HESI Med Surg Evolve Exam Questions and Answers Latest Update
HESI Med Surg Evolve Exam Questions and
Answers Latest Update
Question 1
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
Correct Answer
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.
Page 1 of 79
, HESI Med Surg Evolve Exam Questions and Answers Latest Update
Question 2
The nurse teaches a client with type 2 diabetes nutritional strategies to decrease
obesity. Which food items chosen by the client indicate understanding of the
teaching? (Select all that apply.)
A.
White bread
B.
Salmon
C.
Broccoli
D.
Whole milk
E.
Banana
Correct Answer
B,C,E
Rationale: Options B, C, and E provide fresh fruits, lean meats and fish, vegetables,
whole grains, and low-fat dairy products. All are recommended by the American
Diabetes Association (ADA) and are a part of the My Plate guidelines recommended
by the U.S. Department of Agriculture (USDA). Whole milk is high in fat and is not
recommended by the ADA. White bread is milled, a process that removes the
essential nutrients. It should be avoided for weight loss and is a poor choice for the
client with diabetes.
Page 2 of 79
, HESI Med Surg Evolve Exam Questions and Answers Latest Update
Question 3
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.
Correct Answer
A
Rationale: 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.
Question 4
The nurse initiates neurologic checks for a client who is at risk for neurologic
compromise. Which manifestation typically provides the first indication of altered
neurologic function?
A. Change in level of consciousness
B. Increasing muscular weakness
C. Changes in pupil size bilaterally
D. Progressive nuchal rigidity
Correct Answer
A
Rationale: A decrease or change in the level of consciousness is usually the first
indication of neurologic deterioration. Options B and C may also occur but are
much less likely to be the first sign of neurologic compromise. Option D is often a
sign of meningitis.
Page 3 of 79
, HESI Med Surg Evolve Exam Questions and Answers Latest Update
Question 5
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.
Correct Answer
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.
Question 6
During the shift report, the charge nurse informs a nurse that she has been assigned
to another unit for the day. The nurse begins to sigh deeply and tosses about her
belongings as she prepares to leave, making it known that she is very unhappy about
being floated to the other unit. What is the best immediate action for the charge
nurse to take?
A. Continue with the shift report and talk to the nurse about the incident at a later
time.
B. Ask the nurse to call the house supervisor to see if she must be reassigned.
C. Stop the shift report and remind the nurse that all staff are floated equally.
D. Inform the nurse that her behavior is disruptive to the rest of the staff.
Correct Answer
A
Rationale: Continuing with the shift report is the best immediate action because it
allows the nurse who was floated some cooling off time. At a later time (after the
nurse has cooled off) the charge nurse should discuss the conduct of the nurse in
private. Option B encourages the nurse to shirk the float assignment. Option C is
disruptive. Reprimanding the nurse in front of the staff would increase the nurse's
hostility, so the nurse should be counseled in private.
Page 4 of 79
HESI Med Surg Evolve Exam Questions and
Answers Latest Update
Question 1
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
Correct Answer
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.
Page 1 of 79
, HESI Med Surg Evolve Exam Questions and Answers Latest Update
Question 2
The nurse teaches a client with type 2 diabetes nutritional strategies to decrease
obesity. Which food items chosen by the client indicate understanding of the
teaching? (Select all that apply.)
A.
White bread
B.
Salmon
C.
Broccoli
D.
Whole milk
E.
Banana
Correct Answer
B,C,E
Rationale: Options B, C, and E provide fresh fruits, lean meats and fish, vegetables,
whole grains, and low-fat dairy products. All are recommended by the American
Diabetes Association (ADA) and are a part of the My Plate guidelines recommended
by the U.S. Department of Agriculture (USDA). Whole milk is high in fat and is not
recommended by the ADA. White bread is milled, a process that removes the
essential nutrients. It should be avoided for weight loss and is a poor choice for the
client with diabetes.
Page 2 of 79
, HESI Med Surg Evolve Exam Questions and Answers Latest Update
Question 3
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.
Correct Answer
A
Rationale: 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.
Question 4
The nurse initiates neurologic checks for a client who is at risk for neurologic
compromise. Which manifestation typically provides the first indication of altered
neurologic function?
A. Change in level of consciousness
B. Increasing muscular weakness
C. Changes in pupil size bilaterally
D. Progressive nuchal rigidity
Correct Answer
A
Rationale: A decrease or change in the level of consciousness is usually the first
indication of neurologic deterioration. Options B and C may also occur but are
much less likely to be the first sign of neurologic compromise. Option D is often a
sign of meningitis.
Page 3 of 79
, HESI Med Surg Evolve Exam Questions and Answers Latest Update
Question 5
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.
Correct Answer
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.
Question 6
During the shift report, the charge nurse informs a nurse that she has been assigned
to another unit for the day. The nurse begins to sigh deeply and tosses about her
belongings as she prepares to leave, making it known that she is very unhappy about
being floated to the other unit. What is the best immediate action for the charge
nurse to take?
A. Continue with the shift report and talk to the nurse about the incident at a later
time.
B. Ask the nurse to call the house supervisor to see if she must be reassigned.
C. Stop the shift report and remind the nurse that all staff are floated equally.
D. Inform the nurse that her behavior is disruptive to the rest of the staff.
Correct Answer
A
Rationale: Continuing with the shift report is the best immediate action because it
allows the nurse who was floated some cooling off time. At a later time (after the
nurse has cooled off) the charge nurse should discuss the conduct of the nurse in
private. Option B encourages the nurse to shirk the float assignment. Option C is
disruptive. Reprimanding the nurse in front of the staff would increase the nurse's
hostility, so the nurse should be counseled in private.
Page 4 of 79
