EVOLVE MED SURG HESI ACTUAL EXAM REVIEW 140
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES 2026/2027 LATEST
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. - CORRECT ANSWER-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 - CORRECT ANSWER-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 - CORRECT ANSWER-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, 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. - CORRECT ANSWER-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 - CORRECT ANSWER-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. - CORRECT
ANSWER-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 - CORRECT ANSWER-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 - CORRECT ANSWER-Correct Answer: B
Rationale:The blood urea nitrogen (BUN) level indicates the effectiveness of the kidneys in filtering
waste from the blood. Dehydration, which could be caused by vomiting, would cause an increased
BUN level. Option A would affect serum enzyme levels, not the BUN level. Option C would primarily
affect the blood glucose level; renal failure that could increase the BUN level would be unlikely in a
client newly diagnosed with type 2 diabetes. Effects of option D might affect the complete blood
count (CBC) but would not directly increase the BUN level.
Which instruction is best for the nurse to provide to a client with emphysema and chronic fatigue?
, A."Pace your activities and schedule rest periods."
B."Increase the amount of oxygen you use at night."
C."Obtain medical evaluation for antibiotic therapy."
D."Reduce your intake of fluids containing caffeine." - CORRECT ANSWER-Correct Answer: A
Rationale:Manifestations of emphysema include an increase in AP diameter (referred to as a barrel
chest), nail bed clubbing, and fatigue. The nurse can provide instructions to promote energy
management, such as pacing activities and scheduling rest periods. Option B may result in a
decreased drive to breathe. The client is not exhibiting any symptoms of infection, so option C is not
necessary. Option D is less beneficial than option A.
Which nursing action would be appropriate for a client who is newly diagnosed with Cushing
syndrome?
A.Monitor blood glucose levels daily.
B.Increase intake of fluids high in potassium.
C.Encourage adequate rest between activities.
D.Offer the client a sodium-enriched menu. - CORRECT ANSWER-Correct Answer: A
Rationale: Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex.
Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of serum glucose levels
assesses for increased blood glucose levels so that treatment can begin early. A common finding in
Cushing syndrome is generalized edema. Although potassium is needed, it is generally obtained from
food intake, not by offering potassium-enhanced fluids. Fatigue is usually not an overwhelming
factor in Cushing syndrome, so an emphasis on the need for rest is not indicated. A low-calorie, low-
carbohydrate, low-sodium diet is not recommended.
During the change of shift report, the charge nurse reviews the infusions being received by clients on
the oncology unit. The client receiving which infusion should be assessed first?
A.Continuous IV infusion of magnesium
B.One-time infusion of albumin
C.Continuous epidural infusion of morphine
D.Intermittent infusion of IV vancomycin - CORRECT ANSWER-Correct Answer: C
Rationale: All four of these clients have the potential to have significant complications. The client
with the morphine epidural infusion is at highest risk for respiratory depression and should be
assessed first. Option A can cause hypotension. The client receiving option B is at lowest risk for
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES 2026/2027 LATEST
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. - CORRECT ANSWER-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 - CORRECT ANSWER-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 - CORRECT ANSWER-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, 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. - CORRECT ANSWER-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 - CORRECT ANSWER-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. - CORRECT
ANSWER-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 - CORRECT ANSWER-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 - CORRECT ANSWER-Correct Answer: B
Rationale:The blood urea nitrogen (BUN) level indicates the effectiveness of the kidneys in filtering
waste from the blood. Dehydration, which could be caused by vomiting, would cause an increased
BUN level. Option A would affect serum enzyme levels, not the BUN level. Option C would primarily
affect the blood glucose level; renal failure that could increase the BUN level would be unlikely in a
client newly diagnosed with type 2 diabetes. Effects of option D might affect the complete blood
count (CBC) but would not directly increase the BUN level.
Which instruction is best for the nurse to provide to a client with emphysema and chronic fatigue?
, A."Pace your activities and schedule rest periods."
B."Increase the amount of oxygen you use at night."
C."Obtain medical evaluation for antibiotic therapy."
D."Reduce your intake of fluids containing caffeine." - CORRECT ANSWER-Correct Answer: A
Rationale:Manifestations of emphysema include an increase in AP diameter (referred to as a barrel
chest), nail bed clubbing, and fatigue. The nurse can provide instructions to promote energy
management, such as pacing activities and scheduling rest periods. Option B may result in a
decreased drive to breathe. The client is not exhibiting any symptoms of infection, so option C is not
necessary. Option D is less beneficial than option A.
Which nursing action would be appropriate for a client who is newly diagnosed with Cushing
syndrome?
A.Monitor blood glucose levels daily.
B.Increase intake of fluids high in potassium.
C.Encourage adequate rest between activities.
D.Offer the client a sodium-enriched menu. - CORRECT ANSWER-Correct Answer: A
Rationale: Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex.
Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of serum glucose levels
assesses for increased blood glucose levels so that treatment can begin early. A common finding in
Cushing syndrome is generalized edema. Although potassium is needed, it is generally obtained from
food intake, not by offering potassium-enhanced fluids. Fatigue is usually not an overwhelming
factor in Cushing syndrome, so an emphasis on the need for rest is not indicated. A low-calorie, low-
carbohydrate, low-sodium diet is not recommended.
During the change of shift report, the charge nurse reviews the infusions being received by clients on
the oncology unit. The client receiving which infusion should be assessed first?
A.Continuous IV infusion of magnesium
B.One-time infusion of albumin
C.Continuous epidural infusion of morphine
D.Intermittent infusion of IV vancomycin - CORRECT ANSWER-Correct Answer: C
Rationale: All four of these clients have the potential to have significant complications. The client
with the morphine epidural infusion is at highest risk for respiratory depression and should be
assessed first. Option A can cause hypotension. The client receiving option B is at lowest risk for
