ACTUAL EVOLVE ELSEVIER HESI MED SURG EXAM
2024-2025 COMPLETE REAL QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(CORRECT VERIFIED SOLUTIONS) A NEW
UPDATED VERSION |GUARANTEED PASS.
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
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.
,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?
A. Turns on the continuous wall suction to 190 mm Hg.
B. Inserts the catheter until resistance or coughing occurs.
C. Withdraws the catheter while maintaining suctioning.
D. Reclears the tracheostomy after suctioning the mouth.
Answer- B
Rationale:Option B indicates correct technique for performing
suctioning. Suction pressure should be between 80 and 120 mm Hg, not
190 mm Hg. The catheter should be withdrawn 1 to 2 cm at a time with
intermittent, not continuous, suction. Option D introduces pathogens
unnecessarily into the tracheobronchial tree.
A client is diagnosed with an acute small bowel obstruction. Which
assessment finding requires the most immediate intervention by the
nurse?
A. Fever of 102° F
B. Blood pressure of 150/90 mm Hg
C. Abdominal cramping
,D. Dry mucous membranes
Answer- A
Rationale:A sudden increase in temperature is an indicator of
peritonitis. The nurse should notify the health care provider
immediately. Options B, C, and D are also findings that require
intervention by the nurse but are of less priority than option A. Option
B may indicate a hypertensive condition but is not as acute a condition
as peritonitis. Option C is an expected finding in clients with small
bowel obstruction and may require medication. Option D indicates
probable fluid volume deficit, which requires fluid volume replacement.
In assessing a client diagnosed with primary aldosteronism, the nurse
expects the laboratory test results to indicate a decreased serum level
of which substance?
A. Sodium
B. Phosphate
C. Potassium D. Glucose
Answer- C
Rationale: Clients with primary aldosteronism exhibit a profound
decline in serum levels of potassium; hypokalemia; hypertension is the
most prominent and universal sign. The serum sodium level is normal
, or elevated, depending on the amount of water resorbed with the
sodium. Option B is influenced by parathyroid hormone (PTH). Option D
is not affected by primary aldosteronism.
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.
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.
2024-2025 COMPLETE REAL QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(CORRECT VERIFIED SOLUTIONS) A NEW
UPDATED VERSION |GUARANTEED PASS.
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
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.
,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?
A. Turns on the continuous wall suction to 190 mm Hg.
B. Inserts the catheter until resistance or coughing occurs.
C. Withdraws the catheter while maintaining suctioning.
D. Reclears the tracheostomy after suctioning the mouth.
Answer- B
Rationale:Option B indicates correct technique for performing
suctioning. Suction pressure should be between 80 and 120 mm Hg, not
190 mm Hg. The catheter should be withdrawn 1 to 2 cm at a time with
intermittent, not continuous, suction. Option D introduces pathogens
unnecessarily into the tracheobronchial tree.
A client is diagnosed with an acute small bowel obstruction. Which
assessment finding requires the most immediate intervention by the
nurse?
A. Fever of 102° F
B. Blood pressure of 150/90 mm Hg
C. Abdominal cramping
,D. Dry mucous membranes
Answer- A
Rationale:A sudden increase in temperature is an indicator of
peritonitis. The nurse should notify the health care provider
immediately. Options B, C, and D are also findings that require
intervention by the nurse but are of less priority than option A. Option
B may indicate a hypertensive condition but is not as acute a condition
as peritonitis. Option C is an expected finding in clients with small
bowel obstruction and may require medication. Option D indicates
probable fluid volume deficit, which requires fluid volume replacement.
In assessing a client diagnosed with primary aldosteronism, the nurse
expects the laboratory test results to indicate a decreased serum level
of which substance?
A. Sodium
B. Phosphate
C. Potassium D. Glucose
Answer- C
Rationale: Clients with primary aldosteronism exhibit a profound
decline in serum levels of potassium; hypokalemia; hypertension is the
most prominent and universal sign. The serum sodium level is normal
, or elevated, depending on the amount of water resorbed with the
sodium. Option B is influenced by parathyroid hormone (PTH). Option D
is not affected by primary aldosteronism.
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.
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.
