Evolve Elsevier Hesi Med Surg Actual Exam With 155
Exam Questions And Correct Answers With Well-
elaborated Rationales__ Evolve Hesi Medical Surgical
(Brand New!!)
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.
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.
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.
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
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.
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.
, A client is diagnosed with an acute small bowel obstruction. Which assessment 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.
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
Exam Questions And Correct Answers With Well-
elaborated Rationales__ Evolve Hesi Medical Surgical
(Brand New!!)
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.
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.
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.
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
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.
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.
, A client is diagnosed with an acute small bowel obstruction. Which assessment 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.
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
