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 personnel 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 respiratory 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 hemorrhage,
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
, HESI med surg evolve
Study online at https://quizlet.com/_apy0cb
C. Potential for injury related to impaired lung expansion
D. Social isolation related to inability to communicate: A
Rationale:To increase the client's tolerance of endotracheal intubation and/or mechanical 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 ex-
pects the laboratory test results to indicate a decreased serum level of which
substance?
, HESI med surg evolve
Study online at https://quizlet.com/_apy0cb
A. Sodium
B. Phosphate
C. Potassium
D. Glucose: C
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 ra-
diograph 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?
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
, HESI med surg evolve
Study online at https://quizlet.com/_apy0cb
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 increased
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 potassium
level.: C
Rationale: In older adults, the protein found in urine slightly rises, probably as a result of kidney changes or subclinica
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 un-
available
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 am-
bulating 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.
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 personnel 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 respiratory 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 hemorrhage,
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
, HESI med surg evolve
Study online at https://quizlet.com/_apy0cb
C. Potential for injury related to impaired lung expansion
D. Social isolation related to inability to communicate: A
Rationale:To increase the client's tolerance of endotracheal intubation and/or mechanical 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 ex-
pects the laboratory test results to indicate a decreased serum level of which
substance?
, HESI med surg evolve
Study online at https://quizlet.com/_apy0cb
A. Sodium
B. Phosphate
C. Potassium
D. Glucose: C
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 ra-
diograph 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?
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
, HESI med surg evolve
Study online at https://quizlet.com/_apy0cb
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 increased
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 potassium
level.: C
Rationale: In older adults, the protein found in urine slightly rises, probably as a result of kidney changes or subclinica
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 un-
available
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 am-
bulating 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.
