HESI Med Surg Evolve Exam Questions with Solutions 2024.
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HESI Med Surg Evolve
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HESI Med Surg Evolve
HESI Med Surg Evolve Exam Questions with Solutions 2024.HESI Med Surg Evolve Exam Questions with Solutions 2024.HESI Med Surg Evolve Exam Questions with Solutions 2024.HESI Med Surg Evolve Exam Questions with Solutions 2024.HESI Med Surg Evolve Exam Questions with Solutions 2024.
HESI Med Surg Evolve Exam Questions with Solutions 2024.
When educating a client after a total laryngectomy, which instruction would be 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 medical alert card that explains his condition.
D. Caution the client not to travel outside the United States alone. - Correct Answer C
Rationale: Neck breathers carry a medical alert card that notifies health care personnel of the need to use mouth to stoma breathing in the event of a cardiac arrest in this client. Mouth to mouth resuscitation will not establish a patent airway. Options A and D are not necessary. There are many alternative means of communication for clients who have had a laryngectomy; dependence on writing messages is probably the least effective.
The nurse receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse implement? HESI Med Surg Evolve Exam Questions with Solutions 2024.
A. Hang the solution at the current rate.
B. Refrigerate the solution until needed.
C.Prepare the solution with new tubing.
D.Return the solution to the pharmacy. - Correct Answer D
Rationale: Only regular insulin is administered by the IV route, so the TPN solution containing NPH insulin should be returned to the pharmacy. Options A, B, and C are not indicated because the solution should not be administered.
A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by
the nurse?
A. Hypoactive bowel sounds with abdominal distention
B. Client reports continued pain of 8 on a 10-point scale
C. Respiratory rate of 12 breaths/min, with O2 saturation of 85%
D. Client reports nausea after receiving the medication - Correct Answer C HESI Med Surg Evolve Exam Questions with Solutions 2024.
Rationale: Administration of a Schedule II opioid analgesic can result in respiratory depression, which requires immediate intervention by the nurse to prevent respiratory arrest. Options A, B, and D require action by the nurse but are of less priority than option C.
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 - Correct 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 HESI Med Surg Evolve Exam Questions with Solutions 2024.
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. - Correct 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.
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