EVOLVE MED SURG HESI EXAM V2
2025. LATEST FINAL EXAM 2025
UPDATE WITH CORRECT ANSWER.
ALREADY GRADED A+
The nurse is concerned about infection for a client after an esophagogastrostomy for
esophageal cancer. Which actions should the nurse include in the client's plan of care?
(Select all that apply.)
A. Frequent oral care every 2 hours while awake.
B. Use incentive spirometer every 2 hours.
C. Empty contents from NG tube every 8 hours.
D. Ambulate within 1 hour of return from the PACU.
E. Limit visitors until postoperative day 2. - CORRECT ANS>> A,B,C
The client is return demonstrating wrapping of the left limb amputated above the knee.
The nurse evaluates the client is starting the wrapping method correctly when the client
places the end of the bandage at which point?
A. Around the waist
B. At the inner aspect of the left stump
C. At the outer aspect of the left stump
D. At the left groin area - CORRECT ANS>> A
A nurse is assisting an 82-year-old client with ambulation and is concerned that the client
may fall. Which area contains the older person's center of gravity?
A. Head and neck
B. Upper torso
C. Bilateral arms
D. Feet and legs - CORRECT ANS>> B
,A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks and is
scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg.
Which action should the nurse take?
A. Administer the prescribed dose at the scheduled time.
B. Hold the dose and contact the health care provider.
C. Hold the dose and recheck the blood pressure in 1 hour.
D. Check the health care provider's prescription to clarify the dose. - CORRECT ANSWER
- Correct Answer: A
The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic
douloureux). Which symptoms will the nurse be looking for in the focused assessment
related to this condition? (Select all that apply.)
A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in
chewing E.Tinnitus
F.Hearing difficulties - CORRECT ANS>> A,B
In caring for a client with acute diverticulitis, which assessment data warrants an
immediate nursing action?
A. The client has a rigid hard abdomen and elevated WBC.
B. The client has left lower quadrant pain and an elevated temperature.
C.The client is refusing to eat any of the meal and is complaining of nausea.
D. The client has not had a bowel movement in 2 days and has a soft abdomen. - CORRECT
ANS>> A
- EXP>> A hard rigid abdomen and elevated WBC is indicative of peritonitis, which is a
medical emergency and should be reported to the health care provider immediately.
Options B and C are expected clinical manifestations of diverticulitis. Option D does not
warrant immediate intervention.
,The nurse is caring for a client with a fractured right elbow. Which assessment finding has
the highest priority and requires immediate intervention?
A. Ecchymosis over the right elbow area
B. Deep unrelenting pain in the right arm
C. An edematous right elbow
D. The presence of crepitus in the right elbow - CORRECT ANS>> B
The nurse notes that a client who is scheduled for surgery the next morning has an
elevated blood urea nitrogen (BUN) level. Which condition is most likely to have
contributed to this finding?
A. Myocardial infarction 2 months ago
B. Anorexia and vomiting for the past 2 days
C.Recently diagnosed type 2 diabetes mellitus
D. Skeletal traction for a right hip fracture - CORRECT ANS>> B
Which instruction is best for the nurse to provide to a client with emphysema and chronic
fatigue?
A."Pace your activities and schedule rest periods."
B."Increase the amount of oxygen you use at night."
C."Obtain medical evaluation for antibiotic therapy."
D."Reduce your intake of fluids containing caffeine." - CORRECT ANS>> A
Which nursing action would be appropriate for a client who is newly diagnosed with
Cushing syndrome?
A.Monitor blood glucose levels daily.
B.Increase intake of fluids high in potassium.
C.Encourage adequate rest between activities.
D.Offer the client a sodium-enriched menu. - CORRECT ANS>> A
, - EXP>> Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal
cortex. Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of
serum glucose levels assesses for increased blood glucose levels so that treatment can
begin early.
A common finding in Cushing syndrome is generalized edema. Although potassium is
needed, it is generally obtained from food intake, not by offering potassium-enhanced
fluids. Fatigue is usually not an overwhelming factor in Cushing syndrome, so an emphasis
on the need for rest is not indicated. A low-calorie, low-carbohydrate, low-sodium diet is
not
recommended.
During the change of shift report, the charge nurse reviews the infusions being received by
clients on the oncology unit. The client receiving which infusion should be assessed first?
A.Continuous IV infusion of magnesium
B.One-time infusion of albumin
C.Continuous epidural infusion of
morphine
D.Intermittent infusion of IV vancomycin - CORRECT ANS>> C
- EXP>> All four of these clients have the potential to have significant complications. The
client with the morphine epidural infusion is at highest risk for respiratory depression
and should be assessed first. Option A can cause hypotension. The client receiving option
B is at lowest risk for serious complications. Although option D can cause nephrotoxicity
and phlebitis, these problems are not as immediately life threatening as option C.
2025. LATEST FINAL EXAM 2025
UPDATE WITH CORRECT ANSWER.
ALREADY GRADED A+
The nurse is concerned about infection for a client after an esophagogastrostomy for
esophageal cancer. Which actions should the nurse include in the client's plan of care?
(Select all that apply.)
A. Frequent oral care every 2 hours while awake.
B. Use incentive spirometer every 2 hours.
C. Empty contents from NG tube every 8 hours.
D. Ambulate within 1 hour of return from the PACU.
E. Limit visitors until postoperative day 2. - CORRECT ANS>> A,B,C
The client is return demonstrating wrapping of the left limb amputated above the knee.
The nurse evaluates the client is starting the wrapping method correctly when the client
places the end of the bandage at which point?
A. Around the waist
B. At the inner aspect of the left stump
C. At the outer aspect of the left stump
D. At the left groin area - CORRECT ANS>> A
A nurse is assisting an 82-year-old client with ambulation and is concerned that the client
may fall. Which area contains the older person's center of gravity?
A. Head and neck
B. Upper torso
C. Bilateral arms
D. Feet and legs - CORRECT ANS>> B
,A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks and is
scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg.
Which action should the nurse take?
A. Administer the prescribed dose at the scheduled time.
B. Hold the dose and contact the health care provider.
C. Hold the dose and recheck the blood pressure in 1 hour.
D. Check the health care provider's prescription to clarify the dose. - CORRECT ANSWER
- Correct Answer: A
The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic
douloureux). Which symptoms will the nurse be looking for in the focused assessment
related to this condition? (Select all that apply.)
A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in
chewing E.Tinnitus
F.Hearing difficulties - CORRECT ANS>> A,B
In caring for a client with acute diverticulitis, which assessment data warrants an
immediate nursing action?
A. The client has a rigid hard abdomen and elevated WBC.
B. The client has left lower quadrant pain and an elevated temperature.
C.The client is refusing to eat any of the meal and is complaining of nausea.
D. The client has not had a bowel movement in 2 days and has a soft abdomen. - CORRECT
ANS>> A
- EXP>> A hard rigid abdomen and elevated WBC is indicative of peritonitis, which is a
medical emergency and should be reported to the health care provider immediately.
Options B and C are expected clinical manifestations of diverticulitis. Option D does not
warrant immediate intervention.
,The nurse is caring for a client with a fractured right elbow. Which assessment finding has
the highest priority and requires immediate intervention?
A. Ecchymosis over the right elbow area
B. Deep unrelenting pain in the right arm
C. An edematous right elbow
D. The presence of crepitus in the right elbow - CORRECT ANS>> B
The nurse notes that a client who is scheduled for surgery the next morning has an
elevated blood urea nitrogen (BUN) level. Which condition is most likely to have
contributed to this finding?
A. Myocardial infarction 2 months ago
B. Anorexia and vomiting for the past 2 days
C.Recently diagnosed type 2 diabetes mellitus
D. Skeletal traction for a right hip fracture - CORRECT ANS>> B
Which instruction is best for the nurse to provide to a client with emphysema and chronic
fatigue?
A."Pace your activities and schedule rest periods."
B."Increase the amount of oxygen you use at night."
C."Obtain medical evaluation for antibiotic therapy."
D."Reduce your intake of fluids containing caffeine." - CORRECT ANS>> A
Which nursing action would be appropriate for a client who is newly diagnosed with
Cushing syndrome?
A.Monitor blood glucose levels daily.
B.Increase intake of fluids high in potassium.
C.Encourage adequate rest between activities.
D.Offer the client a sodium-enriched menu. - CORRECT ANS>> A
, - EXP>> Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal
cortex. Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of
serum glucose levels assesses for increased blood glucose levels so that treatment can
begin early.
A common finding in Cushing syndrome is generalized edema. Although potassium is
needed, it is generally obtained from food intake, not by offering potassium-enhanced
fluids. Fatigue is usually not an overwhelming factor in Cushing syndrome, so an emphasis
on the need for rest is not indicated. A low-calorie, low-carbohydrate, low-sodium diet is
not
recommended.
During the change of shift report, the charge nurse reviews the infusions being received by
clients on the oncology unit. The client receiving which infusion should be assessed first?
A.Continuous IV infusion of magnesium
B.One-time infusion of albumin
C.Continuous epidural infusion of
morphine
D.Intermittent infusion of IV vancomycin - CORRECT ANS>> C
- EXP>> All four of these clients have the potential to have significant complications. The
client with the morphine epidural infusion is at highest risk for respiratory depression
and should be assessed first. Option A can cause hypotension. The client receiving option
B is at lowest risk for serious complications. Although option D can cause nephrotoxicity
and phlebitis, these problems are not as immediately life threatening as option C.
