HESI med surg evolve
Study online at https://quizlet.com/_apy0cb
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 per-
sonnel 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 respira-
tory 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 hemor-
rhage, 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
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Rationale:To increase the client's tolerance of endotracheal intubation and/or me-
chanical 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 assess-
ment 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
, HESI med surg evolve
Study online at https://quizlet.com/_apy0cb
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 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.
9. 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 medica-
tion?
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.: 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.
10. Which data would the nurse expect to find when reviewing laboratory
values of an 80-year-old man who is in good health overall?
A. Complete blood count reveals increased white blood cell (WBC) and de-
creased red blood cell (RBC) counts.
B. Chemistries reveal an increased serum bilirubin level with slightly in-
, HESI med surg evolve
Study online at https://quizlet.com/_apy0cb
creased liver enzyme levels.
C. Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria.
D. Serum electrolytes reveal a decreased sodium level and increased potassi-
um level.: C
Rationale: In older adults, the protein found in urine slightly rises, probably as a
result of kidney changes or subclinical urinary tract infections, and clients frequently
experience asymptomatic bacteriuria and pyuria as a result of incomplete bladder
emptying. Laboratory findings in options A, B, and D are not considered to be normal
findings in an older adult.
11. The nurse witnesses a baseball player receive a blunt trauma to the back
of the head with a softball. What assessment data should the nurse collect
immediately?
A. Reactivity of deep tendon reflexes, comparing upper with lower extremities
B. Vital sign readings, excluding blood pressure if needed equipment is
unavailable
C. Memory of events that occurred before and after the blow to the head
D. Ability to open the eyes spontaneously before any tactile stimuli are
given: D
Rationale: The level of consciousness (LOC) should be established immediately
when a head injury has occurred. Spontaneous eye opening is a simple measure
of alertness that indicates that arousal mechanisms are intact. Option A is not the
best indicator of LOC. Although option B is important, vital signs are not the best
indicators of LOC and can be evaluated after the client's LOC has been determined.
Option C can be assessed after LOC has been established by assessing eye
opening.
12. 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 interven-
tions are implemented, the client can be escorted back to the room via wheelchair
or stretcher.
13. 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?
Study online at https://quizlet.com/_apy0cb
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 per-
sonnel 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 respira-
tory 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 hemor-
rhage, 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
, HESI med surg evolve
Study online at https://quizlet.com/_apy0cb
Rationale:To increase the client's tolerance of endotracheal intubation and/or me-
chanical 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 assess-
ment 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
, HESI med surg evolve
Study online at https://quizlet.com/_apy0cb
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 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.
9. 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 medica-
tion?
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.: 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.
10. Which data would the nurse expect to find when reviewing laboratory
values of an 80-year-old man who is in good health overall?
A. Complete blood count reveals increased white blood cell (WBC) and de-
creased red blood cell (RBC) counts.
B. Chemistries reveal an increased serum bilirubin level with slightly in-
, HESI med surg evolve
Study online at https://quizlet.com/_apy0cb
creased liver enzyme levels.
C. Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria.
D. Serum electrolytes reveal a decreased sodium level and increased potassi-
um level.: C
Rationale: In older adults, the protein found in urine slightly rises, probably as a
result of kidney changes or subclinical urinary tract infections, and clients frequently
experience asymptomatic bacteriuria and pyuria as a result of incomplete bladder
emptying. Laboratory findings in options A, B, and D are not considered to be normal
findings in an older adult.
11. The nurse witnesses a baseball player receive a blunt trauma to the back
of the head with a softball. What assessment data should the nurse collect
immediately?
A. Reactivity of deep tendon reflexes, comparing upper with lower extremities
B. Vital sign readings, excluding blood pressure if needed equipment is
unavailable
C. Memory of events that occurred before and after the blow to the head
D. Ability to open the eyes spontaneously before any tactile stimuli are
given: D
Rationale: The level of consciousness (LOC) should be established immediately
when a head injury has occurred. Spontaneous eye opening is a simple measure
of alertness that indicates that arousal mechanisms are intact. Option A is not the
best indicator of LOC. Although option B is important, vital signs are not the best
indicators of LOC and can be evaluated after the client's LOC has been determined.
Option C can be assessed after LOC has been established by assessing eye
opening.
12. 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 interven-
tions are implemented, the client can be escorted back to the room via wheelchair
or stretcher.
13. 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?
