HESI EVOLVE Questions
□ The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)?
A Serum PTT of 10 seconds.
B Serum calcium of 5 mg/dl. Correct
C Oxygen...
hesi evolve questions □ the nurse is assessing a clients laboratory values following administration of chemotherapy which lab value leads the nurse to suspect that the clie
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HESI EVOLVE Questions
□ The nurse is assessing a client's laboratory values
following administration of chemotherapy. Which lab value
leads the nurse to suspect that the client is experiencing
tumor lysis syndrome (TLS)?
A Serum PTT of 10 seconds.
B Serum calcium of 5 mg/dl. Correct
C Oxygen saturation of 90%.
D Hemoglobin of 10 g/dl.
□ TLS results in hyperkalemia, hypocalcemia,
hyperuricemia, and hyperphosphatemia. A serum calcium
level of 5 (B), which is low, is an indicator of possible
tumor lysis syndrome. (A, C, and D) are not particularly
related to TLS. Awarded 0.0 points out of 1.0 possible
points.
□ 2.ID: 6974889585A client is admitted to the hospital with
a diagnosis of severe acute diverticulitis. Which assessment
finding should the nurse expect this client to exhibit?
A Lower left quadrant pain and a low-grade fever. Correct
B Severe pain at McBurney's point and
nausea. C Abdominal pain and intermittent tenesmus.
D Exacerbations of severe diarrhea.
□ Left lower quadrant pain occurs with diverticulitis
because the sigmoid colon is the most common area for
diverticula, and the inflammation of diverticula causes a low-
grade fever (A). (B) would be indicative of appendicitis. (C
and D) are symptoms exhibited with ulcerative colitis.
Awarded 0.0 points out of 1.0 possible points.
□ 3.ID: 6974891763During CPR, when attempting to
ventilate a client's lungs, the nurse notes that the chest is
not moving. What action should the nurse take first?
A Use a laryngoscope to check for a foreign body lodged in
the esophagus.
B Reposition the head to validate that the head is in the proper
position to open the airway. Correct
C Turn the client to the side and administer three back blows.
D Perform a finger sweep of the mouth to remove any vomitus.
□ The most frequent cause of inadequate aeration of the
, client's lungs during CPR is improper positioning of the head
resulting in occlusion of the airway (B). A foreign body can
occlude the airway, but this is not common unless choking
preceded the cardiac emergency, and (A, C and D) should
not be the nurse's first action. Awarded 0.0 points out of 1.0
possible points.
□ 4.ID: 6974891794A client is admitted to the hospital with
a medical diagnosis of pneumococcal pneumonia. The
nurse knows that the prognosis for gram-negative
pneumonias (such as E. coli, Klebsiella, Pseudomonas, and
Proteus) is very poor because
A they occur in the lower lobe alveoli which are more sensitive
to infection.
B gram-negative organisms are more resistant to antibiotic
therapy. Correct
C they occur in healthy young adults who have recently been
debilitated by an upper respiratory infection.
D gram-negative pneumonias usually affect infants and small
children.
□ The gram-negative organisms are resistant to drug
therapy (B) which makes recovery very difficult. Gram-
negative pneumonias affect all lobes of the lung (A). The
mean age for contracting this type of pneumonia is 50
years (C and D), and it usually strikes debilitated persons
such as alcoholics, diabetics, and those with chronic lung
diseases.
Awarded 0.0 points out of 1.0 possible points.
□ 5.ID: 6974891705A client is placed on a mechanical
ventilator following a cerebral hemorrhage, and vecuronium
bromide (Norcuron) 0.04 mg/kg q12 hours IV is prescribed.
What is the priority nursing diagnosis for this client?
A Impaired communication related to paralysis of skeletal
muscles. Correct
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.
□ To increase the client's tolerance of endotracheal
intubation and/or mechanical ventilation, a skeletal-muscle
relaxant, such as vecuronium, is usually prescribed. Impaired
, communication (A) is a serious outcome because the client
cannot communicate his/her needs due to intubation and
diaphragmatic paralysis caused by the drug. Although this
client might also experience (D), it is not a priority when
compared to (A). Infection is not related to increased
intracranial pressure (B). The mechanical venilator provides
consistent lung expansion (C). Awarded 0.0 points out of 1.0
possible points.
□ 6.ID: 6974890435When preparing a client who has had a
total laryngectomy for discharge, what instruction is most
important for the nurse to include in the discharge teaching?
A Recommend that the client carry suction equipment at all
times.
B Instruct the client to have writing materials with him at
all times.
C Tell the client to carry a medic alert card stating that he is
a total neck breather. Correct
D Tell the client not to travel alone.
□ It is imperative that total neck breathers carry a medic
alert notice (C) so that if they have a cardiac arrest, mouth-
to-neck breathing can be done. Mouth-to-mouth
resuscitation will not help them. They do not need to carry
(A) nor refrain from (D). There are many alternative means of
communication for clients who have had a laryngectomy;
depending on (B) is probably the least effective. How do you
know he can read and write? Awarded 0.0 points out of 1.0
possible points.
□ 7.ID: 6974891729The nurse would be correct in
withholding a dose of digoxin in a client with congestive
heart failure without specific instruction from the
healthcare provider if the client's
A serum digoxin level is 1.5.
B blood pressure is 104/68.
C serum potassium level is 3. Correct
D apical pulse is 68/min.
□ Hypokalemia (C) can precipitate digitalis toxicity in
persons receiving digoxin which will increase the chance of
dangerous dysrhythmias (normal potassium level is 3.5 to
, 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2
ng/ml (toxic levels=>2 ng/ml); (A) is within this range. (B)
would not warrant the nurse withholding the digoxin. The
nurse should withhold the digoxin if the apical pulse is less
than 60/min (D). Awarded 0.0 points out of 1.0 possible
points.
□ 8.ID: 6974890473After the fourth dose of gentamicin
sulfate (Garamycin) IV, the nurse plans to draw blood
samples to determine peak and trough levels. When are the
best times to draw these samples?
A 15 minutes before and 15 minutes after the next
dose. B One hour before and one hour after the next dose.
C 5 minutes before and 30 minutes after the next dose. Correct
D 30 minutes before and 30 minutes after the next dose.
□ Peak drug serum levels are achieved 30 minutes after
IV administration of aminoglycosides. The best time to draw
a trough is the closest time to the next administration (C).
(A, B, and D) are not as good a time to draw the trough as
(C). (B and D) are not the best times to draw the peak of an
aminoglycoside that has been administered IV. Awarded 0.0
points out of 1.0 possible points.
□ 9.ID: 6974891711A client has undergone insertion of a
permanent pacemaker. When developing a discharge
teaching plan, the nurse writes a goal of, "The client will
verbalize symptoms of pacemaker failure." Which symptoms
are most important to teach the client?
A Facial flushing.
B Fever.
C Pounding headache.
D Feelings of dizziness. Correct
□ Feelings of dizziness (D) may occur as the result of
a decreased heart rate, leading to decreased cardiac
output. (A and C) will not occur as the result of pacemaker
failure.
(B) may be an indication of infection postoperatively, but is
not an indication of pacemaker failure. Awarded 0.0 points
out of 1.0 possible points.
□ 10.ID: 6974890487A client with heart disease is on a
continuous telemetry monitor and has developed sinus
bradycardia. In determining the possible cause of the
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