EVOLVE ELSEVIER HESI MED SURG ACTUAL EXAM
WITH 450 test bank EXAM verified QUESTIONS
AND ANSWERS WITH WELL-ELABORATED
RATIONALES/ EVOLVE HESI MEDICAL SURGICAL
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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
, EVOLVE ELSEVIER HESI MED SURG
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.
TEST BANK 2
, EVOLVE ELSEVIER HESI MED SURG
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?
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.
TEST BANK 3
, EVOLVE ELSEVIER HESI MED SURG
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.
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).
TEST BANK 4