HESI med surg evolve Exam Questions
Answered with Rationales (97% score)
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.
,HESI med surg evolve Exam Questions
Answered with Rationales (97% score)
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. - 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
,HESI med surg evolve Exam Questions
Answered with Rationales (97% score)
C. Respiratory rate of 12 breaths/min, with O2 saturation
of 85%
D. Client reports nausea after receiving the medication -
Correct Answer ✅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
, HESI med surg evolve Exam Questions
Answered with Rationales (97% score)
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 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.
Answered with Rationales (97% score)
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.
,HESI med surg evolve Exam Questions
Answered with Rationales (97% score)
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. - 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
,HESI med surg evolve Exam Questions
Answered with Rationales (97% score)
C. Respiratory rate of 12 breaths/min, with O2 saturation
of 85%
D. Client reports nausea after receiving the medication -
Correct Answer ✅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
, HESI med surg evolve Exam Questions
Answered with Rationales (97% score)
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 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.
