EVOLVE ELSEVIER HESI MED SURG ACTUAL EXAM
WITH 150 REAL EXAM QUESTIONS AND CORRECT
ANSWERS WITH WELL-ELABORATED RATIONALES/
EVOLVE HESI MEDICAL SURGICAL LATEST EXAM
2024
Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old man who is in
good health overall?
A. Complete blood count reveals increased white blood cell (WBC) and decreased red blood cell (RBC)
counts.
B. Chemistries reveal an increased serum bilirubin level with slightly increased liver enzyme levels.
C. Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria.
D. Serum electrolytes reveal a decreased sodium level and increased potassium level.
C
Rationale: In older adults, the protein found in urine slightly rises, probably as a result of kidney changes or
subclinical urinary tract infections, and clients frequently experience asymptomatic bacteriuria and pyuria as
a result of incomplete bladder emptying. Laboratory findings in options A, B, and D are not considered to be
normal findings in an older adult.
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?
A. Reactivity of deep tendon reflexes, comparing upper with lower extremities
B. Vital sign readings, excluding blood pressure if needed equipment is unavailable
C. Memory of events that occurred before and after the blow to the head
D. Ability to open the eyes spontaneously before any tactile stimuli are given
D
Rationale: The level of consciousness (LOC) should be established immediately when a head injury has
occurred. Spontaneous eye opening is a simple measure of alertness that indicates that arousal mechanisms
are intact. Option A is not the best indicator of LOC. Although option B is important, vital signs are not the
best indicators of LOC and can be evaluated after the client's LOC has been determined. Option C can be
assessed after LOC has been established by assessing eye opening.
A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which
action should the nurse implement first?
A. Support the client to a sitting position.
B. Ask the client to walk slowly back to the room.
C. Administer a sublingual nitroglycerin tablet.
D. Provide oxygen via nasal cannula.
A
Rationale: The nurse should safely assist the client to a resting position and then perform options C and D.
The client must cease all activity immediately, which will decrease the oxygen requirement of the myocardial
muscle. After these interventions are implemented, the client can be escorted back to the room via
wheelchair or stretcher.
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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?
A. Advise the client that the shunt is intact and ready for dialysis as scheduled.
B. Encourage the client to keep the shunt site elevated above the level of the heart.
,C. Notify the health care provider of the findings immediately.
D. Flush the site at least once with a heparinized saline solution.
C
Rationale: Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse should notify the
health care provider so that intervention can be initiated to restore function of the shunt. Option A is incorrect.
Option B will not resolve the obstruction. An AV shunt is internal and cannot be flushed without access using
special needles.
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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?
A. Change in level of consciousness
B. Increasing muscular weakness
C. Changes in pupil size bilaterally
D. Progressive nuchal rigidity
A
Rationale: A decrease or change in the level of consciousness is usually the first indication of neurologic
deterioration. Options B and C may also occur but are much less likely to be the first sign of neurologic
compromise. Option D is often a sign of meningitis.
What is the most important nursing priority for a client who has been admitted for a possible kidney stone?
A. Reducing dairy products in the diet
B. Straining all urine
C. Measuring intake and output
D. Increasing fluid intake
B
Rationale: Straining all urine is the most important nursing action to take in this case. Encouraging fluid
intake is important for any client who may have a kidney stone, but it is even more important to strain all
urine. Straining urine will enable the nurse to determine when the kidney stone has been passed and may
prevent the need for surgery. Option C is not the highest priority action. Option A is usually not recommended
until the stone is obtained and the content of the stone is determined. Even then, dietary restrictions are
controversial.
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During the shift report, the charge nurse informs a nurse that she has been assigned to another unit for the
day. The nurse begins to sigh deeply and tosses about her belongings as she prepares to leave, making it
known that she is very unhappy about being floated to the other unit. What is the best immediate action for
the charge nurse to take?
A. Continue with the shift report and talk to the nurse about the incident at a later time.
B. Ask the nurse to call the house supervisor to see if she must be reassigned.
C. Stop the shift report and remind the nurse that all staff are floated equally.
D. Inform the nurse that her behavior is disruptive to the rest of the staff.
A
Rationale: Continuing with the shift report is the best immediate action because it allows the nurse who was
floated some cooling off time. At a later time (after the nurse has cooled off) the charge nurse should discuss
the conduct of the nurse in private. Option B encourages the nurse to shirk the float assignment. Option C is
disruptive. Reprimanding the nurse in front of the staff would increase the nurse's hostility, so the nurse
should be counseled in private.
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.
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?
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.
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.
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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
C
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
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.
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
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
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.
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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.
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.
