EVOLVE ELSEVIER HESI MED SURG ACTUAL EXAM WITH 50
REAL EXAM QUESTIONS AND CORRECT ANSWERS WITH WELL-
ELABORATED RATIONALES/ EVOLVE HESI MEDICAL SURGICAL
LATEST EXAM 2025
1. A nurse is caring for a client who is receiving a blood
transfusion and develops chills, fever, and back pain. What is
the priority nursing action?
a) Discontinue the transfusion immediately
b) Administer acetaminophen for the fever
c) Obtain a blood sample for crossmatch
d) Notify the healthcare provider
Answer: a) Discontinue the transfusion immediately
Rationale: The symptoms of chills, fever, and back pain are
indicative of a transfusion reaction. The nurse should
immediately stop the transfusion and maintain an IV line with
normal saline to prevent further complications. After
discontinuing the transfusion, the nurse can notify the
healthcare provider, obtain a blood sample, and treat
symptoms as ordered.
2. A nurse is caring for a client who has a new diagnosis of heart
failure. Which of the following instructions should the nurse
include in the discharge teaching?
,a) "You should weigh yourself daily at the same time and report
a gain of 2 pounds in one day."
b) "You should limit your fluid intake to 3 liters per day."
c) "You can increase your sodium intake to enhance your
energy."
d) "Take your diuretic in the evening to avoid nocturia."
Answer: a) "You should weigh yourself daily at the same time
and report a gain of 2 pounds in one day."
Rationale: Weight gain is an early indicator of fluid retention in
heart failure, and the client should monitor their weight daily. A
gain of 2 pounds in one day may indicate fluid overload, which
needs to be reported. Fluid intake should be restricted based on
the healthcare provider's orders, and sodium intake should be
reduced. Diuretics should be taken in the morning to avoid
nocturia.
3. A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy at home. The nurse should instruct
the client to:
a) Use the oxygen when feeling short of breath
b) Keep the oxygen tank in the bedroom while sleeping
c) Adjust the oxygen flow rate as needed based on symptoms
d) Avoid smoking while using oxygen
Answer: d) Avoid smoking while using oxygen
Rationale: Oxygen supports combustion and smoking in the
, presence of oxygen is a fire hazard. The client should never
smoke while using oxygen. The nurse should also educate the
client on using oxygen as prescribed and avoiding adjustments
without consultation with the healthcare provider.
4. A nurse is caring for a client with a wound infection. Which of
the following is the most appropriate method for assessing the
severity of the infection?
a) Observing the appearance of the wound
b) Assessing the client's temperature
c) Checking the white blood cell count
d) Collecting a wound culture
Answer: d) Collecting a wound culture
Rationale: A wound culture is the best way to assess the
causative organism and guide appropriate antibiotic therapy.
While appearance, temperature, and white blood cell count are
important for monitoring infection, a culture will provide
definitive information.
5. A nurse is caring for a client with a deep vein thrombosis
(DVT). Which of the following should the nurse include in the
care plan?
a) Apply heat to the affected limb
b) Encourage bed rest with the leg elevated
REAL EXAM QUESTIONS AND CORRECT ANSWERS WITH WELL-
ELABORATED RATIONALES/ EVOLVE HESI MEDICAL SURGICAL
LATEST EXAM 2025
1. A nurse is caring for a client who is receiving a blood
transfusion and develops chills, fever, and back pain. What is
the priority nursing action?
a) Discontinue the transfusion immediately
b) Administer acetaminophen for the fever
c) Obtain a blood sample for crossmatch
d) Notify the healthcare provider
Answer: a) Discontinue the transfusion immediately
Rationale: The symptoms of chills, fever, and back pain are
indicative of a transfusion reaction. The nurse should
immediately stop the transfusion and maintain an IV line with
normal saline to prevent further complications. After
discontinuing the transfusion, the nurse can notify the
healthcare provider, obtain a blood sample, and treat
symptoms as ordered.
2. A nurse is caring for a client who has a new diagnosis of heart
failure. Which of the following instructions should the nurse
include in the discharge teaching?
,a) "You should weigh yourself daily at the same time and report
a gain of 2 pounds in one day."
b) "You should limit your fluid intake to 3 liters per day."
c) "You can increase your sodium intake to enhance your
energy."
d) "Take your diuretic in the evening to avoid nocturia."
Answer: a) "You should weigh yourself daily at the same time
and report a gain of 2 pounds in one day."
Rationale: Weight gain is an early indicator of fluid retention in
heart failure, and the client should monitor their weight daily. A
gain of 2 pounds in one day may indicate fluid overload, which
needs to be reported. Fluid intake should be restricted based on
the healthcare provider's orders, and sodium intake should be
reduced. Diuretics should be taken in the morning to avoid
nocturia.
3. A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy at home. The nurse should instruct
the client to:
a) Use the oxygen when feeling short of breath
b) Keep the oxygen tank in the bedroom while sleeping
c) Adjust the oxygen flow rate as needed based on symptoms
d) Avoid smoking while using oxygen
Answer: d) Avoid smoking while using oxygen
Rationale: Oxygen supports combustion and smoking in the
, presence of oxygen is a fire hazard. The client should never
smoke while using oxygen. The nurse should also educate the
client on using oxygen as prescribed and avoiding adjustments
without consultation with the healthcare provider.
4. A nurse is caring for a client with a wound infection. Which of
the following is the most appropriate method for assessing the
severity of the infection?
a) Observing the appearance of the wound
b) Assessing the client's temperature
c) Checking the white blood cell count
d) Collecting a wound culture
Answer: d) Collecting a wound culture
Rationale: A wound culture is the best way to assess the
causative organism and guide appropriate antibiotic therapy.
While appearance, temperature, and white blood cell count are
important for monitoring infection, a culture will provide
definitive information.
5. A nurse is caring for a client with a deep vein thrombosis
(DVT). Which of the following should the nurse include in the
care plan?
a) Apply heat to the affected limb
b) Encourage bed rest with the leg elevated
