EVOLVE ELSEVIER HESI MED SURG EXIT EXAM WITH CORRECT VERIFIED
ANSWERS
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.(ANSWER) C RATIONALE(ANSWER) 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.(ANSWER) D
RATIONALE(ANSWER) 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(ANSWER) C
RATIONALE(ANSWER) 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?
, EVOLVE ELSEVIER HESI MED SURG EXIT EXAM WITH CORRECT VERIFIED
ANSWERS
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(ANSWER) A
, EVOLVE ELSEVIER HESI MED SURG EXIT EXAM WITH CORRECT VERIFIED
ANSWERS
RATIONALE(ANSWER)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.(ANSWER) B RATIONALE(ANSWER)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(ANSWER) A
RATIONALE(ANSWER)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(ANSWER) C
, EVOLVE ELSEVIER HESI MED SURG EXIT EXAM WITH CORRECT VERIFIED
ANSWERS
RATIONALE(ANSWER) 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.(ANSWER) A
RATIONALE(ANSWER) 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.(ANSWER) D
RATIONALE(ANSWER)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-
ANSWERS
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.(ANSWER) C RATIONALE(ANSWER) 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.(ANSWER) D
RATIONALE(ANSWER) 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(ANSWER) C
RATIONALE(ANSWER) 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?
, EVOLVE ELSEVIER HESI MED SURG EXIT EXAM WITH CORRECT VERIFIED
ANSWERS
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(ANSWER) A
, EVOLVE ELSEVIER HESI MED SURG EXIT EXAM WITH CORRECT VERIFIED
ANSWERS
RATIONALE(ANSWER)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.(ANSWER) B RATIONALE(ANSWER)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(ANSWER) A
RATIONALE(ANSWER)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(ANSWER) C
, EVOLVE ELSEVIER HESI MED SURG EXIT EXAM WITH CORRECT VERIFIED
ANSWERS
RATIONALE(ANSWER) 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.(ANSWER) A
RATIONALE(ANSWER) 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.(ANSWER) D
RATIONALE(ANSWER)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-
