EVOLVE ELSEVIER HESI MED SURG ACTUAL EXAM WITH test bank EXAM verified
QUESTIONS AND ANSWERS MEDICAL SURGICAL LATEST EXAM (latest) ACE YOUR
TEST GRADED A+
What is the priority nursing action while caring for a client on a ventilator when an electrical fire occurs in
the intensive care unit?
a. Tell another staff member to bring extinguishing equipment to the bedside.
b. Close the doors to the client's area when attempting to extinguish the fire.
c. Use a bag-valve-mask resuscitator while removing the client from the area.
d. Implement an emergency protocol to remove the client from the ventilator.
- ANS :c. Use a bag-valve-mask resuscitator while removing the client from the area.
Rationale: A client on a ventilator should have respirations maintained with a manual bag-valve-mask resuscitator
while being moved away from the oxygen wall outlet and fire sourc
A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate 4 mg
every 2 hours and a clear liquid diet. The client complains of feeling distended and has sharp, cramping gas
pains. What nursing intervention should be implemented?
TEST BANK 1
,a. Obtain a prescription for a laxative.
b. Withhold all oral fluid and food.
c. Assist the client to ambulate in the hall.
d. Administer the prescribed morphine sulfate.
- ANS :c. Assist the client to ambulate in the hall.
Rationale
Postoperative abdominal distention is caused by decreased peristalsis as a result of handling the intestine during
surgery, limited dietary intake before and after surgery, and anesthetic and analgesic agents. Peristalsis is
stimulated, flatus passed and distention minimized by implementing early and frequent ambulation.
A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal
discharge as having a "cottage-cheese" appearance. Which prescription should the nurse implement first?
a. Cleanse perineum with warm soapy water 3 times per day.
b. Instill the first dose of nystatin (Mycostatin) vaginally per applicator.
c. Perform glucose measurement using a capillary blood sample.
d. Obtain a blood specimen for sexually transmitted diseases (STDs). –
ANS :b. Instill the first dose of nystatin (Mycostatin) vaginally per applicator.
Rationale: Candidiasis, also known as a yeast infection, is characterized by a white, vaginal discharge with a
"cottage-cheese" appearance and vaginal nystatin (Mycostatin) should be implemented first to initiate treatment to
provide relief of symptoms.
The nurse directs an unlicensed assistive personnel (UAP) to obtain the vital signs for a client who returns to
the unit after having a mastectomy for cancer. What information should the nurse provide the UAP?
TEST BANK 2
,a. Elevate the arm with an IV infusing on the operative side with a pillow.
b. Apply the blood pressure cuff to the arm on the non-operative side.
c. Position the arm on the operative side close to the body.
d. Collect a fingerstick blood specimen from the arm on the operative side.
- ANS :b. Apply the blood pressure cuff to the arm on the non-operative side
Rationale: The nurse give the UAP the following instructions when providing care to a post-op mastectomy client.
Blood pressure readings should be obtained from the arm on the nonoperative side to reduce the risk of injury of the
extremity that may have compromised lymphatic drainage postoperatively. The arm on the operative side of the
mastectomy should be elevated on a pillow above the level of the right atrium to facilitate lymphatic drainage.
The nurse is giving discharge instructions to a client with chronic prostatitis. Which instruction should the
nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary
tract?
Wear a condom when having sexual intercourse.
Avoid consuming alcohol and caffeinated beverages.
Empty the bladder completely with each voiding.
Have intercourse or masturbate at least twice a week. –
ANS :Have intercourse or masturbate at least twice a week.
Rationale
The prostate is not easily penetrated by antibiotics and can serve as a reservoir for microorganisms, which can infect
other areas of the genitourinary tract. Draining the prostate regularly through intercourse or masturbation decreases
the number of microorganisms present and reduces the risk of further infection from stored contaminated seminal
fluids.
TEST BANK 3
, An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive
medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment
should the nurse complete?
Palpate the pedal pulse volume.
Count the brachial pulse rate.
Measure the blood pressure.
Assess for a carotid bruit. –
ANS :Measure the blood pressure
Rationale
Elderly clients who take antihypertensive medications often experience side effects, such as hypotension, which
causes tachycardia, a compensatory mechanism to maintain adequate cardiac output, so the client's blood pressure
should be measured.
A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute
Coronary Syndrome (ACS). Which cardiac biomarker should the nurse anticipate to be elevated if the client
experienced myocardial damage?
Creatine Kinase (CK-MB).
Serum troponin.
Myoglobin.
Ischemia-modified albumin.
TEST BANK 4
QUESTIONS AND ANSWERS MEDICAL SURGICAL LATEST EXAM (latest) ACE YOUR
TEST GRADED A+
What is the priority nursing action while caring for a client on a ventilator when an electrical fire occurs in
the intensive care unit?
a. Tell another staff member to bring extinguishing equipment to the bedside.
b. Close the doors to the client's area when attempting to extinguish the fire.
c. Use a bag-valve-mask resuscitator while removing the client from the area.
d. Implement an emergency protocol to remove the client from the ventilator.
- ANS :c. Use a bag-valve-mask resuscitator while removing the client from the area.
Rationale: A client on a ventilator should have respirations maintained with a manual bag-valve-mask resuscitator
while being moved away from the oxygen wall outlet and fire sourc
A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate 4 mg
every 2 hours and a clear liquid diet. The client complains of feeling distended and has sharp, cramping gas
pains. What nursing intervention should be implemented?
TEST BANK 1
,a. Obtain a prescription for a laxative.
b. Withhold all oral fluid and food.
c. Assist the client to ambulate in the hall.
d. Administer the prescribed morphine sulfate.
- ANS :c. Assist the client to ambulate in the hall.
Rationale
Postoperative abdominal distention is caused by decreased peristalsis as a result of handling the intestine during
surgery, limited dietary intake before and after surgery, and anesthetic and analgesic agents. Peristalsis is
stimulated, flatus passed and distention minimized by implementing early and frequent ambulation.
A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal
discharge as having a "cottage-cheese" appearance. Which prescription should the nurse implement first?
a. Cleanse perineum with warm soapy water 3 times per day.
b. Instill the first dose of nystatin (Mycostatin) vaginally per applicator.
c. Perform glucose measurement using a capillary blood sample.
d. Obtain a blood specimen for sexually transmitted diseases (STDs). –
ANS :b. Instill the first dose of nystatin (Mycostatin) vaginally per applicator.
Rationale: Candidiasis, also known as a yeast infection, is characterized by a white, vaginal discharge with a
"cottage-cheese" appearance and vaginal nystatin (Mycostatin) should be implemented first to initiate treatment to
provide relief of symptoms.
The nurse directs an unlicensed assistive personnel (UAP) to obtain the vital signs for a client who returns to
the unit after having a mastectomy for cancer. What information should the nurse provide the UAP?
TEST BANK 2
,a. Elevate the arm with an IV infusing on the operative side with a pillow.
b. Apply the blood pressure cuff to the arm on the non-operative side.
c. Position the arm on the operative side close to the body.
d. Collect a fingerstick blood specimen from the arm on the operative side.
- ANS :b. Apply the blood pressure cuff to the arm on the non-operative side
Rationale: The nurse give the UAP the following instructions when providing care to a post-op mastectomy client.
Blood pressure readings should be obtained from the arm on the nonoperative side to reduce the risk of injury of the
extremity that may have compromised lymphatic drainage postoperatively. The arm on the operative side of the
mastectomy should be elevated on a pillow above the level of the right atrium to facilitate lymphatic drainage.
The nurse is giving discharge instructions to a client with chronic prostatitis. Which instruction should the
nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary
tract?
Wear a condom when having sexual intercourse.
Avoid consuming alcohol and caffeinated beverages.
Empty the bladder completely with each voiding.
Have intercourse or masturbate at least twice a week. –
ANS :Have intercourse or masturbate at least twice a week.
Rationale
The prostate is not easily penetrated by antibiotics and can serve as a reservoir for microorganisms, which can infect
other areas of the genitourinary tract. Draining the prostate regularly through intercourse or masturbation decreases
the number of microorganisms present and reduces the risk of further infection from stored contaminated seminal
fluids.
TEST BANK 3
, An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive
medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment
should the nurse complete?
Palpate the pedal pulse volume.
Count the brachial pulse rate.
Measure the blood pressure.
Assess for a carotid bruit. –
ANS :Measure the blood pressure
Rationale
Elderly clients who take antihypertensive medications often experience side effects, such as hypotension, which
causes tachycardia, a compensatory mechanism to maintain adequate cardiac output, so the client's blood pressure
should be measured.
A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute
Coronary Syndrome (ACS). Which cardiac biomarker should the nurse anticipate to be elevated if the client
experienced myocardial damage?
Creatine Kinase (CK-MB).
Serum troponin.
Myoglobin.
Ischemia-modified albumin.
TEST BANK 4
