EVOLVE HESI MEDICAL SURGICAL EXAM / EVOLVE
ELSEVIER HESI MED SURG REAL EXAM 2024-2025 WITH
COMPLETE APPROVED QUESTIONS AND WELL
ELABORATED ANSWERS WITH RATIONALES (CORRECT
VERIFIED SOLUTIONS) A NEW UPDATED VERSION
|GUARANTEED PASS A+ (ACTUAL EXAM)
A client is placed on a mechanical ventilator following a
cerebral hemorrhage, and vecuronium bromide, 0.04 mg/kg
every 12 hours IV, is prescribed. What is the priority nursing
diagnosis for this client?
A. Impaired communication related to paralysis of skeletal
muscles
B. High risk for infection related to increased intracranial
pressure
C. Potential for injury related to impaired lung expansion
D. Social isolation related to inability to communicate
Answer- A
Rationale:To increase the client's tolerance of endotracheal
intubation and/or mechanical ventilation, a skeletal muscle
relaxant such as vecuronium is usually prescribed. Option A is a
serious outcome because the client cannot communicate his or
her needs. Although this client might also experience option D,
it is not a priority when compared with option A. Infection is
,not related to increased intracranial pressure. The respirator
will ensure that the lungs are expanded, so option C is
incorrect.
A family member was taught to suction a client's tracheostomy
prior to the client's discharge from the hospital. Which
observation by the nurse indicates that the family member is
capable of correctly performing the suctioning technique?
A. Turns on the continuous wall suction to 190 mm Hg.
B. Inserts the catheter until resistance or coughing occurs.
C. Withdraws the catheter while maintaining suctioning.
D. Reclears the tracheostomy after suctioning the mouth.
Answer- B
Rationale:Option B indicates correct technique for performing
suctioning. Suction pressure should be between 80 and 120
mm Hg, not 190 mm Hg. The catheter should be withdrawn 1 to
2 cm at a time with intermittent, not continuous, suction.
Option D introduces pathogens unnecessarily into the
tracheobronchial tree.
,A client is diagnosed with an acute small bowel obstruction.
Which assessment finding requires the most immediate
intervention by the nurse?
A. Fever of 102° F
B. Blood pressure of 150/90 mm Hg
C. Abdominal cramping
D. Dry mucous membranes
Answer- A
Rationale:A sudden increase in temperature is an indicator of
peritonitis. The nurse should notify the health care provider
immediately. Options B, C, and D are also findings that require
intervention by the nurse but are of less priority than option A.
Option B may indicate a hypertensive condition but is not as
acute a condition as peritonitis. Option C is an expected finding
in clients with small bowel obstruction and may require
medication. Option D indicates probable fluid volume deficit,
which requires fluid volume replacement.
, 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 intervention should the nurse
implement?
ELSEVIER HESI MED SURG REAL EXAM 2024-2025 WITH
COMPLETE APPROVED QUESTIONS AND WELL
ELABORATED ANSWERS WITH RATIONALES (CORRECT
VERIFIED SOLUTIONS) A NEW UPDATED VERSION
|GUARANTEED PASS A+ (ACTUAL EXAM)
A client is placed on a mechanical ventilator following a
cerebral hemorrhage, and vecuronium bromide, 0.04 mg/kg
every 12 hours IV, is prescribed. What is the priority nursing
diagnosis for this client?
A. Impaired communication related to paralysis of skeletal
muscles
B. High risk for infection related to increased intracranial
pressure
C. Potential for injury related to impaired lung expansion
D. Social isolation related to inability to communicate
Answer- A
Rationale:To increase the client's tolerance of endotracheal
intubation and/or mechanical ventilation, a skeletal muscle
relaxant such as vecuronium is usually prescribed. Option A is a
serious outcome because the client cannot communicate his or
her needs. Although this client might also experience option D,
it is not a priority when compared with option A. Infection is
,not related to increased intracranial pressure. The respirator
will ensure that the lungs are expanded, so option C is
incorrect.
A family member was taught to suction a client's tracheostomy
prior to the client's discharge from the hospital. Which
observation by the nurse indicates that the family member is
capable of correctly performing the suctioning technique?
A. Turns on the continuous wall suction to 190 mm Hg.
B. Inserts the catheter until resistance or coughing occurs.
C. Withdraws the catheter while maintaining suctioning.
D. Reclears the tracheostomy after suctioning the mouth.
Answer- B
Rationale:Option B indicates correct technique for performing
suctioning. Suction pressure should be between 80 and 120
mm Hg, not 190 mm Hg. The catheter should be withdrawn 1 to
2 cm at a time with intermittent, not continuous, suction.
Option D introduces pathogens unnecessarily into the
tracheobronchial tree.
,A client is diagnosed with an acute small bowel obstruction.
Which assessment finding requires the most immediate
intervention by the nurse?
A. Fever of 102° F
B. Blood pressure of 150/90 mm Hg
C. Abdominal cramping
D. Dry mucous membranes
Answer- A
Rationale:A sudden increase in temperature is an indicator of
peritonitis. The nurse should notify the health care provider
immediately. Options B, C, and D are also findings that require
intervention by the nurse but are of less priority than option A.
Option B may indicate a hypertensive condition but is not as
acute a condition as peritonitis. Option C is an expected finding
in clients with small bowel obstruction and may require
medication. Option D indicates probable fluid volume deficit,
which requires fluid volume replacement.
, 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 intervention should the nurse
implement?
