Test Bank for EVOLVE HESI MED SURG Exam 2025 |
Actual Exam Questions and Correct Answers with
Rationales | Latest Version | Verified Answers |
Brand New Version!
A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly
treated at a community hemodialysis facility. Before the scheduled dialysis
treatment, which electrolyte imbalance should the nurse anticipate?
A. Hypophosphatemia
B. Hypocalcemia
C.Hyponatremia
D. Hypokalemia ---------CORRECT ANSWER-----------------Correct Answer: B
Rationale:
Hypocalcemia develops in CKD because of chronic hyperphosphatemia, not
option A. Increased phosphate levels cause the peripheral deposition of calcium
and resistance to vitamin D absorption needed for calcium absorption. Prior to
dialysis, the nurse would expect to find the client hypernatremic and
hyperkalemic, not with option C or D.
A hospitalized client is receiving nasogastric tube feedings via a small-bore tube
and a continuous pump infusion. The client begins to cough and produces a
moderate amount of white sputum. Which action should the nurse take first?
,A. Auscultate the client's breath sounds.
B. Turn off the continuous feeding pump.
C. Check placement of the nasogastric tube.
D. Measure the amount of residual feeding. ---------CORRECT ANSWER----------------
-Correct Answer: B
Rationale:
A productive cough may indicate that the feeding has been aspirated. The nurse
should first stop the feeding to prevent further aspiration. Options A, C, and D
should all be performed before restarting the tube feeding if no evidence of
aspiration is present and the tube is in place.
A client is ready for discharge following the creation of an ileostomy. Which
instruction should the nurse include in discharge teaching?
A.
Replace the stoma appliance every day.
B.
Use warm tap water to irrigate the ileostomy.
C.
Change the bag when the seal is broken.
D.
Measure and record the ileostomy output. ---------CORRECT ANSWER-----------------
Correct Answer: C
,Rationale: A seal must be maintained to prevent leakage of irritating liquid stool
onto the skin. Option A is excessive and can cause skin irritation and
breakdown. Ileostomies produce liquid fecal drainage, so option B is not
necessary. Option D is not needed.
The nurse is caring for a client who is one day post-acute myocardial infarction.
The client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral
saline lock. The nurse notes that the client is having eight premature ventricular
contractions (PVCs) per minute. Which action should the nurse take first?
A.
Obtain an IV pump for antiarrhythmic infusion.
B.
Increase the client's oxygen flow rate.
C.
Prepare for immediate countershock.
D.
Gather equipment for endotracheal intubation. ---------CORRECT ANSWER-----------
------Correct Answer: B
Rationale: Increasing the oxygen flow rate provides more oxygen to the client's
myocardium and may decrease myocardial irritability as manifested by the
frequent PVCs. Option A can be delegated and is a lower priority action than
option B. Defibrillation may eventually be necessary, but option C is not the
immediate treatment for frequent PVCs. Option D may become necessary if the
client stops breathing but is not indicated at this time.
, 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 ---------CORRECT ANSWER-----
------------Correct Answer: 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
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?
A.
Review the client's history for diabetes mellitus.
B.
Observe the extremity distal to the IV site.
C.
Monitor the client's serum potassium and blood glucose levels.
Actual Exam Questions and Correct Answers with
Rationales | Latest Version | Verified Answers |
Brand New Version!
A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly
treated at a community hemodialysis facility. Before the scheduled dialysis
treatment, which electrolyte imbalance should the nurse anticipate?
A. Hypophosphatemia
B. Hypocalcemia
C.Hyponatremia
D. Hypokalemia ---------CORRECT ANSWER-----------------Correct Answer: B
Rationale:
Hypocalcemia develops in CKD because of chronic hyperphosphatemia, not
option A. Increased phosphate levels cause the peripheral deposition of calcium
and resistance to vitamin D absorption needed for calcium absorption. Prior to
dialysis, the nurse would expect to find the client hypernatremic and
hyperkalemic, not with option C or D.
A hospitalized client is receiving nasogastric tube feedings via a small-bore tube
and a continuous pump infusion. The client begins to cough and produces a
moderate amount of white sputum. Which action should the nurse take first?
,A. Auscultate the client's breath sounds.
B. Turn off the continuous feeding pump.
C. Check placement of the nasogastric tube.
D. Measure the amount of residual feeding. ---------CORRECT ANSWER----------------
-Correct Answer: B
Rationale:
A productive cough may indicate that the feeding has been aspirated. The nurse
should first stop the feeding to prevent further aspiration. Options A, C, and D
should all be performed before restarting the tube feeding if no evidence of
aspiration is present and the tube is in place.
A client is ready for discharge following the creation of an ileostomy. Which
instruction should the nurse include in discharge teaching?
A.
Replace the stoma appliance every day.
B.
Use warm tap water to irrigate the ileostomy.
C.
Change the bag when the seal is broken.
D.
Measure and record the ileostomy output. ---------CORRECT ANSWER-----------------
Correct Answer: C
,Rationale: A seal must be maintained to prevent leakage of irritating liquid stool
onto the skin. Option A is excessive and can cause skin irritation and
breakdown. Ileostomies produce liquid fecal drainage, so option B is not
necessary. Option D is not needed.
The nurse is caring for a client who is one day post-acute myocardial infarction.
The client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral
saline lock. The nurse notes that the client is having eight premature ventricular
contractions (PVCs) per minute. Which action should the nurse take first?
A.
Obtain an IV pump for antiarrhythmic infusion.
B.
Increase the client's oxygen flow rate.
C.
Prepare for immediate countershock.
D.
Gather equipment for endotracheal intubation. ---------CORRECT ANSWER-----------
------Correct Answer: B
Rationale: Increasing the oxygen flow rate provides more oxygen to the client's
myocardium and may decrease myocardial irritability as manifested by the
frequent PVCs. Option A can be delegated and is a lower priority action than
option B. Defibrillation may eventually be necessary, but option C is not the
immediate treatment for frequent PVCs. Option D may become necessary if the
client stops breathing but is not indicated at this time.
, 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 ---------CORRECT ANSWER-----
------------Correct Answer: 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
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?
A.
Review the client's history for diabetes mellitus.
B.
Observe the extremity distal to the IV site.
C.
Monitor the client's serum potassium and blood glucose levels.
