Evolve Elsevier HESI Med Surg Exam
Questions With Well -Elaborated
Answers And Rationales 2025-2026
[most Recent] Instant download Pdf
Question 1: A patient with heart failure is experiencing dyspnea and has
a respiratory rate of 28 breaths per minute. What is the nurse's priority
action?
A) Administer a diuretic
B) Encourage deep breathing exercises
C) Position the patient in high Fowler's position
D) Obtain a chest X-ray
Answer C
Rationale: Positioning the patient in high Fowler's position facilitates
lung expansion and improves oxygenation, which is the priority for a
patient with dyspnea due to heart failure. This intervention can be
implemented immediately before other interventions are initiated .
Question 2: A postoperative patient develops a fever of 101.2°F on day
2. What is the most likely cause?
A) Urinary tract infection
B) Atelectasis
C) Wound infection
D) Deep vein thrombosis
Answer B
,Rationale: Atelectasis, a common postoperative complication, often
causes fever within the first 48 hours due to impaired lung expansion.
The fever is typically low-grade and resolves with deep breathing and
early ambulation .
Question 3: A client with chronic kidney disease (CKD) has a potassium
level of 6.2 mEq/L. What should the nurse anticipate administering?
A) Kayexalate (sodium polystyrene sulfonate)
B) Magnesium sulfate
C) Potassium chloride
D) Sodium bicarbonate
Answer A
Rationale: Hyperkalemia (potassium >5.0 mEq/L) in CKD requires
immediate intervention. Kayexalate binds potassium in the intestines for
excretion, reducing serum potassium levels .
Question 4: A client is 6 hours post-operative and reports sudden onset
of chest pain and dyspnea. The nurse notes jugular venous distension
and hypotension. Which complication should the nurse suspect?
A) Myocardial infarction
B) Pulmonary embolism
C) Atelectasis
D) Pneumothorax
Answer B
Rationale: Sudden onset of chest pain, dyspnea, JVD, and hypotension
in a postoperative patient is concerning for pulmonary embolism. This is
a life-threatening emergency requiring immediate intervention .
,Question 5: The nurse should withhold a dose of digoxin in a client with
congestive heart failure without specific instruction from the healthcare
provider if the client's:
A) Serum digoxin level is 1.5 ng/mL
B) Blood pressure is 104/68 mmHg
C) Apical pulse is 52 beats/min
D) Heart rate is 92 beats/min
Answer C
Rationale: Digoxin slows the heart rate, and the dose should be held if
the apical pulse is below 60 beats/min in adults. The provider should be
notified before administering the dose .
Question 6: An older client who is agitated, dyspneic, orthopneic, and
using accessory muscles to breathe is admitted. An hour after receiving
IV medication, which assessments should the nurse obtain to determine
the client's response to treatment? (Select all that apply)
A) Skin assessment
B) Pain scale
C) Lung sounds
D) Urinary output
E) Oxygen saturation
Answer C, E
Rationale: Lung sounds and oxygen saturation are the most direct
indicators of respiratory improvement following treatment for respiratory
distress .
, Question 7: A client with Addison's disease taking hydrocortisone in a
divided daily dose is admitted. It is most important for the nurse to
monitor which serum lab value?
A) Osmolarity
B) Glucose
C) Albumin
D) Platelets
Answer B
Rationale: Corticosteroids like hydrocortisone can cause hyperglycemia.
Monitoring blood glucose is essential to prevent complications
associated with elevated glucose levels .
Question 8: A client with AIDS has impaired gas exchange from a
respiratory infection. Which assessment finding warrants immediate
intervention by the nurse?
A) Elevated temperature
B) Generalized weakness
C) Diminished lung sounds
D) Pain when swallowing
Answer D
Rationale: Pain when swallowing may indicate esophageal candidiasis or
other infection that could compromise the client's ability to take
medications and maintain nutrition, requiring immediate intervention .
Question 9: Fluids are restricted to 1500 mL/day for a male client with
AKI. He is frustrated and complaining of constant thirst, and the nurse
discovers the family is providing additional fluids. What intervention
should the nurse implement?
Questions With Well -Elaborated
Answers And Rationales 2025-2026
[most Recent] Instant download Pdf
Question 1: A patient with heart failure is experiencing dyspnea and has
a respiratory rate of 28 breaths per minute. What is the nurse's priority
action?
A) Administer a diuretic
B) Encourage deep breathing exercises
C) Position the patient in high Fowler's position
D) Obtain a chest X-ray
Answer C
Rationale: Positioning the patient in high Fowler's position facilitates
lung expansion and improves oxygenation, which is the priority for a
patient with dyspnea due to heart failure. This intervention can be
implemented immediately before other interventions are initiated .
Question 2: A postoperative patient develops a fever of 101.2°F on day
2. What is the most likely cause?
A) Urinary tract infection
B) Atelectasis
C) Wound infection
D) Deep vein thrombosis
Answer B
,Rationale: Atelectasis, a common postoperative complication, often
causes fever within the first 48 hours due to impaired lung expansion.
The fever is typically low-grade and resolves with deep breathing and
early ambulation .
Question 3: A client with chronic kidney disease (CKD) has a potassium
level of 6.2 mEq/L. What should the nurse anticipate administering?
A) Kayexalate (sodium polystyrene sulfonate)
B) Magnesium sulfate
C) Potassium chloride
D) Sodium bicarbonate
Answer A
Rationale: Hyperkalemia (potassium >5.0 mEq/L) in CKD requires
immediate intervention. Kayexalate binds potassium in the intestines for
excretion, reducing serum potassium levels .
Question 4: A client is 6 hours post-operative and reports sudden onset
of chest pain and dyspnea. The nurse notes jugular venous distension
and hypotension. Which complication should the nurse suspect?
A) Myocardial infarction
B) Pulmonary embolism
C) Atelectasis
D) Pneumothorax
Answer B
Rationale: Sudden onset of chest pain, dyspnea, JVD, and hypotension
in a postoperative patient is concerning for pulmonary embolism. This is
a life-threatening emergency requiring immediate intervention .
,Question 5: The nurse should withhold a dose of digoxin in a client with
congestive heart failure without specific instruction from the healthcare
provider if the client's:
A) Serum digoxin level is 1.5 ng/mL
B) Blood pressure is 104/68 mmHg
C) Apical pulse is 52 beats/min
D) Heart rate is 92 beats/min
Answer C
Rationale: Digoxin slows the heart rate, and the dose should be held if
the apical pulse is below 60 beats/min in adults. The provider should be
notified before administering the dose .
Question 6: An older client who is agitated, dyspneic, orthopneic, and
using accessory muscles to breathe is admitted. An hour after receiving
IV medication, which assessments should the nurse obtain to determine
the client's response to treatment? (Select all that apply)
A) Skin assessment
B) Pain scale
C) Lung sounds
D) Urinary output
E) Oxygen saturation
Answer C, E
Rationale: Lung sounds and oxygen saturation are the most direct
indicators of respiratory improvement following treatment for respiratory
distress .
, Question 7: A client with Addison's disease taking hydrocortisone in a
divided daily dose is admitted. It is most important for the nurse to
monitor which serum lab value?
A) Osmolarity
B) Glucose
C) Albumin
D) Platelets
Answer B
Rationale: Corticosteroids like hydrocortisone can cause hyperglycemia.
Monitoring blood glucose is essential to prevent complications
associated with elevated glucose levels .
Question 8: A client with AIDS has impaired gas exchange from a
respiratory infection. Which assessment finding warrants immediate
intervention by the nurse?
A) Elevated temperature
B) Generalized weakness
C) Diminished lung sounds
D) Pain when swallowing
Answer D
Rationale: Pain when swallowing may indicate esophageal candidiasis or
other infection that could compromise the client's ability to take
medications and maintain nutrition, requiring immediate intervention .
Question 9: Fluids are restricted to 1500 mL/day for a male client with
AKI. He is frustrated and complaining of constant thirst, and the nurse
discovers the family is providing additional fluids. What intervention
should the nurse implement?
