2025 EVOLVE ELSEVIER HESI MED SURG EXAM NEWEST 2025.
3 VERSIONS OF QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) ALREADY GRADED A+ BRAND
NEW!!
VOLUME 1: 100 QUESTIONS
VOLUME 2: 130 QUESTIONS
VOLUME 3: 130 QUESTIONS
VOLUME 1.
1. When educating a client after a total laryngectomy, which instruction would be
most important for the nurse to include in the discharge teaching? A. Recommend
that the client carry suction equipment at all times.
B. Instruct the client to have writing materials with him at all times.
C. Tell the client to carry a medical alert card that explains his condition.D.
Caution the client not to travel outside the United States alone.: C
Rationale: Neck breathers carry a medical alert card that notifies health care personnel of
the need to use mouth to stoma breathing in the event of a cardiac arrest in this client.
Mouth to mouth resuscitation will not establish a patent airway. Options A and D are not
necessary. There are many alternative means of communication for clients who have had
a laryngectomy; dependence on writing messages is probably the least effective.
2. The nurse receives the client's next scheduled bag of TPN labeled with the
additive NPH insulin. Which action should the nurse implement? A. Hang the
solution at the current rate.
,B. Refrigerate the solution until needed.
C.Prepare the solution with new tubing.
D.Return the solution to the pharmacy.: D
Rationale: Only regular insulin is administered by the IV route, so the TPN solution
containing NPH insulin should be returned to the pharmacy. Options A, B, and C are not
indicated because the solution should not be administered.
3. A postoperative client receives a Schedule II opioid analgesic for pain.
Which assessment finding requires the most immediate intervention by the nurse?
A. Hypoactive bowel sounds with abdominal distention
B. Client reports continued pain of 8 on a 10-point scale
C. Respiratory rate of 12 breaths/min, with O2 saturation of 85%
D. Client reports nausea after receiving the medication: C
Rationale: Administration of a Schedule II opioid analgesic can result in respiratory
depression, which requires immediate intervention by the nurse to prevent respiratory
arrest. Options A, B, and D require action by the nurse but are of less priority than option
C.
4. 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: 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.
5. 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.: 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.
6. 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: 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.
7. 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: 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.
8. 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?
A. Prepare the client for a pericardial tap.
B. Administer intravenous furosemide (Lasix).
C. Assist the client to cough and breathe deeply.
D. Instruct the client to restrict oral fluid intake.: 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
3 VERSIONS OF QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) ALREADY GRADED A+ BRAND
NEW!!
VOLUME 1: 100 QUESTIONS
VOLUME 2: 130 QUESTIONS
VOLUME 3: 130 QUESTIONS
VOLUME 1.
1. When educating a client after a total laryngectomy, which instruction would be
most important for the nurse to include in the discharge teaching? A. Recommend
that the client carry suction equipment at all times.
B. Instruct the client to have writing materials with him at all times.
C. Tell the client to carry a medical alert card that explains his condition.D.
Caution the client not to travel outside the United States alone.: C
Rationale: Neck breathers carry a medical alert card that notifies health care personnel of
the need to use mouth to stoma breathing in the event of a cardiac arrest in this client.
Mouth to mouth resuscitation will not establish a patent airway. Options A and D are not
necessary. There are many alternative means of communication for clients who have had
a laryngectomy; dependence on writing messages is probably the least effective.
2. The nurse receives the client's next scheduled bag of TPN labeled with the
additive NPH insulin. Which action should the nurse implement? A. Hang the
solution at the current rate.
,B. Refrigerate the solution until needed.
C.Prepare the solution with new tubing.
D.Return the solution to the pharmacy.: D
Rationale: Only regular insulin is administered by the IV route, so the TPN solution
containing NPH insulin should be returned to the pharmacy. Options A, B, and C are not
indicated because the solution should not be administered.
3. A postoperative client receives a Schedule II opioid analgesic for pain.
Which assessment finding requires the most immediate intervention by the nurse?
A. Hypoactive bowel sounds with abdominal distention
B. Client reports continued pain of 8 on a 10-point scale
C. Respiratory rate of 12 breaths/min, with O2 saturation of 85%
D. Client reports nausea after receiving the medication: C
Rationale: Administration of a Schedule II opioid analgesic can result in respiratory
depression, which requires immediate intervention by the nurse to prevent respiratory
arrest. Options A, B, and D require action by the nurse but are of less priority than option
C.
4. 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: 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.
5. 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.: 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.
6. 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: 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.
7. 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: 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.
8. 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?
A. Prepare the client for a pericardial tap.
B. Administer intravenous furosemide (Lasix).
C. Assist the client to cough and breathe deeply.
D. Instruct the client to restrict oral fluid intake.: 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
