EVOLVE ELSEVIER HESI MED SURG ACTUAL EXAM
QUESTIONS WITH COMPLETE SOLUTIONS
GUARANTEED PASS BRAND NEW 2025
The nurse is providing care to a client admitted to the
emergency room with a blood glucose level of 40 mg/dL and is
semiconscious. What are the nurse's next actions? (Select all
that apply.) - ANSWER - >-Start an IV of Normal Saline.
-Obtain a 50% dextrose solution.
-Administer glucagon as per the standing order.
-Turn the client to the side.
Rationale: Oral carbohydrates, such as sugar and honey, should
never be given to the semiconscious or unconscious clients with
low blood sugar levels, for concern for aspiration. Glucagon can
be administered immediately, followed by starting an IV. Await
the orders for the 50% dextrose solution. Place the client in a
side lying position as there is a risk for vomiting and aspiration
with these clients.
An 81-year-old client has emphysema. The client lives at home
with a cat and manages self-care with no difficulty. When
making a home visit, the nurse notices that this client's tongue
is somewhat cracked and his eyeballs appear sunken. Which
nursing action is indicated? - ANSWER - >Help the client
determine ways to increase fluid intake.
,Rationale: Clients with COPD should ingest 3 L of fluids daily but
may experience a fluid deficit because of shortness of breath.
The nurse should suggest creative methods to increase the
intake of fluids, such as having fruit juices in disposable
containers readily available.
A 58-year-old client who has no health problems asks the nurse
about receiving the pneumococcal vaccine. Which statement
given by the nurse would offer the client accurate information
about this vaccine? - ANSWER - >The immunization is
administered once to older adults or those at risk for illness.
Rationale:It is usually recommended that persons older than 65
years and those with a history of chronic illness should receive
the vaccine once in their lifetime. Some recommend receiving
the vaccine at 50 years of age. The influenza vaccine is given
once a year. Although the vaccine might be given to a person
traveling overseas, that is not the main rationale for
administering the vaccine. The vaccine is usually given once in a
lifetime, but with immunosuppressed clients or clients with a
history of pneumonia, revaccination is sometimes required.
The clinic nurse is teaching a client with osteoarthritis to the
knees bilaterally about self-care. Which teaching points will the
nurse include in the client's plan of care? (Select all that apply.)
- ANSWER - >-Apply heat packs to your knees as needed for
pain.
-Support your knees while you are in bed with a pillow or a
rolled towel.
,-Get 7 to 8 hours of sleep every night.
-Eat a balanced diet, including fish with Omega-3 fatty acids.
Rationale:The maximum daily dose of acetaminophen is 4 g, the
instruction includes up to 6 g/per day. The best type of exercise
does not place additional stress on the knee joints, such as
biking or swimming. Apply heat to increase circulation and ice
packs to decrease swelling. Support to the knees can take the
strain off of the joint. Getting rest will help with coping with the
pain of the disease. Eating a balanced diet may help with
weight loss; additional weight places strain on the joint.
The nurse notes that the client's drainage has decreased from
50 to 5 mL/hr 12 hours after chest tube insertion for
hemothorax. What is the best initial action for the nurse to
take? - ANSWER - >Assess for kinks or dependent loops in the
tubing.
Rationale: The least invasive nursing action should be
performed first to determine why the drainage has diminished.
During report, the nurse learns that a client with tumor lysis
syndrome is receiving an IV infusion containing insulin. Which
action should the nurse complete first? - ANSWER - >Monitor
the client's serum potassium and blood glucose levels.
Rationale: Clients with tumor lysis syndrome may experience
hyperkalemia, requiring the addition of insulin to the IV
, solution to reduce the serum potassium level. It is most
important for the nurse to monitor the client's serum
potassium and blood glucose levels to ensure that they are not
at dangerous levels.
For the client undergoing hemodialysis, the nurse suspects the
client has an air embolism. What symptoms lead the nurse to
this conclusion? (Select all that apply.) - ANSWER - >-Dyspnea
-Chest pain
-Anxiety
-Blue nail beds
Rationale: For the client experiencing an air embolism, the
nurse will see hypotension and not hypertension. The O2
saturation will also fall with an air embolism. The remaining are
signs of an air embolism.
A client on telemetry has a pattern of uncontrolled atrial
fibrillation with a rapid ventricular response. Based on this
finding, the nurse anticipates assisting the physician with which
treatment? - ANSWER - >Perform synchronized cardioversion.
Rationale: With uncontrolled atrial fibrillation, the treatment of
choice is synchronized cardioversion to convert the cardiac
rhythm back to normal sinus rhythm.
The post-operative client states to the nurse, "I hate the feeling
of those compression stockings as they inflate and deflate all
the time. It keeps me awake." What is the nurse's best
QUESTIONS WITH COMPLETE SOLUTIONS
GUARANTEED PASS BRAND NEW 2025
The nurse is providing care to a client admitted to the
emergency room with a blood glucose level of 40 mg/dL and is
semiconscious. What are the nurse's next actions? (Select all
that apply.) - ANSWER - >-Start an IV of Normal Saline.
-Obtain a 50% dextrose solution.
-Administer glucagon as per the standing order.
-Turn the client to the side.
Rationale: Oral carbohydrates, such as sugar and honey, should
never be given to the semiconscious or unconscious clients with
low blood sugar levels, for concern for aspiration. Glucagon can
be administered immediately, followed by starting an IV. Await
the orders for the 50% dextrose solution. Place the client in a
side lying position as there is a risk for vomiting and aspiration
with these clients.
An 81-year-old client has emphysema. The client lives at home
with a cat and manages self-care with no difficulty. When
making a home visit, the nurse notices that this client's tongue
is somewhat cracked and his eyeballs appear sunken. Which
nursing action is indicated? - ANSWER - >Help the client
determine ways to increase fluid intake.
,Rationale: Clients with COPD should ingest 3 L of fluids daily but
may experience a fluid deficit because of shortness of breath.
The nurse should suggest creative methods to increase the
intake of fluids, such as having fruit juices in disposable
containers readily available.
A 58-year-old client who has no health problems asks the nurse
about receiving the pneumococcal vaccine. Which statement
given by the nurse would offer the client accurate information
about this vaccine? - ANSWER - >The immunization is
administered once to older adults or those at risk for illness.
Rationale:It is usually recommended that persons older than 65
years and those with a history of chronic illness should receive
the vaccine once in their lifetime. Some recommend receiving
the vaccine at 50 years of age. The influenza vaccine is given
once a year. Although the vaccine might be given to a person
traveling overseas, that is not the main rationale for
administering the vaccine. The vaccine is usually given once in a
lifetime, but with immunosuppressed clients or clients with a
history of pneumonia, revaccination is sometimes required.
The clinic nurse is teaching a client with osteoarthritis to the
knees bilaterally about self-care. Which teaching points will the
nurse include in the client's plan of care? (Select all that apply.)
- ANSWER - >-Apply heat packs to your knees as needed for
pain.
-Support your knees while you are in bed with a pillow or a
rolled towel.
,-Get 7 to 8 hours of sleep every night.
-Eat a balanced diet, including fish with Omega-3 fatty acids.
Rationale:The maximum daily dose of acetaminophen is 4 g, the
instruction includes up to 6 g/per day. The best type of exercise
does not place additional stress on the knee joints, such as
biking or swimming. Apply heat to increase circulation and ice
packs to decrease swelling. Support to the knees can take the
strain off of the joint. Getting rest will help with coping with the
pain of the disease. Eating a balanced diet may help with
weight loss; additional weight places strain on the joint.
The nurse notes that the client's drainage has decreased from
50 to 5 mL/hr 12 hours after chest tube insertion for
hemothorax. What is the best initial action for the nurse to
take? - ANSWER - >Assess for kinks or dependent loops in the
tubing.
Rationale: The least invasive nursing action should be
performed first to determine why the drainage has diminished.
During report, the nurse learns that a client with tumor lysis
syndrome is receiving an IV infusion containing insulin. Which
action should the nurse complete first? - ANSWER - >Monitor
the client's serum potassium and blood glucose levels.
Rationale: Clients with tumor lysis syndrome may experience
hyperkalemia, requiring the addition of insulin to the IV
, solution to reduce the serum potassium level. It is most
important for the nurse to monitor the client's serum
potassium and blood glucose levels to ensure that they are not
at dangerous levels.
For the client undergoing hemodialysis, the nurse suspects the
client has an air embolism. What symptoms lead the nurse to
this conclusion? (Select all that apply.) - ANSWER - >-Dyspnea
-Chest pain
-Anxiety
-Blue nail beds
Rationale: For the client experiencing an air embolism, the
nurse will see hypotension and not hypertension. The O2
saturation will also fall with an air embolism. The remaining are
signs of an air embolism.
A client on telemetry has a pattern of uncontrolled atrial
fibrillation with a rapid ventricular response. Based on this
finding, the nurse anticipates assisting the physician with which
treatment? - ANSWER - >Perform synchronized cardioversion.
Rationale: With uncontrolled atrial fibrillation, the treatment of
choice is synchronized cardioversion to convert the cardiac
rhythm back to normal sinus rhythm.
The post-operative client states to the nurse, "I hate the feeling
of those compression stockings as they inflate and deflate all
the time. It keeps me awake." What is the nurse's best
