EVOLVE MED SURG HESI EXAM QUESTIONS AND
CORRECT ANSWERS WITH RATIONALES |ALL GRADED A+
The nurse is concerned about infection for a client after an
esophagogastrostomy for esophageal cancer. Which actions should the
nurse include in the client's plan of care? (Select all that apply.)
A. Frequent oral care every 2 hours while awake.
B. Use incentive spirometer every 2 hours.
C. Empty contents from NG tube every 8 hours.
D. Ambulate within 1 hour of return from the PACU.
E. Limit visitors until postoperative day 2. - ANS.... -Correct Answer: A, B,C
Rationale: One hour post op is too soon to ambulate for this client. Visitors
help support the patient and are encouraged to visit. Oral care is necessary
as the client will be NPO. To decrease the risk of infection post operatively,
implement routine pulmonary exercises. The client will have an NG tube in
place, likely to intermittent suction, to decompress the stomach post-
surgery.
The client is return demonstrating wrapping of the left limb amputated
above the knee. The nurse evaluates the client is starting the wrapping
method correctly when the client places the end of the bandage at which
point?
A. Around the waist
B. At the inner aspect of the left stump
C. At the outer aspect of the left stump
D. At the left groin area - ANS.... -Correct Answer: A
,Rationale: The waist is the anchor point for the bandage for an above the
knee amputation.
A nurse is assisting an 82-year-old client with ambulation and is concerned
that the client may fall. Which area contains the older person's center of
gravity?
A. Head and neck
B. Upper torso
C. Bilateral arms
D. Feet and legs - ANS.... -Correct Answer: B
Rationale: Stooped posture results in the upper torso becoming the center
of gravity for older persons. The center of gravity for adults is the hips.
However, as a person grows older, a stooped posture is common because
of changes caused by osteoporosis and normal bone degeneration.
Furthermore, the knees, hips, and elbows flex. The head and neck and feet
and legs are not the center of gravity in the older adult. Although the arms
comprise a part of the upper torso, they do not reflect the best and most
complete answer.
A client with hypertension has been receiving Ramipril, 5 mg PO, and daily
for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the
client's blood pressure is 120/70 mm Hg. Which action should the nurse
take?
A. Administer the prescribed dose at the scheduled time.
B. Hold the dose and contact the health care provider.
C. Hold the dose and recheck the blood pressure in 1 hour.
D. Check the health care provider's prescription to clarify the dose. -
ANS.... -Correct Answer: A
Rationale: The client's blood pressure is within normal limits, indicating that
the ramipril, an antihypertensive, is having the desired effect and should be
,administered. Options B and C would be appropriate if the client's blood
pressure was excessively low (<100 mm Hg systolic) or if the client were
exhibiting signs of hypotension such as dizziness. This prescribed dose is
within the normal dosage range, as defined by the manufacturer; therefore,
option D is not necessary
The nurse is providing care for a client diagnosed with trigeminal neuralgia
(tic douloureux). Which symptoms will the nurse be looking for in the
focused assessment related to this condition? (Select all that apply.)
A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in chewing
E. Tinnitus
F. Hearing difficulties - ANS.... -Correct Answer: A, B
Rationale: Trigeminal neuralgia is characterized by paroxysms of pain,
similar to an electric shock, in the area innervated by one or more branches
of the trigeminal nerve (cranial V). The remaining symptoms are not related
to trigeminal neuralgia.
In caring for a client with acute diverticulitis, which assessment data
warrants an immediate nursing action?
A. The client has a rigid hard abdomen and elevated WBC.
B. The client has left lower quadrant pain and an elevated temperature.
C. The client is refusing to eat any of the meal and is complaining of
nausea.
D. The client has not had a bowel movement in 2 days and has a soft
abdomen. - ANS.... -Correct Answer: A
, Rationale: A hard rigid abdomen and elevated WBC is indicative of
peritonitis, which is a medical emergency and should be reported to the
health care provider immediately. Options B and C are expected clinical
manifestations of diverticulitis. Option D does not warrant immediate
intervention.
The nurse is caring for a client with a fractured right elbow. Which
assessment finding has the highest priority and requires immediate
intervention?
A. Ecchymosis over the right elbow area
B. Deep unrelenting pain in the right arm
C. An edematous right elbow
D. The presence of crepitus in the right elbow - ANS.... -Correct Answer: B
Rationale: Compartment syndrome is a condition involving increased
pressure and constriction of the nerves and vessels within an anatomic
compartment, causing pain uncontrolled by opioids and neurovascular
compromise. Option A is an expected finding. Option C related to
compartment syndrome cannot be seen, and any visible edema is an
expected finding related to the injury. Option D is an expected finding.
The nurse notes that a client who is scheduled for surgery the next morning
has an elevated blood urea nitrogen (BUN) level. Which condition is most
likely to have contributed to this finding?
A. Myocardial infarction 2 months ago
B. Anorexia and vomiting for the past 2 days
C. Recently diagnosed type 2 diabetes mellitus
D. Skeletal traction for a right hip fracture - ANS.... -Correct Answer: B
CORRECT ANSWERS WITH RATIONALES |ALL GRADED A+
The nurse is concerned about infection for a client after an
esophagogastrostomy for esophageal cancer. Which actions should the
nurse include in the client's plan of care? (Select all that apply.)
A. Frequent oral care every 2 hours while awake.
B. Use incentive spirometer every 2 hours.
C. Empty contents from NG tube every 8 hours.
D. Ambulate within 1 hour of return from the PACU.
E. Limit visitors until postoperative day 2. - ANS.... -Correct Answer: A, B,C
Rationale: One hour post op is too soon to ambulate for this client. Visitors
help support the patient and are encouraged to visit. Oral care is necessary
as the client will be NPO. To decrease the risk of infection post operatively,
implement routine pulmonary exercises. The client will have an NG tube in
place, likely to intermittent suction, to decompress the stomach post-
surgery.
The client is return demonstrating wrapping of the left limb amputated
above the knee. The nurse evaluates the client is starting the wrapping
method correctly when the client places the end of the bandage at which
point?
A. Around the waist
B. At the inner aspect of the left stump
C. At the outer aspect of the left stump
D. At the left groin area - ANS.... -Correct Answer: A
,Rationale: The waist is the anchor point for the bandage for an above the
knee amputation.
A nurse is assisting an 82-year-old client with ambulation and is concerned
that the client may fall. Which area contains the older person's center of
gravity?
A. Head and neck
B. Upper torso
C. Bilateral arms
D. Feet and legs - ANS.... -Correct Answer: B
Rationale: Stooped posture results in the upper torso becoming the center
of gravity for older persons. The center of gravity for adults is the hips.
However, as a person grows older, a stooped posture is common because
of changes caused by osteoporosis and normal bone degeneration.
Furthermore, the knees, hips, and elbows flex. The head and neck and feet
and legs are not the center of gravity in the older adult. Although the arms
comprise a part of the upper torso, they do not reflect the best and most
complete answer.
A client with hypertension has been receiving Ramipril, 5 mg PO, and daily
for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the
client's blood pressure is 120/70 mm Hg. Which action should the nurse
take?
A. Administer the prescribed dose at the scheduled time.
B. Hold the dose and contact the health care provider.
C. Hold the dose and recheck the blood pressure in 1 hour.
D. Check the health care provider's prescription to clarify the dose. -
ANS.... -Correct Answer: A
Rationale: The client's blood pressure is within normal limits, indicating that
the ramipril, an antihypertensive, is having the desired effect and should be
,administered. Options B and C would be appropriate if the client's blood
pressure was excessively low (<100 mm Hg systolic) or if the client were
exhibiting signs of hypotension such as dizziness. This prescribed dose is
within the normal dosage range, as defined by the manufacturer; therefore,
option D is not necessary
The nurse is providing care for a client diagnosed with trigeminal neuralgia
(tic douloureux). Which symptoms will the nurse be looking for in the
focused assessment related to this condition? (Select all that apply.)
A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in chewing
E. Tinnitus
F. Hearing difficulties - ANS.... -Correct Answer: A, B
Rationale: Trigeminal neuralgia is characterized by paroxysms of pain,
similar to an electric shock, in the area innervated by one or more branches
of the trigeminal nerve (cranial V). The remaining symptoms are not related
to trigeminal neuralgia.
In caring for a client with acute diverticulitis, which assessment data
warrants an immediate nursing action?
A. The client has a rigid hard abdomen and elevated WBC.
B. The client has left lower quadrant pain and an elevated temperature.
C. The client is refusing to eat any of the meal and is complaining of
nausea.
D. The client has not had a bowel movement in 2 days and has a soft
abdomen. - ANS.... -Correct Answer: A
, Rationale: A hard rigid abdomen and elevated WBC is indicative of
peritonitis, which is a medical emergency and should be reported to the
health care provider immediately. Options B and C are expected clinical
manifestations of diverticulitis. Option D does not warrant immediate
intervention.
The nurse is caring for a client with a fractured right elbow. Which
assessment finding has the highest priority and requires immediate
intervention?
A. Ecchymosis over the right elbow area
B. Deep unrelenting pain in the right arm
C. An edematous right elbow
D. The presence of crepitus in the right elbow - ANS.... -Correct Answer: B
Rationale: Compartment syndrome is a condition involving increased
pressure and constriction of the nerves and vessels within an anatomic
compartment, causing pain uncontrolled by opioids and neurovascular
compromise. Option A is an expected finding. Option C related to
compartment syndrome cannot be seen, and any visible edema is an
expected finding related to the injury. Option D is an expected finding.
The nurse notes that a client who is scheduled for surgery the next morning
has an elevated blood urea nitrogen (BUN) level. Which condition is most
likely to have contributed to this finding?
A. Myocardial infarction 2 months ago
B. Anorexia and vomiting for the past 2 days
C. Recently diagnosed type 2 diabetes mellitus
D. Skeletal traction for a right hip fracture - ANS.... -Correct Answer: B
