EVOLVE ELSEVIER HESI MED SURG LATEST 2025 TEST BANK|
COMPLETE 350 REAL EXAM QUESTIONS AND CORRECT
ANSWERS WITH WELL-ELABORATED RATIONALES/ EVOLVE HESI
MEDICAL SURGICAL LATEST EXAM 2025 (BRAND NEW!!)
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 - Correct Answers - 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 - Correct Answers - C
pg. 1
,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?
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. - Correct Answers - 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.
A central venous catheter has been inserted via a jugular vein, and a
radiograph has confirmed placement of the catheter. A prescription has
been received for a medication STAT, but IV fluids have not yet been
started. Which action should the nurse take prior to administering the
prescribed medication?
pg. 2
,A. Assess for signs of jugular venous distention.
B. Obtain the needed intravenous solution.
C. Flush the line with heparinized solution.
D. Flush the line with normal saline. - Correct Answers - D
Rationale:
Medication can be administered via a central line without additional IV
fluids. The line should first be flushed with a normal saline solution to
ensure patency. Insufficient evidence exists on the effectiveness of flushing
catheters with heparin. Option A will not affect the decision to administer
the medication and is not a priority. Administration of the medication STAT
is of greater priority than option B.
In assessing a client with an arteriovenous (AV) shunt who is scheduled for
dialysis today, the nurse notes the absence of a thrill or bruit at the shunt
site. What action should the nurse take?
A. Advise the client that the shunt is intact and ready for dialysis as
scheduled.
B. Encourage the client to keep the shunt site elevated above the level of
the heart.
C. Notify the health care provider of the findings immediately.
D. Flush the site at least once with a heparinized saline solution. - Correct
Answers - C
Rationale:
Absence of a thrill or bruit indicates that the shunt may be obstructed. The
nurse should notify the health care provider so that intervention can be
initiated to restore function of the shunt. Option A is incorrect. Option B will
not resolve the obstruction. An AV shunt is internal and cannot be flushed
without access using special needles.
pg. 3
, The nurse initiates neurologic checks for a client who is at risk for
neurologic compromise. Which manifestation typically provides the first
indication of altered neurologic function?
A. Change in level of consciousness
B. Increasing muscular weakness
C. Changes in pupil size bilaterally
D. Progressive nuchal rigidity - Correct Answers - A
Rationale:
A decrease or change in the level of consciousness is usually the first
indication of neurologic deterioration. Options B and C may also occur but
are much less likely to be the first sign of neurologic compromise. Option D
is often a sign of meningitis.
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 - Correct Answers - 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.
pg. 4
COMPLETE 350 REAL EXAM QUESTIONS AND CORRECT
ANSWERS WITH WELL-ELABORATED RATIONALES/ EVOLVE HESI
MEDICAL SURGICAL LATEST EXAM 2025 (BRAND NEW!!)
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 - Correct Answers - 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 - Correct Answers - C
pg. 1
,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?
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. - Correct Answers - 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.
A central venous catheter has been inserted via a jugular vein, and a
radiograph has confirmed placement of the catheter. A prescription has
been received for a medication STAT, but IV fluids have not yet been
started. Which action should the nurse take prior to administering the
prescribed medication?
pg. 2
,A. Assess for signs of jugular venous distention.
B. Obtain the needed intravenous solution.
C. Flush the line with heparinized solution.
D. Flush the line with normal saline. - Correct Answers - D
Rationale:
Medication can be administered via a central line without additional IV
fluids. The line should first be flushed with a normal saline solution to
ensure patency. Insufficient evidence exists on the effectiveness of flushing
catheters with heparin. Option A will not affect the decision to administer
the medication and is not a priority. Administration of the medication STAT
is of greater priority than option B.
In assessing a client with an arteriovenous (AV) shunt who is scheduled for
dialysis today, the nurse notes the absence of a thrill or bruit at the shunt
site. What action should the nurse take?
A. Advise the client that the shunt is intact and ready for dialysis as
scheduled.
B. Encourage the client to keep the shunt site elevated above the level of
the heart.
C. Notify the health care provider of the findings immediately.
D. Flush the site at least once with a heparinized saline solution. - Correct
Answers - C
Rationale:
Absence of a thrill or bruit indicates that the shunt may be obstructed. The
nurse should notify the health care provider so that intervention can be
initiated to restore function of the shunt. Option A is incorrect. Option B will
not resolve the obstruction. An AV shunt is internal and cannot be flushed
without access using special needles.
pg. 3
, The nurse initiates neurologic checks for a client who is at risk for
neurologic compromise. Which manifestation typically provides the first
indication of altered neurologic function?
A. Change in level of consciousness
B. Increasing muscular weakness
C. Changes in pupil size bilaterally
D. Progressive nuchal rigidity - Correct Answers - A
Rationale:
A decrease or change in the level of consciousness is usually the first
indication of neurologic deterioration. Options B and C may also occur but
are much less likely to be the first sign of neurologic compromise. Option D
is often a sign of meningitis.
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 - Correct Answers - 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.
pg. 4
