HESI Med Surg Evolve Questions And Correct Detailed Answers (Verified Answers) Already Graded A+

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HESI Med Surg Evolve Questions And Correct Detailed Answers (Verified Answers) Already Graded A+

• Which data would the nurse expect to find when reviewing laboratory values of an

80-year-old man who is in good health overall?

• Complete blood count reveals increased white blood cell (WBC) and decreased red

blood cell (RBC) counts.

• Chemistries reveal an increased serum bilirubin level with slightly increased liver

enzyme levels.

• Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria.
• Serum electrolytes reveal a decreased sodium level and increased potassium level.

Correct Answer: C

• A central venous catheter has been inserted via a jugular vein, and a radiograph has

confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication?

• Assess for signs of jugular venous distention.
• Obtain the needed intravenous solution.
• Flush the line with heparinized solution.
• Flush the line with normal saline.

Correct Answer: D

• 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?

• Prepare the client for a pericardial tap.

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• Administer intravenous furosemide (Lasix).
• Assist the client to cough and breathe deeply.
• Instruct the client to restrict oral fluid intake.

Correct Answer: A

• In assessing a client diagnosed with primary aldosteronism, the nurse expects the

laboratory test results to indicate a decreased serum level of which substance?

• Sodium
• Phosphate
• Potassium
• Glucose

Correct Answer: C

• A client is diagnosed with an acute small bowel obstruction. Which assessment

finding requires the most immediate intervention by the nurse?

• Fever of 102° F
• Blood pressure of 150/90 mm Hg
• Abdominal cramping
• Dry mucous membranes

Correct Answer: A

• A family member was taught to suction a client's tracheostomy prior to the client's

discharge from the hospital. Which observation by the nurse indicates that the family member is capable of correctly performing the suctioning technique?

• Turns on the continuous wall suction to 190 mm Hg.
• Inserts the catheter until resistance or coughing occurs.
• Withdraws the catheter while maintaining suctioning.
• Reclears the tracheostomy after suctioning the mouth.

Correct Answer: B

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• 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?

• Impaired communication related to paralysis of skeletal muscles
• High risk for infection related to increased intracranial pressure
• Potential for injury related to impaired lung expansion
• Social isolation related to inability to communicate

Correct Answer: A

• A postoperative client receives a Schedule II opioid analgesic for pain. Which

assessment finding requires the most immediate intervention by the nurse?

• Hypoactive bowel sounds with abdominal distention
• Client reports continued pain of 8 on a 10-point scale
• Respiratory rate of 12 breaths/min, with O2 saturation of 85%
• Client reports nausea after receiving the medication

Correct Answer: C

• The nurse receives the client's next scheduled bag of TPN labeled with the additive

NPH insulin. Which action should the nurse implement?

• Hang the solution at the current rate.
• Refrigerate the solution until needed.
• Prepare the solution with new tubing.
• Return the solution to the pharmacy.

Correct Answer: D

• When educating a client after a total laryngectomy, which instruction would be

most important for the nurse to include in the discharge teaching?

• Recommend that the client carry suction equipment at all times.
• Instruct the client to have writing materials with him at all times.
• Tell the client to carry a medical alert card that explains his condition.

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• Caution the client not to travel outside the United States alone.

Correct Answer: C

• The nurse witnesses a baseball player receive a blunt trauma to the back of the

head with a softball. What assessment data should the nurse collect immediately?

• Reactivity of deep tendon reflexes, comparing upper with lower extremities
• Vital sign readings, excluding blood pressure if needed equipment is unavailable
• Memory of events that occurred before and after the blow to the head
• Ability to open the eyes spontaneously before any tactile stimuli are given

Correct Answer: D

• A client diagnosed with angina pectoris complains of chest pain while ambulating

in the hallway. Which action should the nurse implement first?

• Support the client to a sitting position.
• Ask the client to walk slowly back to the room.
• Administer a sublingual nitroglycerin tablet.
• Provide oxygen via nasal cannula.

Correct Answer: A

• In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis

today, the nurse notes the absence of a thrill or bruit at the shunt site. What action should the nurse take?

• Advise the client that the shunt is intact and ready for dialysis as scheduled.
• Encourage the client to keep the shunt site elevated above the level of the heart.
• Notify the health care provider of the findings immediately.
• Flush the site at least once with a heparinized saline solution.

Correct Answer: C

• 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?

• Change in level of consciousness