HESI med surg evolve
1. When educating a client after a total la- C
ryngectomy, which instruction would be Rationale: Neck breathers carry a medical alert
most important for the nurse to include card that notifies health care personnel of the
in the discharge teaching? need to use mouth to stoma breathing in the
A. Recommend that the client carry suc- event of a cardiac arrest in this client. Mouth to
tion equipment at all times. mouth resuscitation will not establish a patent
B. Instruct the client to have writing ma- airway. Options A and D are not necessary.
terials with him at all times. There are many alternative means of commu-
C. Tell the client to carry a medical alert nication for clients who have had a laryngecto-
card that explains his condition. my; dependence on writing messages is prob-
D. Caution the client not to travel outside ably the least effective.
the United States alone.
2. The nurse receives the client's next D
scheduled bag of TPN labeled with Rationale: Only regular insulin is administered
the additive NPH insulin. Which action by the IV route, so the TPN solution containing
should the nurse implement? NPH insulin should be returned to the phar-
A. Hang the solution at the current rate. macy. Options A, B, and C are not indicated
B. Refrigerate the solution until needed. because the solution should not be adminis-
C.Prepare the solution with new tubing. tered.
D.Return the solution to the pharmacy.
3. A postoperative client receives a Sched- C
ule II opioid analgesic for pain. Which as- Rationale: Administration of a Schedule II opi-
sessment finding requires the most im- oid analgesic can result in respiratory depres-
mediate intervention by the nurse? sion, which requires immediate intervention
A. Hypoactive bowel sounds with abdom- by the nurse to prevent respiratory arrest. Op-
inal distention tions A, B, and D require action by the nurse
B. Client reports continued pain of 8 on a but are of less priority than option C.
10-point scale
C. Respiratory rate of 12 breaths/min,
with O2 saturation of 85%
, HESI med surg evolve
D. Client reports nausea after receiving
the medication
4. A client is placed on a mechanical ven- A
tilator following a cerebral hemorrhage, Rationale:To increase the client's tolerance of
and vecuronium bromide, 0.04 mg/kg endotracheal intubation and/or mechanical
every 12 hours IV, is prescribed. What ventilation, a skeletal muscle relaxant such as
is the priority nursing diagnosis for this vecuronium is usually prescribed. Option A is
client? a serious outcome because the client cannot
A. Impaired communication related to communicate his or her needs. Although this
paralysis of skeletal muscles client might also experience option D, it is not
B. High risk for infection related to in- a priority when compared with option A. In-
creased intracranial pressure fection is not related to increased intracranial
C. Potential for injury related to impaired pressure. The respirator will ensure that the
lung expansion lungs are expanded, so option C is incorrect.
D. Social isolation related to inability to
communicate
5. A family member was taught to suction a B
client's tracheostomy prior to the client's Rationale:Option B indicates correct technique
discharge from the hospital. Which ob- for performing suctioning. Suction pressure
servation by the nurse indicates that the should be between 80 and 120 mm Hg, not
family member is capable of correctly 190 mm Hg. The catheter should be with-
performing the suctioning technique? drawn 1 to 2 cm at a time with intermit-
A. Turns on the continuous wall suction tent, not continuous, suction. Option D intro-
to 190 mm Hg. duces pathogens unnecessarily into the tra-
B. Inserts the catheter until resistance or cheobronchial tree.
coughing occurs.
C. Withdraws the catheter while main-
taining suctioning.
D. Reclears the tracheostomy after suc-
tioning the mouth.
, HESI med surg evolve
6. A client is diagnosed with an acute small A
bowel obstruction. Which assessment Rationale:A sudden increase in temperature is
finding requires the most immediate in- an indicator of peritonitis. The nurse should
tervention by the nurse? notify the health care provider immediately.
A. Fever of 102° F Options B, C, and D are also findings that
B. Blood pressure of 150/90 mm Hg require intervention by the nurse but are of
C. Abdominal cramping less priority than option A. Option B may in-
D. Dry mucous membranes dicate 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. Op-
tion D indicates probable fluid volume deficit,
which requires fluid volume replacement.
7. In assessing a client diagnosed with pri- C
mary aldosteronism, the nurse expects Rationale: Clients with primary aldosteronism
the laboratory test results to indicate exhibit a profound decline in serum levels of
a decreased serum level of which sub- potassium; hypokalemia; hypertension is the
stance? most prominent and universal sign. The serum
A. Sodium sodium level is normal or elevated, depending
B. Phosphate on the amount of water resorbed with the
C. Potassium sodium. Option B is influenced by parathyroid
D. Glucose hormone (PTH). Option D is not affected by
primary aldosteronism.
8. During assessment of a client in the in- A
tensive care unit, the nurse notes that Rationale: The client is exhibiting symptoms
the client's breath sounds are clear on of cardiac tamponade, a collection of fluid in
auscultation, but jugular vein distention the pericardial sac that results in a reduc-
and muffled heart sounds are present. tion in cardiac output, which is a potential-
Which intervention should the nurse im- ly fatal complication of pericarditis. Treatment
plement? for tamponade is a pericardial tap. Lasix IV
, HESI med surg evolve
A. Prepare the client for a pericardial is not indicated for treatment of pericarditis.
tap. Because the client's breath sounds are clear,
B. Administer intravenous furosemide option C is not a priority. Fluids are frequently
(Lasix). increased in the initial treatment of tampon-
C. Assist the client to cough and breathe ade to compensate for the decrease in cardiac
deeply. output, but this is not the same priority as
D. Instruct the client to restrict oral fluid option A.
intake.
9. A central venous catheter has been in- D
serted via a jugular vein, and a radi- Rationale:Medication can be administered via
ograph has confirmed placement of the a central line without additional IV fluids. The
catheter. A prescription has been re- line should first be flushed with a normal
ceived for a medication STAT, but IV fluids saline solution to ensure patency. Insufficient
have not yet been started. Which action evidence exists on the effectiveness of flushing
should the nurse take prior to adminis- catheters with heparin. Option A will not affect
tering the prescribed medication? the decision to administer the medication and
A. Assess for signs of jugular venous dis- is not a priority. Administration of the medica-
tention. tion STAT is of greater priority than option B.
B. Obtain the needed intravenous solu-
tion.
C. Flush the line with heparinized solu-
tion.
D. Flush the line with normal saline.
10. Which data would the nurse expect to C
find when reviewing laboratory values of Rationale: In older adults, the protein found
an 80-year-old man who is in good health in urine slightly rises, probably as a result
overall? of kidney changes or subclinical urinary tract
A. Complete blood count reveals in- infections, and clients frequently experience
creased white blood cell (WBC) and de- asymptomatic bacteriuria and pyuria as a re-
creased red blood cell (RBC) counts. sult of incomplete bladder emptying. Labora-
1. When educating a client after a total la- C
ryngectomy, which instruction would be Rationale: Neck breathers carry a medical alert
most important for the nurse to include card that notifies health care personnel of the
in the discharge teaching? need to use mouth to stoma breathing in the
A. Recommend that the client carry suc- event of a cardiac arrest in this client. Mouth to
tion equipment at all times. mouth resuscitation will not establish a patent
B. Instruct the client to have writing ma- airway. Options A and D are not necessary.
terials with him at all times. There are many alternative means of commu-
C. Tell the client to carry a medical alert nication for clients who have had a laryngecto-
card that explains his condition. my; dependence on writing messages is prob-
D. Caution the client not to travel outside ably the least effective.
the United States alone.
2. The nurse receives the client's next D
scheduled bag of TPN labeled with Rationale: Only regular insulin is administered
the additive NPH insulin. Which action by the IV route, so the TPN solution containing
should the nurse implement? NPH insulin should be returned to the phar-
A. Hang the solution at the current rate. macy. Options A, B, and C are not indicated
B. Refrigerate the solution until needed. because the solution should not be adminis-
C.Prepare the solution with new tubing. tered.
D.Return the solution to the pharmacy.
3. A postoperative client receives a Sched- C
ule II opioid analgesic for pain. Which as- Rationale: Administration of a Schedule II opi-
sessment finding requires the most im- oid analgesic can result in respiratory depres-
mediate intervention by the nurse? sion, which requires immediate intervention
A. Hypoactive bowel sounds with abdom- by the nurse to prevent respiratory arrest. Op-
inal distention tions A, B, and D require action by the nurse
B. Client reports continued pain of 8 on a but are of less priority than option C.
10-point scale
C. Respiratory rate of 12 breaths/min,
with O2 saturation of 85%
, HESI med surg evolve
D. Client reports nausea after receiving
the medication
4. A client is placed on a mechanical ven- A
tilator following a cerebral hemorrhage, Rationale:To increase the client's tolerance of
and vecuronium bromide, 0.04 mg/kg endotracheal intubation and/or mechanical
every 12 hours IV, is prescribed. What ventilation, a skeletal muscle relaxant such as
is the priority nursing diagnosis for this vecuronium is usually prescribed. Option A is
client? a serious outcome because the client cannot
A. Impaired communication related to communicate his or her needs. Although this
paralysis of skeletal muscles client might also experience option D, it is not
B. High risk for infection related to in- a priority when compared with option A. In-
creased intracranial pressure fection is not related to increased intracranial
C. Potential for injury related to impaired pressure. The respirator will ensure that the
lung expansion lungs are expanded, so option C is incorrect.
D. Social isolation related to inability to
communicate
5. A family member was taught to suction a B
client's tracheostomy prior to the client's Rationale:Option B indicates correct technique
discharge from the hospital. Which ob- for performing suctioning. Suction pressure
servation by the nurse indicates that the should be between 80 and 120 mm Hg, not
family member is capable of correctly 190 mm Hg. The catheter should be with-
performing the suctioning technique? drawn 1 to 2 cm at a time with intermit-
A. Turns on the continuous wall suction tent, not continuous, suction. Option D intro-
to 190 mm Hg. duces pathogens unnecessarily into the tra-
B. Inserts the catheter until resistance or cheobronchial tree.
coughing occurs.
C. Withdraws the catheter while main-
taining suctioning.
D. Reclears the tracheostomy after suc-
tioning the mouth.
, HESI med surg evolve
6. A client is diagnosed with an acute small A
bowel obstruction. Which assessment Rationale:A sudden increase in temperature is
finding requires the most immediate in- an indicator of peritonitis. The nurse should
tervention by the nurse? notify the health care provider immediately.
A. Fever of 102° F Options B, C, and D are also findings that
B. Blood pressure of 150/90 mm Hg require intervention by the nurse but are of
C. Abdominal cramping less priority than option A. Option B may in-
D. Dry mucous membranes dicate 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. Op-
tion D indicates probable fluid volume deficit,
which requires fluid volume replacement.
7. In assessing a client diagnosed with pri- C
mary aldosteronism, the nurse expects Rationale: Clients with primary aldosteronism
the laboratory test results to indicate exhibit a profound decline in serum levels of
a decreased serum level of which sub- potassium; hypokalemia; hypertension is the
stance? most prominent and universal sign. The serum
A. Sodium sodium level is normal or elevated, depending
B. Phosphate on the amount of water resorbed with the
C. Potassium sodium. Option B is influenced by parathyroid
D. Glucose hormone (PTH). Option D is not affected by
primary aldosteronism.
8. During assessment of a client in the in- A
tensive care unit, the nurse notes that Rationale: The client is exhibiting symptoms
the client's breath sounds are clear on of cardiac tamponade, a collection of fluid in
auscultation, but jugular vein distention the pericardial sac that results in a reduc-
and muffled heart sounds are present. tion in cardiac output, which is a potential-
Which intervention should the nurse im- ly fatal complication of pericarditis. Treatment
plement? for tamponade is a pericardial tap. Lasix IV
, HESI med surg evolve
A. Prepare the client for a pericardial is not indicated for treatment of pericarditis.
tap. Because the client's breath sounds are clear,
B. Administer intravenous furosemide option C is not a priority. Fluids are frequently
(Lasix). increased in the initial treatment of tampon-
C. Assist the client to cough and breathe ade to compensate for the decrease in cardiac
deeply. output, but this is not the same priority as
D. Instruct the client to restrict oral fluid option A.
intake.
9. A central venous catheter has been in- D
serted via a jugular vein, and a radi- Rationale:Medication can be administered via
ograph has confirmed placement of the a central line without additional IV fluids. The
catheter. A prescription has been re- line should first be flushed with a normal
ceived for a medication STAT, but IV fluids saline solution to ensure patency. Insufficient
have not yet been started. Which action evidence exists on the effectiveness of flushing
should the nurse take prior to adminis- catheters with heparin. Option A will not affect
tering the prescribed medication? the decision to administer the medication and
A. Assess for signs of jugular venous dis- is not a priority. Administration of the medica-
tention. tion STAT is of greater priority than option B.
B. Obtain the needed intravenous solu-
tion.
C. Flush the line with heparinized solu-
tion.
D. Flush the line with normal saline.
10. Which data would the nurse expect to C
find when reviewing laboratory values of Rationale: In older adults, the protein found
an 80-year-old man who is in good health in urine slightly rises, probably as a result
overall? of kidney changes or subclinical urinary tract
A. Complete blood count reveals in- infections, and clients frequently experience
creased white blood cell (WBC) and de- asymptomatic bacteriuria and pyuria as a re-
creased red blood cell (RBC) counts. sult of incomplete bladder emptying. Labora-
