2022
Evolve HESI Med SURG
EXAM
100% Verified Q&A
, Evolve HESI Med SURG EXAM
Questions
□ The nurse is assessing a client's laboratory values
following administration of chemotherapy. Which lab value leads
the nurse to suspect that the client is experiencing tumor lysis
syndrome (TLS)?
A Serum PTT of 10 seconds.
B Serum calcium of 5 mg/dl. Correct
C Oxygen saturation of 90%.
D Hemoglobin of 10 g/dl.
□ TLS results in hyperkalemia, hypocalcemia, hyperuricemia,
and hyperphosphatemia. A serum calcium level of 5 (B), which is
low, is an indicator of possible tumorlysis syndrome. (A, C, and D)
are not particularly related to TLS. Awarded 0.0 points out of 1.0
possible points.
□ 2.ID: 6974889585A client is admitted to the hospital with a
diagnosis of severe acute diverticulitis. Which assessment finding
should the nurse expect this client to exhibit?
A Lower left quadrant pain and a low-grade fever. Correct
B Severe pain at McBurney's point and nausea.C
Abdominal pain and intermittent tenesmus.
D Exacerbations of severe diarrhea.
□ Left lower quadrant pain occurs with diverticulitis because the
sigmoid colon is the most common area for diverticula, and the
inflammation of diverticula causes a low-grade fever (A). (B) would
be indicative of appendicitis. (C and D) are symptoms exhibited with
ulcerative colitis.
Awarded 0.0 points out of 1.0 possible points.
□ 3.ID: 6974891763During CPR, when attempting to
ventilate a client's lungs, the nurse notes that the chest isnot
moving. What action should the nurse take first?
A Use a laryngoscope to check for a foreign body lodged in the
esophagus.
B Reposition the head to validate that the head is in the proper
position to open the airway. Correct
C Turn the client to the side and administer three back blows. D
Perform a finger sweep of the mouth to remove any vomitus.
□ The most frequent cause of inadequate aeration of the
, client's lungs during CPR is improper positioning of the head
resulting in occlusion of the airway (B). A foreign body can occlude
the airway, but this is not common unless choking preceded the
cardiac emergency, and (A, C and D) should not be the nurse's first
action. Awarded 0.0 points out of 1.0possible points.
□ 4.ID: 6974891794A client is admitted to the hospital witha
medical diagnosis of pneumococcal pneumonia. The nurseknows
that the prognosis for gram-negative pneumonias (such as E. coli,
Klebsiella, Pseudomonas, and Proteus) is very poor because
A they occur in the lower lobe alveoli which are more sensitiveto
infection.
B gram-negative organisms are more resistant to antibiotic
therapy. Correct
C they occur in healthy young adults who have recently been
debilitated by an upper respiratory infection.
D gram-negative pneumonias usually affect infants and small
children.
□ The gram-negative organisms are resistant to drug therapy
(B) which makes recovery very difficult. Gram- negative
pneumonias affect all lobes of the lung (A). The mean age for
contracting this type of pneumonia is 50 years(C and D), and it
usually strikes debilitated persons such as alcoholics, diabetics,
and those with chronic lung diseases.
Awarded 0.0 points out of 1.0 possible points.
□ 5.ID: 6974891705A client is placed on a mechanical
ventilator following a cerebral hemorrhage, and vecuronium
bromide (Norcuron) 0.04 mg/kg q12 hours IV is prescribed. What
is the priority nursing diagnosis for this client?
A Impaired communication related to paralysis of skeletal
muscles. Correct
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.
□ To increase the client's tolerance of endotracheal intubation
and/or mechanical ventilation, a skeletal-muscle relaxant, such as
vecuronium, is usually prescribed. Impaired
, communication (A) is a serious outcome because the client cannot
communicate his/her needs due to intubation and diaphragmatic
paralysis caused by the drug. Although this client might also
experience (D), it is not a priority when compared to (A). Infection is
not related to increased intracranial pressure (B). The mechanical
venilator provides consistent lung expansion (C). Awarded 0.0 points
out of 1.0possible points.
□ 6.ID: 6974890435When preparing a client who has had a
total laryngectomy for discharge, what instruction is most
important for the nurse to include in the discharge teaching?
A Recommend that the client carry suction equipment at alltimes.
B Instruct the client to have writing materials with him at alltimes.
C Tell the client to carry a medic alert card stating that he is atotal
neck breather. Correct
D Tell the client not to travel alone.
□ It is imperative that total neck breathers carry a medicalert
notice (C) so that if they have a cardiac arrest, mouth-to-neck
breathing can be done. Mouth-to-mouth resuscitation will not help
them. They do not need to carry
(A) nor refrain from (D). There are many alternative means of
communication for clients who have had a laryngectomy; depending
on (B) is probably the least effective. How do you know he can read
and write? Awarded 0.0 points out of 1.0 possible points.
□ 7.ID: 6974891729The nurse would be correct in withholding
a dose of digoxin in a client with congestive heart failure without
specific instruction from the healthcareprovider if the client's
A serum digoxin level is 1.5.
B blood pressure is 104/68.
C serum potassium level is 3. Correct
D apical pulse is 68/min.
□ Hypokalemia (C) can precipitate digitalis toxicity in persons
receiving digoxin which will increase the chance ofdangerous
dysrhythmias (normal potassium level is 3.5 to
Evolve HESI Med SURG
EXAM
100% Verified Q&A
, Evolve HESI Med SURG EXAM
Questions
□ The nurse is assessing a client's laboratory values
following administration of chemotherapy. Which lab value leads
the nurse to suspect that the client is experiencing tumor lysis
syndrome (TLS)?
A Serum PTT of 10 seconds.
B Serum calcium of 5 mg/dl. Correct
C Oxygen saturation of 90%.
D Hemoglobin of 10 g/dl.
□ TLS results in hyperkalemia, hypocalcemia, hyperuricemia,
and hyperphosphatemia. A serum calcium level of 5 (B), which is
low, is an indicator of possible tumorlysis syndrome. (A, C, and D)
are not particularly related to TLS. Awarded 0.0 points out of 1.0
possible points.
□ 2.ID: 6974889585A client is admitted to the hospital with a
diagnosis of severe acute diverticulitis. Which assessment finding
should the nurse expect this client to exhibit?
A Lower left quadrant pain and a low-grade fever. Correct
B Severe pain at McBurney's point and nausea.C
Abdominal pain and intermittent tenesmus.
D Exacerbations of severe diarrhea.
□ Left lower quadrant pain occurs with diverticulitis because the
sigmoid colon is the most common area for diverticula, and the
inflammation of diverticula causes a low-grade fever (A). (B) would
be indicative of appendicitis. (C and D) are symptoms exhibited with
ulcerative colitis.
Awarded 0.0 points out of 1.0 possible points.
□ 3.ID: 6974891763During CPR, when attempting to
ventilate a client's lungs, the nurse notes that the chest isnot
moving. What action should the nurse take first?
A Use a laryngoscope to check for a foreign body lodged in the
esophagus.
B Reposition the head to validate that the head is in the proper
position to open the airway. Correct
C Turn the client to the side and administer three back blows. D
Perform a finger sweep of the mouth to remove any vomitus.
□ The most frequent cause of inadequate aeration of the
, client's lungs during CPR is improper positioning of the head
resulting in occlusion of the airway (B). A foreign body can occlude
the airway, but this is not common unless choking preceded the
cardiac emergency, and (A, C and D) should not be the nurse's first
action. Awarded 0.0 points out of 1.0possible points.
□ 4.ID: 6974891794A client is admitted to the hospital witha
medical diagnosis of pneumococcal pneumonia. The nurseknows
that the prognosis for gram-negative pneumonias (such as E. coli,
Klebsiella, Pseudomonas, and Proteus) is very poor because
A they occur in the lower lobe alveoli which are more sensitiveto
infection.
B gram-negative organisms are more resistant to antibiotic
therapy. Correct
C they occur in healthy young adults who have recently been
debilitated by an upper respiratory infection.
D gram-negative pneumonias usually affect infants and small
children.
□ The gram-negative organisms are resistant to drug therapy
(B) which makes recovery very difficult. Gram- negative
pneumonias affect all lobes of the lung (A). The mean age for
contracting this type of pneumonia is 50 years(C and D), and it
usually strikes debilitated persons such as alcoholics, diabetics,
and those with chronic lung diseases.
Awarded 0.0 points out of 1.0 possible points.
□ 5.ID: 6974891705A client is placed on a mechanical
ventilator following a cerebral hemorrhage, and vecuronium
bromide (Norcuron) 0.04 mg/kg q12 hours IV is prescribed. What
is the priority nursing diagnosis for this client?
A Impaired communication related to paralysis of skeletal
muscles. Correct
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.
□ To increase the client's tolerance of endotracheal intubation
and/or mechanical ventilation, a skeletal-muscle relaxant, such as
vecuronium, is usually prescribed. Impaired
, communication (A) is a serious outcome because the client cannot
communicate his/her needs due to intubation and diaphragmatic
paralysis caused by the drug. Although this client might also
experience (D), it is not a priority when compared to (A). Infection is
not related to increased intracranial pressure (B). The mechanical
venilator provides consistent lung expansion (C). Awarded 0.0 points
out of 1.0possible points.
□ 6.ID: 6974890435When preparing a client who has had a
total laryngectomy for discharge, what instruction is most
important for the nurse to include in the discharge teaching?
A Recommend that the client carry suction equipment at alltimes.
B Instruct the client to have writing materials with him at alltimes.
C Tell the client to carry a medic alert card stating that he is atotal
neck breather. Correct
D Tell the client not to travel alone.
□ It is imperative that total neck breathers carry a medicalert
notice (C) so that if they have a cardiac arrest, mouth-to-neck
breathing can be done. Mouth-to-mouth resuscitation will not help
them. They do not need to carry
(A) nor refrain from (D). There are many alternative means of
communication for clients who have had a laryngectomy; depending
on (B) is probably the least effective. How do you know he can read
and write? Awarded 0.0 points out of 1.0 possible points.
□ 7.ID: 6974891729The nurse would be correct in withholding
a dose of digoxin in a client with congestive heart failure without
specific instruction from the healthcareprovider if the client's
A serum digoxin level is 1.5.
B blood pressure is 104/68.
C serum potassium level is 3. Correct
D apical pulse is 68/min.
□ Hypokalemia (C) can precipitate digitalis toxicity in persons
receiving digoxin which will increase the chance ofdangerous
dysrhythmias (normal potassium level is 3.5 to
