EVOLVE ELSEVIER HESI MED SURG LATEST
2026/2027 TEST BANK| COMPLETE REAL EXAM
MOST TESTED QUESTIONS AND CORRECT
ANSWERS| INSTANT PDF ACCESS
A client diagnosed with angina pectoris complains of chest pain while
ambulating in the hallway. Which action should the nurse implement first?
A. Support the client to a sitting position.
B. Ask the client to walk slowly back to the room.
C. Administer a sublingual nitroglycerin tablet.
D. Provide oxygen via nasal cannula.
A
Rationale: The nurse should safely assist the client to a resting position and then
perform options C and D. The client must cease all activity immediately, which will
decrease the oxygen requirement of the myocardial muscle. After these
interventions are implemented, the client can be escorted back to the room via
wheelchair or stretcher.
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.
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.
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
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
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.
During the shift report, the charge nurse informs a nurse that she has been
assigned to another unit for the day. The nurse begins to sigh deeply and tosses
about her belongings as she prepares to leave, making it known that she is very
unhappy about being floated to the other unit. What is the best immediate
,action for the charge nurse to take?
A. Continue with the shift report and talk to the nurse about the incident at a
later time.
B. Ask the nurse to call the house supervisor to see if she must be reassigned.
C. Stop the shift report and remind the nurse that all staff are floated equally.
D. Inform the nurse that her behavior is disruptive to the rest of the staff.
A
Rationale: Continuing with the shift report is the best immediate action because it
allows the nurse who was floated some cooling off time. At a later time (after the
nurse has cooled off) the charge nurse should discuss the conduct of the nurse in
private. Option B encourages the nurse to shirk the float assignment. Option C is
disruptive. Reprimanding the nurse in front of the staff would increase the nurse's
hostility, so the nurse should be counseled in private.
The nurse is counseling a healthy 30-year-old female client regarding
osteoporosis prevention. Which activity would be most beneficial in achieving
the client's goal of osteoporosis prevention?
A. Cross-country skiing
B. Scuba diving
C. Horseback riding
D. Kayaking
A
Rationale: Weight-bearing exercise is an important measure to reduce the risk of
osteoporosis. Of the activities listed, cross-country skiing includes the most
weight-bearing, whereas options B, C, and D involve less.
The nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A)
and ribavirin (Virazole) combination therapy for hepatitis C. The client reports
experiencing overwhelming feelings of depression. Which action should the
nurse implement first?
A.Recommend mental health counseling.
B. Review the medication actions and interactions.
C. Assess for the client's daily activity level.
D. Provide information regarding a support group.
, B
Rationale: Interferon-alfa-2a and ribavirin combination therapy can cause severe
depression; therefore, it is most important for the nurse to review the medication
effects and report these to the health care provider. Options A, C, and D might be
implemented after the physiologic aspects of the situation have been assessed.
The nurse is giving preoperative instructions to a 14-year-old client scheduled
for surgery to correct a spinal curvature. Which statement by the client best
demonstrates that learning has taken place?
A.
"I will read all the teaching booklets you gave me before surgery."
B.
"I have had surgery before, so I know what to expect afterward."
C.
"All the things people have told me will help me take care of my back."
D.
"Let me show you the method of turning I will use after surgery."
D
Rationale: The outcome of learning is best demonstrated when the client not only
verbalizes an understanding but can also provide a return demonstration. A 14-
year-old client may or may not follow through with option A, and there is no
measurement of learning. Option B may help the client understand the surgical
process, but the type of surgery may have been very different, with differing
postoperative care. In option C, the client may be saying what the nurse wants to
hear without expressing any real understanding of what to do after surgery.
Client census is often used to determine staffing needs. Which method of
obtaining census determination for a particular unit provides the best formula
for determining long-range staffing patterns?
A.
Midnight census
B.
Oncoming shift census
C.
Average daily census
2026/2027 TEST BANK| COMPLETE REAL EXAM
MOST TESTED QUESTIONS AND CORRECT
ANSWERS| INSTANT PDF ACCESS
A client diagnosed with angina pectoris complains of chest pain while
ambulating in the hallway. Which action should the nurse implement first?
A. Support the client to a sitting position.
B. Ask the client to walk slowly back to the room.
C. Administer a sublingual nitroglycerin tablet.
D. Provide oxygen via nasal cannula.
A
Rationale: The nurse should safely assist the client to a resting position and then
perform options C and D. The client must cease all activity immediately, which will
decrease the oxygen requirement of the myocardial muscle. After these
interventions are implemented, the client can be escorted back to the room via
wheelchair or stretcher.
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.
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.
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
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
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.
During the shift report, the charge nurse informs a nurse that she has been
assigned to another unit for the day. The nurse begins to sigh deeply and tosses
about her belongings as she prepares to leave, making it known that she is very
unhappy about being floated to the other unit. What is the best immediate
,action for the charge nurse to take?
A. Continue with the shift report and talk to the nurse about the incident at a
later time.
B. Ask the nurse to call the house supervisor to see if she must be reassigned.
C. Stop the shift report and remind the nurse that all staff are floated equally.
D. Inform the nurse that her behavior is disruptive to the rest of the staff.
A
Rationale: Continuing with the shift report is the best immediate action because it
allows the nurse who was floated some cooling off time. At a later time (after the
nurse has cooled off) the charge nurse should discuss the conduct of the nurse in
private. Option B encourages the nurse to shirk the float assignment. Option C is
disruptive. Reprimanding the nurse in front of the staff would increase the nurse's
hostility, so the nurse should be counseled in private.
The nurse is counseling a healthy 30-year-old female client regarding
osteoporosis prevention. Which activity would be most beneficial in achieving
the client's goal of osteoporosis prevention?
A. Cross-country skiing
B. Scuba diving
C. Horseback riding
D. Kayaking
A
Rationale: Weight-bearing exercise is an important measure to reduce the risk of
osteoporosis. Of the activities listed, cross-country skiing includes the most
weight-bearing, whereas options B, C, and D involve less.
The nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A)
and ribavirin (Virazole) combination therapy for hepatitis C. The client reports
experiencing overwhelming feelings of depression. Which action should the
nurse implement first?
A.Recommend mental health counseling.
B. Review the medication actions and interactions.
C. Assess for the client's daily activity level.
D. Provide information regarding a support group.
, B
Rationale: Interferon-alfa-2a and ribavirin combination therapy can cause severe
depression; therefore, it is most important for the nurse to review the medication
effects and report these to the health care provider. Options A, C, and D might be
implemented after the physiologic aspects of the situation have been assessed.
The nurse is giving preoperative instructions to a 14-year-old client scheduled
for surgery to correct a spinal curvature. Which statement by the client best
demonstrates that learning has taken place?
A.
"I will read all the teaching booklets you gave me before surgery."
B.
"I have had surgery before, so I know what to expect afterward."
C.
"All the things people have told me will help me take care of my back."
D.
"Let me show you the method of turning I will use after surgery."
D
Rationale: The outcome of learning is best demonstrated when the client not only
verbalizes an understanding but can also provide a return demonstration. A 14-
year-old client may or may not follow through with option A, and there is no
measurement of learning. Option B may help the client understand the surgical
process, but the type of surgery may have been very different, with differing
postoperative care. In option C, the client may be saying what the nurse wants to
hear without expressing any real understanding of what to do after surgery.
Client census is often used to determine staffing needs. Which method of
obtaining census determination for a particular unit provides the best formula
for determining long-range staffing patterns?
A.
Midnight census
B.
Oncoming shift census
C.
Average daily census
