EVOLVE ELSEVIER HESI MED – SURG EXAM
TEST BANK 2025/2026 QUESTIONS AND
CORRECT ANSWERS
The nurse is providing care to a client admitted to the emergency room with a
blood glucose level of 40 mg/dL and is semiconscious. What are the nurse's
next actions? (Select all that apply.)
-Start an IV of Normal Saline.
-Obtain a 50% dextrose solution.
-Administer glucagon as per the standing order.
-Turn the client to the side.
Rationale:
Oral carbohydrates, such as sugar and honey, should never be given to the
semiconscious or unconscious clients with low blood sugar levels, for
concern for aspiration. Glucagon can be administered immediately,
followed by starting an IV. Await the orders for the 50% dextrose solution.
Place the client in a side lying position as there is a risk for vomiting and
aspiration with these clients.
An 81-year-old client has emphysema. The client lives at home with a cat and
manages self-care with no difficulty. When making a home visit, the nurse
notices that this client's tongue is somewhat cracked and his eyeballs appear
sunken. Which nursing action is indicated?
Help the client determine ways to increase fluid intake.
,Rationale:
Clients with COPD should ingest 3 L of fluids daily but may experience a
fluid deficit because of shortness of breath. The nurse should suggest
creative methods to increase the intake of fluids, such as having fruit juices
in disposable containers readily available.
A 58-year-old client who has no health problems asks the nurse about
receiving the pneumococcal vaccine. Which statement given by the nurse
would offer the client accurate information about this vaccine?
The immunization is administered once to older adults or those at
risk for illness.
Rationale:
It is usually recommended that persons older than 65 years and those with
a history of chronic illness should receive the vaccine once in their lifetime.
Some recommend receiving the vaccine at 50 years of age. The influenza
vaccine is given once a year. Although the vaccine might be given to a
person traveling overseas, that is not the main rationale for administering
the vaccine. The vaccine is usually given once in a lifetime, but with
immunosuppressed clients or clients with a history of pneumonia,
revaccination is sometimes required.
,The clinic nurse is teaching a client with osteoarthritis to the knees bilaterally
about self-care. Which teaching points will the nurse include in the client's plan
of care? (Select all that apply.)
-Apply heat packs to your knees as needed for pain.
-Support your knees while you are in bed with a pillow or a rolled towel.
-Get 7 to 8 hours of sleep every night.
-Eat a balanced diet, including fish with Omega-3 fatty acids.
Rationale:
The maximum daily dose of acetaminophen is 4 g, the instruction includes
up to 6 g/per day. The best type of exercise does not place additional stress
on the knee joints, such as biking or swimming. Apply heat to increase
circulation and ice packs to decrease swelling. Support to the knees can
take the strain off of the joint. Getting rest will help with coping with the
pain of the disease. Eating a balanced diet may help with weight loss;
additional weight places strain on the
joint.
The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12
hours after chest tube insertion for hemothorax. What is the best initial action
for the nurse to take?
Assess for kinks or dependent loops in the tubing.
Rationale:
, The least invasive nursing action should be performed first to determine
why the drainage has diminished.
During report, the nurse learns that a client with tumor lysis syndrome is
receiving an IV infusion containing insulin. Which action should the nurse
complete first?
Monitor the client's serum potassium and blood glucose levels.
Rationale:
Clients with tumor lysis syndrome may experience hyperkalemia, requiring
the addition of insulin to the IV solution to reduce the serum potassium
level. It is most important for the nurse to monitor the client's serum
potassium and blood glucose levels to ensure that they are not at
dangerous levels.
For the client undergoing hemodialysis, the nurse suspects the client has an air
embolism. What symptoms lead the nurse to this conclusion? (Select all that
apply.)
-Dyspnea
-Chest pain
-Anxiety
-Blue nail beds
Rationale:
TEST BANK 2025/2026 QUESTIONS AND
CORRECT ANSWERS
The nurse is providing care to a client admitted to the emergency room with a
blood glucose level of 40 mg/dL and is semiconscious. What are the nurse's
next actions? (Select all that apply.)
-Start an IV of Normal Saline.
-Obtain a 50% dextrose solution.
-Administer glucagon as per the standing order.
-Turn the client to the side.
Rationale:
Oral carbohydrates, such as sugar and honey, should never be given to the
semiconscious or unconscious clients with low blood sugar levels, for
concern for aspiration. Glucagon can be administered immediately,
followed by starting an IV. Await the orders for the 50% dextrose solution.
Place the client in a side lying position as there is a risk for vomiting and
aspiration with these clients.
An 81-year-old client has emphysema. The client lives at home with a cat and
manages self-care with no difficulty. When making a home visit, the nurse
notices that this client's tongue is somewhat cracked and his eyeballs appear
sunken. Which nursing action is indicated?
Help the client determine ways to increase fluid intake.
,Rationale:
Clients with COPD should ingest 3 L of fluids daily but may experience a
fluid deficit because of shortness of breath. The nurse should suggest
creative methods to increase the intake of fluids, such as having fruit juices
in disposable containers readily available.
A 58-year-old client who has no health problems asks the nurse about
receiving the pneumococcal vaccine. Which statement given by the nurse
would offer the client accurate information about this vaccine?
The immunization is administered once to older adults or those at
risk for illness.
Rationale:
It is usually recommended that persons older than 65 years and those with
a history of chronic illness should receive the vaccine once in their lifetime.
Some recommend receiving the vaccine at 50 years of age. The influenza
vaccine is given once a year. Although the vaccine might be given to a
person traveling overseas, that is not the main rationale for administering
the vaccine. The vaccine is usually given once in a lifetime, but with
immunosuppressed clients or clients with a history of pneumonia,
revaccination is sometimes required.
,The clinic nurse is teaching a client with osteoarthritis to the knees bilaterally
about self-care. Which teaching points will the nurse include in the client's plan
of care? (Select all that apply.)
-Apply heat packs to your knees as needed for pain.
-Support your knees while you are in bed with a pillow or a rolled towel.
-Get 7 to 8 hours of sleep every night.
-Eat a balanced diet, including fish with Omega-3 fatty acids.
Rationale:
The maximum daily dose of acetaminophen is 4 g, the instruction includes
up to 6 g/per day. The best type of exercise does not place additional stress
on the knee joints, such as biking or swimming. Apply heat to increase
circulation and ice packs to decrease swelling. Support to the knees can
take the strain off of the joint. Getting rest will help with coping with the
pain of the disease. Eating a balanced diet may help with weight loss;
additional weight places strain on the
joint.
The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12
hours after chest tube insertion for hemothorax. What is the best initial action
for the nurse to take?
Assess for kinks or dependent loops in the tubing.
Rationale:
, The least invasive nursing action should be performed first to determine
why the drainage has diminished.
During report, the nurse learns that a client with tumor lysis syndrome is
receiving an IV infusion containing insulin. Which action should the nurse
complete first?
Monitor the client's serum potassium and blood glucose levels.
Rationale:
Clients with tumor lysis syndrome may experience hyperkalemia, requiring
the addition of insulin to the IV solution to reduce the serum potassium
level. It is most important for the nurse to monitor the client's serum
potassium and blood glucose levels to ensure that they are not at
dangerous levels.
For the client undergoing hemodialysis, the nurse suspects the client has an air
embolism. What symptoms lead the nurse to this conclusion? (Select all that
apply.)
-Dyspnea
-Chest pain
-Anxiety
-Blue nail beds
Rationale:
