EVOLVE ELSEVIER HESI MED SURG REAL EXAMW r r r r r r r
ITH 150 LATEST QUESTIONS WITH CORRECT SOL
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UTIONS| ALREADYGRADED A| ACE YOUR GRAD r r r r r r
ES.
The nurse is concerned about infection for a client after an esophagogastrostomyfor e
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sophageal cancer. Which actions should the nurse include in the client's planof care? (S
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elect all that apply.)
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A. Frequent oral care every 2 hours while awake.B. U
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se incentive spirometer every 2 hours.
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C. Empty contents from NG tube every 8 hours.
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D. Ambulate within 1 hour of return from the PACU. r r r r r r r r
E. Limit visitors until postoperative day 2. - Correct Answer-Correct Answer: A,B,C
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Rationale:One hour post op is too soon to ambulate for this client. Visitors help suppo
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rt the patient and are encouraged to visit. Oral care is necessary as the client will be NP
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O. To decrease the risk of infection post operatively, implementroutine pulmonary e
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xercises. The client will have an NG tube in place, likely to intermittent suction, to dec
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ompress the stomach post surgery.
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,The client is return demonstrating wrapping of the left limb amputated above theknee
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. The nurse evaluates the client is starting the wrapping method correctly whenthe clie
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nt places the end of the bandage at which point?
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A. Around the waist r r
B. At the inner aspect of the left stump
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C. At the outer aspect of the left stump
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D. At the left groin area - Correct Answer-Correct Answer: A
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Rationale:The waist is the anchor point for the bandage for an above the kneeamputa r r r r r r r r r r r r r r
tion.
A nurse is assisting an 82-year-
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old client with ambulation and is concerned thatthe client may fall. Which area conta
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ins the older person's center of gravity?
r r r r r r
A. Headand neckBr r r r
. Upper torso
r r
C. Bilateral arms
r r
D. Feet and legs - Correct Answer-Correct Answer: B
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Rationale:Stooped posture results in the upper torso becoming the center of gravity fo r r r r r r r r r r r r
r older persons. The center of gravity for adults is the hips. However, as a person grows o
r r r r r r r r r r r r r r r r r
lder, a stooped posture is common because of changes caused by osteoporosis and nor
r r r r r r r r r r r r r
mal bone degeneration. Furthermore, the knees, hips, and elbows flex. The head and n
r r r r r r r r r r r r r
eck and feet and legs are not the center of gravityin the older adult. Although the arms c
r r r r r r r r r r r r r r r r r r
omprise a part of the upper torso, they do not reflect the best and most complete answe
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r.
,A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeksand is
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scheduled to receive a dose at 0900. At 0830, the client's blood pressure is120/70mm r r r r r r r r r r r r r r r r
Hg. Which action should the nurse take?
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A. Administer the prescribeddose at the scheduled time. r r r r r r r
B. Hold the dose and contact the health care provider. r r r r r r r r
C. Hold the dose and recheck the blood pressure in 1 hour. r r r r r r r r r r
D. Check the health care provider's prescription to clarify the dose. - r r r r r r r r r r
CorrectAnswer-Correct Answer: A
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Rationale:The client's blood pressure is within normal limits, indicating that the ramipr r r r r r r r r r r r
il, an antihypertensive, is having the desired effect and should be administered. Option
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s B and C would be appropriate if the client's blood pressurewas excessively low (<100
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mm Hg systolic) or if the client were exhibiting signs ofhypotension such as dizziness. T
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his prescribed dose is within the normal dosage range, as defined by the manufacturer;
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therefore, option D is not necessary r r r r r
The nurse is providing care for a client diagnosed with trigeminal neuralgia (ticdoul
r r r r r r r r r r r r r
oureux). Which symptoms will the nurse be looking for in the focused assessment r
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elated to this condition? (Select all that apply.) r r r r r r r
A. FacialmusclespasmsB r r r r
. Suddenfacial pain
r r r
C. Unilateral facial weakness
r r r
D. Difficulty in chewingE
r r r r
.Tinnitus
F.Hearing difficulties- Correct Answer-Correct Answer: A,B r r r r r r
, Rationale:Trigeminal neuralgia is characterized by paroxysms of pain, similar to anelec r r r r r r r r r r r
tric shock, in the area innervated by one or more branches of the trigeminal nerve (crani
r r r r r r r r r r r r r r r
al V). The remaining symptoms are not related to trigeminal neuralgia.
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In caring for a client with acute diverticulitis, which assessment data warrants animm
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ediate nursing action? r r
A. The client has a rigid hard abdomen and elevated WBC.
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B. The client has left lower quadrant pain and an elevated temperature.
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C. The client is refusing to eat any of the meal andis complaining of nausea.
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D. The client has not had a bowel movement in 2 days and has a soft abdomen. -
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Correct Answer-Correct Answer: A
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Rationale: A hard rigid abdomen and elevated WBC is indicative of peritonitis, which is a
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medical emergency and should be reported to the health care provider immediately. O
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ptions B and C are expected clinical manifestations of diverticulitis.Option D does not w
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arrant immediate intervention. r r
The nurse is caring for a client with a fractured right elbow. Which assessmentfindin
r r r r r r r r r r r r r r
g has the highest priority and requires immediate intervention?
r r r r r r r r
A. Ecchymosis over the right elbow area B.
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Deep unrelenting pain in the right arm
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C. An edematous right elbow
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D. The presence of crepitus in the right elbow - Correct Answer-Correct Answer: B
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ITH 150 LATEST QUESTIONS WITH CORRECT SOL
r r r r r r
UTIONS| ALREADYGRADED A| ACE YOUR GRAD r r r r r r
ES.
The nurse is concerned about infection for a client after an esophagogastrostomyfor e
r r r r r r r r r r r r r
sophageal cancer. Which actions should the nurse include in the client's planof care? (S
r r r r r r r r r r r r r r
elect all that apply.)
r r r
A. Frequent oral care every 2 hours while awake.B. U
r r r r r r r r r r
se incentive spirometer every 2 hours.
r r r r r
C. Empty contents from NG tube every 8 hours.
r r r r r r r
D. Ambulate within 1 hour of return from the PACU. r r r r r r r r
E. Limit visitors until postoperative day 2. - Correct Answer-Correct Answer: A,B,C
r r r r r r r r r r
Rationale:One hour post op is too soon to ambulate for this client. Visitors help suppo
r r r r r r r r r r r r r r
rt the patient and are encouraged to visit. Oral care is necessary as the client will be NP
r r r r r r r r r r r r r r r r r
O. To decrease the risk of infection post operatively, implementroutine pulmonary e
r r r r r r r r r r r r
xercises. The client will have an NG tube in place, likely to intermittent suction, to dec
r r r r r r r r r r r r r r r
ompress the stomach post surgery.
r r r r
,The client is return demonstrating wrapping of the left limb amputated above theknee
r r r r r r r r r r r r r
. The nurse evaluates the client is starting the wrapping method correctly whenthe clie
r r r r r r r r r r r r r r
nt places the end of the bandage at which point?
r r r r r r r r r
A. Around the waist r r
B. At the inner aspect of the left stump
r r r r r r r
C. At the outer aspect of the left stump
r r r r r r r
D. At the left groin area - Correct Answer-Correct Answer: A
r r r r r r r r r
Rationale:The waist is the anchor point for the bandage for an above the kneeamputa r r r r r r r r r r r r r r
tion.
A nurse is assisting an 82-year-
r r r r r
old client with ambulation and is concerned thatthe client may fall. Which area conta
r r r r r r r r r r r r r r
ins the older person's center of gravity?
r r r r r r
A. Headand neckBr r r r
. Upper torso
r r
C. Bilateral arms
r r
D. Feet and legs - Correct Answer-Correct Answer: B
r r r r r r r r
Rationale:Stooped posture results in the upper torso becoming the center of gravity fo r r r r r r r r r r r r
r older persons. The center of gravity for adults is the hips. However, as a person grows o
r r r r r r r r r r r r r r r r r
lder, a stooped posture is common because of changes caused by osteoporosis and nor
r r r r r r r r r r r r r
mal bone degeneration. Furthermore, the knees, hips, and elbows flex. The head and n
r r r r r r r r r r r r r
eck and feet and legs are not the center of gravityin the older adult. Although the arms c
r r r r r r r r r r r r r r r r r r
omprise a part of the upper torso, they do not reflect the best and most complete answe
r r r r r r r r r r r r r r r r
r.
,A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeksand is
r r r r r r r r r r r r r r r r r
scheduled to receive a dose at 0900. At 0830, the client's blood pressure is120/70mm r r r r r r r r r r r r r r r r
Hg. Which action should the nurse take?
r r r r r r
A. Administer the prescribeddose at the scheduled time. r r r r r r r
B. Hold the dose and contact the health care provider. r r r r r r r r
C. Hold the dose and recheck the blood pressure in 1 hour. r r r r r r r r r r
D. Check the health care provider's prescription to clarify the dose. - r r r r r r r r r r
CorrectAnswer-Correct Answer: A
r r r r
Rationale:The client's blood pressure is within normal limits, indicating that the ramipr r r r r r r r r r r r
il, an antihypertensive, is having the desired effect and should be administered. Option
r r r r r r r r r r r r
s B and C would be appropriate if the client's blood pressurewas excessively low (<100
r r r r r r r r r r r r r r r r
mm Hg systolic) or if the client were exhibiting signs ofhypotension such as dizziness. T
r r r r r r r r r r r r r r r
his prescribed dose is within the normal dosage range, as defined by the manufacturer;
r r r r r r r r r r r r r r
therefore, option D is not necessary r r r r r
The nurse is providing care for a client diagnosed with trigeminal neuralgia (ticdoul
r r r r r r r r r r r r r
oureux). Which symptoms will the nurse be looking for in the focused assessment r
r r r r r r r r r r r r r
elated to this condition? (Select all that apply.) r r r r r r r
A. FacialmusclespasmsB r r r r
. Suddenfacial pain
r r r
C. Unilateral facial weakness
r r r
D. Difficulty in chewingE
r r r r
.Tinnitus
F.Hearing difficulties- Correct Answer-Correct Answer: A,B r r r r r r
, Rationale:Trigeminal neuralgia is characterized by paroxysms of pain, similar to anelec r r r r r r r r r r r
tric shock, in the area innervated by one or more branches of the trigeminal nerve (crani
r r r r r r r r r r r r r r r
al V). The remaining symptoms are not related to trigeminal neuralgia.
r r r r r r r r r r
In caring for a client with acute diverticulitis, which assessment data warrants animm
r r r r r r r r r r r r r
ediate nursing action? r r
A. The client has a rigid hard abdomen and elevated WBC.
r r r r r r r r r
B. The client has left lower quadrant pain and an elevated temperature.
r r r r r r r r r r
C. The client is refusing to eat any of the meal andis complaining of nausea.
r r r r r r r r r r r r r r
D. The client has not had a bowel movement in 2 days and has a soft abdomen. -
r r r r r r r r r r r r r r r r
Correct Answer-Correct Answer: A
r r r r
Rationale: A hard rigid abdomen and elevated WBC is indicative of peritonitis, which is a
r r r r r r r r r r r r r r r
medical emergency and should be reported to the health care provider immediately. O
r r r r r r r r r r r r
ptions B and C are expected clinical manifestations of diverticulitis.Option D does not w
r r r r r r r r r r r r r r
arrant immediate intervention. r r
The nurse is caring for a client with a fractured right elbow. Which assessmentfindin
r r r r r r r r r r r r r r
g has the highest priority and requires immediate intervention?
r r r r r r r r
A. Ecchymosis over the right elbow area B.
r r r r r r r r
Deep unrelenting pain in the right arm
r r r r r r
C. An edematous right elbow
r r r r
D. The presence of crepitus in the right elbow - Correct Answer-Correct Answer: B
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