Evolve HESI Med-Surg 2025|2026 ACTUAL EXAM REVIEW 150
QUESTIONS AND CORRECT ANSWERS WITH RATIONALES
COVERING MOST TESTED QUESTIONS PERFECT FOR A+
GRADE
1. A client with chronic heart failure reports increasing shortness of breath and swelling in the legs.
Which assessment finding is most concerning?
A. Mild ankle edema
B. Jugular vein distension ✔
C. Dry cough
D. Occasional palpitations
Rationale: Jugular vein distension indicates fluid overload and worsening heart failure.
2. A nurse is caring for a client with COPD who is on oxygen. Which intervention should the nurse
prioritize?
A. Encourage deep breathing exercises
B. Administer bronchodilator
C. Monitor oxygen saturation and maintain prescribed oxygen ✔
D. Encourage fluid restriction
Rationale: Maintaining adequate oxygenation is critical in COPD management.
3. A client with type 1 diabetes reports nausea, vomiting, and fruity-smelling breath. Which action
should the nurse take first?
A. Administer oral glucose
B. Provide a low-carbohydrate snack
C. Check blood glucose and for ketones ✔
D. Encourage exercise
Rationale: Symptoms indicate possible diabetic ketoacidosis, requiring urgent assessment.
4. A post-operative client is receiving morphine for pain. Which assessment is most important for the
nurse to monitor?
A. Blood pressure
B. Respiratory rate ✔
C. Bowel sounds
D. Heart rate
Rationale: Opioids can depress respiration; monitoring is essential for safety.
,5. A client with chronic kidney disease has a serum potassium of 6.2 mEq/L. Which action should the
nurse anticipate?
A. Administer potassium supplement
B. Encourage high-potassium foods
C. Prepare for interventions to lower potassium, such as insulin and glucose ✔
D. No action needed
Rationale: Hyperkalemia is life-threatening; immediate intervention is required.
6. A client with pneumonia is receiving IV antibiotics. Which assessment indicates a therapeutic
response?
A. Fever persists at 102°F
B. Decreased WBC count and improved oxygenation ✔
C. Increased cough with sputum
D. Hypotension
Rationale: Improvement in WBC and oxygenation indicates effective therapy.
7. A nurse is caring for a client with a nasogastric tube. Which action prevents aspiration?
A. Elevate the head of the bed 30–45° ✔
B. Flush the tube with cold water
C. Keep the client supine
D. Administer medications quickly
Rationale: Elevation reduces the risk of aspiration.
8. A client with heart failure is prescribed furosemide. Which electrolyte imbalance should the nurse
monitor?
A. Hyperkalemia
B. Hypokalemia ✔
C. Hypernatremia
D. Hypercalcemia
Rationale: Loop diuretics increase potassium excretion.
9. A client is scheduled for a colonoscopy. Which instruction is most important for bowel prep?
A. Eat high-fiber foods the day before
B. Take daily multivitamins
C. Follow the prescribed clear liquid diet and laxatives ✔
,D. Avoid drinking fluids
Rationale: Bowel cleansing is essential for procedure visualization.
10. A nurse is caring for a client with a chest tube. Which action indicates proper management?
A. Clamping the tube routinely
B. Maintaining the drainage system below chest level ✔
C. Stripping the tubing frequently
D. Connecting suction without order
Rationale: Proper positioning ensures drainage and prevents complications.
11. A client reports new-onset chest pain radiating to the left arm. What is the nurse’s first action?
A. Administer nitroglycerin
B. Obtain vital signs and ECG ✔
C. Encourage rest in bed
D. Document the findings
Rationale: Immediate assessment and ECG are critical for suspected MI.
12. A client receiving warfarin therapy has an INR of 5.2. Which action should the nurse take first?
A. Increase the dose
B. Administer vitamin K as prescribed ✔
C. Encourage high-vitamin K foods
D. No action needed
Rationale: INR above therapeutic range increases bleeding risk; vitamin K reverses warfarin effect.
13. A client with chronic kidney disease is on a low-protein diet. What is the rationale?
A. Prevent hyperglycemia
B. Reduce nitrogenous waste buildup ✔
C. Increase energy levels
D. Promote wound healing
Rationale: Limiting protein helps decrease waste accumulation in renal failure.
14. A post-op client has a temperature of 101.5°F and redness at the incision site. What is the priority
action?
A. Encourage fluid intake
B. Notify the provider for possible infection ✔
, C. Apply cold compresses
D. Encourage ambulation
Rationale: Signs indicate surgical site infection requiring prompt intervention.
15. A client with pneumonia has O2 saturation of 88% on room air. Which action should the nurse
take first?
A. Place on high-flow oxygen
B. Administer oxygen per prescription ✔
C. Encourage deep breathing exercises
D. Obtain chest X-ray
Rationale: Hypoxia is urgent; oxygen administration is priority.
16. A client with a history of MI reports dizziness and heart rate of 42 bpm. Which action is priority?
A. Encourage ambulation
B. Administer oral fluids
C. Assess for symptoms of decreased cardiac output and notify provider ✔
D. Encourage rest
Rationale: Bradycardia can compromise perfusion; prompt assessment is required.
17. A client with COPD has a PaO2 of 55 mmHg. Which intervention should the nurse implement?
A. Increase oxygen to 5 L/min without order
B. Administer prescribed oxygen and monitor response ✔
C. Encourage vigorous exercise
D. Restrict fluid intake
Rationale: Hypoxemia requires prescribed oxygen therapy with monitoring.
18. A client is receiving total parenteral nutrition (TPN). Which is the most important nursing action?
A. Change tubing daily
B. Monitor blood glucose ✔
C. Encourage oral intake
D. Limit fluid intake
Rationale: TPN contains high glucose; hyperglycemia is a major risk.
19. A client with a femur fracture has sudden shortness of breath, tachycardia, and confusion. What is
the priority action?
QUESTIONS AND CORRECT ANSWERS WITH RATIONALES
COVERING MOST TESTED QUESTIONS PERFECT FOR A+
GRADE
1. A client with chronic heart failure reports increasing shortness of breath and swelling in the legs.
Which assessment finding is most concerning?
A. Mild ankle edema
B. Jugular vein distension ✔
C. Dry cough
D. Occasional palpitations
Rationale: Jugular vein distension indicates fluid overload and worsening heart failure.
2. A nurse is caring for a client with COPD who is on oxygen. Which intervention should the nurse
prioritize?
A. Encourage deep breathing exercises
B. Administer bronchodilator
C. Monitor oxygen saturation and maintain prescribed oxygen ✔
D. Encourage fluid restriction
Rationale: Maintaining adequate oxygenation is critical in COPD management.
3. A client with type 1 diabetes reports nausea, vomiting, and fruity-smelling breath. Which action
should the nurse take first?
A. Administer oral glucose
B. Provide a low-carbohydrate snack
C. Check blood glucose and for ketones ✔
D. Encourage exercise
Rationale: Symptoms indicate possible diabetic ketoacidosis, requiring urgent assessment.
4. A post-operative client is receiving morphine for pain. Which assessment is most important for the
nurse to monitor?
A. Blood pressure
B. Respiratory rate ✔
C. Bowel sounds
D. Heart rate
Rationale: Opioids can depress respiration; monitoring is essential for safety.
,5. A client with chronic kidney disease has a serum potassium of 6.2 mEq/L. Which action should the
nurse anticipate?
A. Administer potassium supplement
B. Encourage high-potassium foods
C. Prepare for interventions to lower potassium, such as insulin and glucose ✔
D. No action needed
Rationale: Hyperkalemia is life-threatening; immediate intervention is required.
6. A client with pneumonia is receiving IV antibiotics. Which assessment indicates a therapeutic
response?
A. Fever persists at 102°F
B. Decreased WBC count and improved oxygenation ✔
C. Increased cough with sputum
D. Hypotension
Rationale: Improvement in WBC and oxygenation indicates effective therapy.
7. A nurse is caring for a client with a nasogastric tube. Which action prevents aspiration?
A. Elevate the head of the bed 30–45° ✔
B. Flush the tube with cold water
C. Keep the client supine
D. Administer medications quickly
Rationale: Elevation reduces the risk of aspiration.
8. A client with heart failure is prescribed furosemide. Which electrolyte imbalance should the nurse
monitor?
A. Hyperkalemia
B. Hypokalemia ✔
C. Hypernatremia
D. Hypercalcemia
Rationale: Loop diuretics increase potassium excretion.
9. A client is scheduled for a colonoscopy. Which instruction is most important for bowel prep?
A. Eat high-fiber foods the day before
B. Take daily multivitamins
C. Follow the prescribed clear liquid diet and laxatives ✔
,D. Avoid drinking fluids
Rationale: Bowel cleansing is essential for procedure visualization.
10. A nurse is caring for a client with a chest tube. Which action indicates proper management?
A. Clamping the tube routinely
B. Maintaining the drainage system below chest level ✔
C. Stripping the tubing frequently
D. Connecting suction without order
Rationale: Proper positioning ensures drainage and prevents complications.
11. A client reports new-onset chest pain radiating to the left arm. What is the nurse’s first action?
A. Administer nitroglycerin
B. Obtain vital signs and ECG ✔
C. Encourage rest in bed
D. Document the findings
Rationale: Immediate assessment and ECG are critical for suspected MI.
12. A client receiving warfarin therapy has an INR of 5.2. Which action should the nurse take first?
A. Increase the dose
B. Administer vitamin K as prescribed ✔
C. Encourage high-vitamin K foods
D. No action needed
Rationale: INR above therapeutic range increases bleeding risk; vitamin K reverses warfarin effect.
13. A client with chronic kidney disease is on a low-protein diet. What is the rationale?
A. Prevent hyperglycemia
B. Reduce nitrogenous waste buildup ✔
C. Increase energy levels
D. Promote wound healing
Rationale: Limiting protein helps decrease waste accumulation in renal failure.
14. A post-op client has a temperature of 101.5°F and redness at the incision site. What is the priority
action?
A. Encourage fluid intake
B. Notify the provider for possible infection ✔
, C. Apply cold compresses
D. Encourage ambulation
Rationale: Signs indicate surgical site infection requiring prompt intervention.
15. A client with pneumonia has O2 saturation of 88% on room air. Which action should the nurse
take first?
A. Place on high-flow oxygen
B. Administer oxygen per prescription ✔
C. Encourage deep breathing exercises
D. Obtain chest X-ray
Rationale: Hypoxia is urgent; oxygen administration is priority.
16. A client with a history of MI reports dizziness and heart rate of 42 bpm. Which action is priority?
A. Encourage ambulation
B. Administer oral fluids
C. Assess for symptoms of decreased cardiac output and notify provider ✔
D. Encourage rest
Rationale: Bradycardia can compromise perfusion; prompt assessment is required.
17. A client with COPD has a PaO2 of 55 mmHg. Which intervention should the nurse implement?
A. Increase oxygen to 5 L/min without order
B. Administer prescribed oxygen and monitor response ✔
C. Encourage vigorous exercise
D. Restrict fluid intake
Rationale: Hypoxemia requires prescribed oxygen therapy with monitoring.
18. A client is receiving total parenteral nutrition (TPN). Which is the most important nursing action?
A. Change tubing daily
B. Monitor blood glucose ✔
C. Encourage oral intake
D. Limit fluid intake
Rationale: TPN contains high glucose; hyperglycemia is a major risk.
19. A client with a femur fracture has sudden shortness of breath, tachycardia, and confusion. What is
the priority action?
