended by the U.S. Department of Agriculture
(USDA). Whole milk is high in fat and is not recommended by the ADA. White bread is milled, a
process that removes the essential nutrients. It should be avoided for weight loss and is a poor
choice for the client with diabetes.
A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8 on a 1 to
10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and respirations of 20
breaths/min. The PACU recovery prescription is "Morphine, 2 to 4 mg IV push, while in recovery
for pain level over 5." Which action should the nurse take first?
A. Give the medication as prescribed to decrease the client's pain.
B. Call the anesthesia provider for a different medication for pain.
C. Use nonpharmacologic techniques before giving the medication.
D. Reassess the pain level in 30 minutes and medicate if it remains elevated.
, Answer: B
Rationale:
The nurse should call the provider for a different medication because morphine is a histamine-
releasing opioid and should be avoided when the client has asthma. Option A is unsafe because
it puts the client at risk for an asthma exacerbation. Even if the drug were safe for the client,
options C and D both disregard the prescription and the client's need for pain relief in the
immediate postoperative period.
The nurse is performing a skin assessment on a client who is transferred from a long-term care
facility to an in-patient hospital unit. The client is unable to move independently while in bed.
The nurse observes reddened areas to the sacrum and on the heals bilaterally. What is the next
nursing action?
A.Document the size and shape of the reddened areas.
B.Massage the reddened areas with a hospital-approved lotion.
C.Call the nurse from the transferring facility to determine the client's baseline.
D.Culture the wounds.
Answer: A
Rationale:
The nurse must document any pressure wounds upon admission to establish the client's
baseline and for insurance purposes. Insurance will not reimburse from hospital-acquired
pressure ulcers. Massaging is not recommended as it may dislodge the existing tissue. A call is
not a good use of the nurse's time as the pressure ulcers exist upon transfer, and the baseline is
determined upon admission. The health care provider will order cultures, if needed
The nurse is performing hourly neurologic checks for a client with a head injury. Which new
assessment finding warrants immediate action by the nurse?
A.A unilateral pupil that is dilated and nonreactive to light
B.Client cries out when awakened by a verbal stimulus.
C.Client demonstrates a loss of memory of the events leading up to the injury.
D.Onset of nausea, headache, and vertigo
EXAM QUESTIONS AND CORRECT ANSWERS WITH WELL-ELABORATED
RATIONALES/ GRADED A+| EVOLVE HESI MEDICAL SURGICAL LATEST
EXAM
A client is diagnosed with an acute small bowel obstruction and suddenly spikes a temperature
of 102°F/38.9°C. What other assessments should the nurse include in the client's focused
assessment? (Select all that apply.)
A. Nausea and vomiting
B. Loss of appetite
C. Abdominal cramping
D. Guarding with abdominal palpation
E. Low urine output
F. Cool, clammy skin
Answer: A,B,C,D
Rationale: The client is showing signs of peritonitis with the sudden spike in temperature. Low
urine output and cool clammy skin are not seen with peritonitis. Peritonitis is a medical
emergency and the health care provider must be notified immediately.
In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory
test results to indicate a decreased serum level of which substance?
A.Sodium
B. Phosphate
C. Potassium
D. Glucose
Answer: C
,Rationale:
Clients with primary aldosteronism exhibit a profound decline in serum levels of potassium;
hypokalemia; hypertension is the most prominent and universal sign. The serum sodium level is
normal or elevated, depending on the amount of water resorbed with the sodium. Option B is
influenced by parathyroid hormone (PTH). Option D is not affected by primary aldosteronism
During assessment of a client in the intensive care unit, the nurse notes that the client's breath
sounds are clear on auscultation, but jugular vein distention and muffled heart sounds are
present. Which action should the nurse take first?
A.Prepare the client for a pericardial tap.
B.Administer intravenous furosemide.
C.Assist the client to cough and breathe deeply.
D.Instruct the client to restrict oral fluid intake.
Answer: A
Rationale:The client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the
pericardial sac that results in a reduction in cardiac output, which is a potentially fatal
complication of pericarditis. Treatment for tamponade is a pericardial tap. Lasix IV is not
indicated for treatment of pericarditis. Because the client's breath sounds are clear, option C is
not a priority. Fluids are frequently increased in the initial treatment of tamponade to
compensate for the decrease in cardiac output, but this is not the same priority as option A.
What is the most important nursing priority for a client who has been admitted for a possible
kidney stone?
A. Reducing dairy products in the diet
B. Straining all urine
C. Measuring intake and output
D. Increasing fluid intake
Answer: B
,Rationale: Straining all urine is the most important nursing action to take in this case.
Encouraging fluid intake is important for any client who may have a kidney stone, but it is even
more important to strain all urine. Straining urine will enable the nurse to determine when the
kidney stone has been passed and may prevent the need for surgery. Option C is not the highest
priority action. Option A is usually not recommended until the stone is obtained and the
content of the stone is determined. Even then, dietary restrictions are controversial.
The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which
food items chosen by the client indicate understanding of the teaching? (Select all that apply.)
A. White bread
B. Salmon
C. Broccoli
D. Whole milk
E. Banana
Answer: B,C,E
Rationale:Options B, C, and E provide fresh fruits, lean meats and fish, vegetables, whole grains,
and low-fat dairy products. All are recommended by the American Diabetes Association (ADA)
and are a part of the My Plate guidelines recommended by the U.S. Department of Agriculture
(USDA). Whole milk is high in fat and is not recommended by the ADA. White bread is milled, a
process that removes the essential nutrients. It should be avoided for weight loss and is a poor
choice for the client with diabetes.
A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8 on a 1 to
10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and respirations of 20
breaths/min. The PACU recovery prescription is "Morphine, 2 to 4 mg IV push, while in recovery
for pain level over 5." Which action should the nurse take first?
A. Give the medication as prescribed to decrease the client's pain.
B. Call the anesthesia provider for a different medication for pain.
C. Use nonpharmacologic techniques before giving the medication.
D. Reassess the pain level in 30 minutes and medicate if it remains elevated.
, Answer: B
Rationale:
The nurse should call the provider for a different medication because morphine is a histamine-
releasing opioid and should be avoided when the client has asthma. Option A is unsafe because
it puts the client at risk for an asthma exacerbation. Even if the drug were safe for the client,
options C and D both disregard the prescription and the client's need for pain relief in the
immediate postoperative period.
The nurse is performing a skin assessment on a client who is transferred from a long-term care
facility to an in-patient hospital unit. The client is unable to move independently while in bed.
The nurse observes reddened areas to the sacrum and on the heals bilaterally. What is the next
nursing action?
A.Document the size and shape of the reddened areas.
B.Massage the reddened areas with a hospital-approved lotion.
C.Call the nurse from the transferring facility to determine the client's baseline.
D.Culture the wounds.
Answer: A
Rationale:
The nurse must document any pressure wounds upon admission to establish the client's
baseline and for insurance purposes. Insurance will not reimburse from hospital-acquired
pressure ulcers. Massaging is not recommended as it may dislodge the existing tissue. A call is
not a good use of the nurse's time as the pressure ulcers exist upon transfer, and the baseline is
determined upon admission. The health care provider will order cultures, if needed
The nurse is performing hourly neurologic checks for a client with a head injury. Which new
assessment finding warrants immediate action by the nurse?
A.A unilateral pupil that is dilated and nonreactive to light
B.Client cries out when awakened by a verbal stimulus.
C.Client demonstrates a loss of memory of the events leading up to the injury.
D.Onset of nausea, headache, and vertigo
