EVOLVE HESI MED SURG Exam Test Bank | Actual Exam
Questions and Correct Answers (Detailed Answers) |
Latest Version 2025 | Verified Answers
The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which
symptom of hyperglycemia is an older adult most likely to exhibit?
A. Polyuria
B. Polydipsia
C. Weight loss
D. Infection ---------CORRECT ANSWER-----------------Correct Answer: D
Rationale: Signs and symptoms of hyperglycemia in older adults may include
fatigue, infection, and evidence of neuropathy (e.g., sensory changes). The
nurse needs to remember that classic signs and symptoms of hyperglycemia,
such as options A, B, and C and polyphagia, may be absent in older adults.
The nurse on a medical-surgical unit is receiving a client from the postanesthesia
care unit (PACU) with a Penrose drain. Before choosing a room for this client,
which information is most important for the nurse to obtain?
A. If suctioning will be needed for drainage of the wound
B.If the family would prefer a private or semiprivate room
C.If the client also has a Hemovac in place
D. If the client's wound is infected ---------CORRECT ANSWER-----------------Correct
Answer: D
,Rationale: The fact that the client has a Penrose drain should alert the nurse to
the possibility that the surgical wound is infected. Penrose drains provide a
sinus tract or opening and are often used to provide drainage of an abscess. To
avoid contamination of another postoperative client, it is most important to
place any client with an infected wound in a private room. A Penrose drain does
not require option A. Although option B is helpful information, it does not have
the priority of option D. A Hemovac is used to drain fluid from a dead space and
is not a determinant for the room assignment.
The nurse is giving preoperative instructions to a 14-year-old client scheduled for
surgery to correct a spinal curvature. Which statement by the client best
demonstrates that learning has taken place?
A."I will read all the teaching booklets you gave me before surgery."
B."I have had surgery before, so I know what to expect afterward."
C."All the things people have told me will help me take care of my back."
D."Let me show you the method of turning I will use after surgery." ---------
CORRECT ANSWER-----------------Correct Answer: D
Rationale: The outcome of learning is best demonstrated when the client not
only verbalizes an understanding but also provides a return demonstration. A
14-year-old client may or may not follow through with option A, and there is no
measurement of learning. Option B may help the client understand the surgical
process, but the type of surgery may have been very different, with differing
postoperative care. In option C, the client may be saying what the nurse wants
to hear without expressing any real understanding of what to do after surgery.
,The nurse is administering a nystatin suspension for stomatitis. Which instruction
will the nurse provide to the client when administering this medication?
A. "Hold the medication in your mouth for a few minutes before swallowing it."
B."Do not drink or eat milk products for 1 hour prior to taking this medication."
C."Dilute the medication with juice to reduce the unpleasant taste and odor."
D. "Take the medication before meals to promote increased absorption." ---------
CORRECT ANSWER-----------------Correct Answer: A
Rationale: Nystatin suspension is prescribed for fungal infections of the mouth.
The client should swish the medication in the mouth for 2 minutes and then
swallow. Option B does not affect administration of this medication. The
medication should not be diluted because this will reduce its effectiveness.
Option D is not necessary.
A client with type 2 diabetes takes metformin daily. The client is scheduled for
major surgery requiring general anesthesia the next day. The nurse anticipates
which approach to manage the client's diabetes best while the client is NPO
during the perioperative period?
A.NPO except for metformin and regular snacks
B.NPO except for oral antidiabetic agent
C.Novolin N insulin subcutaneously twice daily
D.Regular insulin subcutaneously per sliding scale ---------CORRECT ANSWER--------
---------Correct Answer: D
Rationale: Regular insulin dosing based on the client's blood glucose levels
(sliding scale) is the best method to achieve control of the client's blood glucose
while the client is NPO and coping with the major stress of surgery. Option A
, increases the risk of vomiting and aspiration. Options B and C provide less
precise control of the blood glucose level.
The nurse in the emergency room assesses a client with a head trauma and notes
a Glasgow Coma Scale (GCS) score of 5. What actions will the nurse take to ensure
the client's safety? (Select all that apply.)
A. Place the client in the supine position.
B. Assess airway and suction secretions as needed.
C.Change the client's position every 2 hours.
D. Avoid mouth care, to avoid stimulating a seizure.
E. Monitor for drainage from the ears. ---------CORRECT ANSWER-----------------
Correct Answer: B,C,E
Rationale: The client should be at least sitting at a 45 degree angle to avoid
aspiration and increased intracranial pressure. Provide frequent mouth care as
the client is unable to do so at this time. The remaining actions are appropriate
for the client with a GCS score of 5.
For the client undergoing hemodialysis, the nurse suspects the client has an air
embolism. What symptoms lead the nurse to this conclusion? (Select all that
apply.)
A. Dyspnea
B. B/P 168/92 mm Hg
Questions and Correct Answers (Detailed Answers) |
Latest Version 2025 | Verified Answers
The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which
symptom of hyperglycemia is an older adult most likely to exhibit?
A. Polyuria
B. Polydipsia
C. Weight loss
D. Infection ---------CORRECT ANSWER-----------------Correct Answer: D
Rationale: Signs and symptoms of hyperglycemia in older adults may include
fatigue, infection, and evidence of neuropathy (e.g., sensory changes). The
nurse needs to remember that classic signs and symptoms of hyperglycemia,
such as options A, B, and C and polyphagia, may be absent in older adults.
The nurse on a medical-surgical unit is receiving a client from the postanesthesia
care unit (PACU) with a Penrose drain. Before choosing a room for this client,
which information is most important for the nurse to obtain?
A. If suctioning will be needed for drainage of the wound
B.If the family would prefer a private or semiprivate room
C.If the client also has a Hemovac in place
D. If the client's wound is infected ---------CORRECT ANSWER-----------------Correct
Answer: D
,Rationale: The fact that the client has a Penrose drain should alert the nurse to
the possibility that the surgical wound is infected. Penrose drains provide a
sinus tract or opening and are often used to provide drainage of an abscess. To
avoid contamination of another postoperative client, it is most important to
place any client with an infected wound in a private room. A Penrose drain does
not require option A. Although option B is helpful information, it does not have
the priority of option D. A Hemovac is used to drain fluid from a dead space and
is not a determinant for the room assignment.
The nurse is giving preoperative instructions to a 14-year-old client scheduled for
surgery to correct a spinal curvature. Which statement by the client best
demonstrates that learning has taken place?
A."I will read all the teaching booklets you gave me before surgery."
B."I have had surgery before, so I know what to expect afterward."
C."All the things people have told me will help me take care of my back."
D."Let me show you the method of turning I will use after surgery." ---------
CORRECT ANSWER-----------------Correct Answer: D
Rationale: The outcome of learning is best demonstrated when the client not
only verbalizes an understanding but also provides a return demonstration. A
14-year-old client may or may not follow through with option A, and there is no
measurement of learning. Option B may help the client understand the surgical
process, but the type of surgery may have been very different, with differing
postoperative care. In option C, the client may be saying what the nurse wants
to hear without expressing any real understanding of what to do after surgery.
,The nurse is administering a nystatin suspension for stomatitis. Which instruction
will the nurse provide to the client when administering this medication?
A. "Hold the medication in your mouth for a few minutes before swallowing it."
B."Do not drink or eat milk products for 1 hour prior to taking this medication."
C."Dilute the medication with juice to reduce the unpleasant taste and odor."
D. "Take the medication before meals to promote increased absorption." ---------
CORRECT ANSWER-----------------Correct Answer: A
Rationale: Nystatin suspension is prescribed for fungal infections of the mouth.
The client should swish the medication in the mouth for 2 minutes and then
swallow. Option B does not affect administration of this medication. The
medication should not be diluted because this will reduce its effectiveness.
Option D is not necessary.
A client with type 2 diabetes takes metformin daily. The client is scheduled for
major surgery requiring general anesthesia the next day. The nurse anticipates
which approach to manage the client's diabetes best while the client is NPO
during the perioperative period?
A.NPO except for metformin and regular snacks
B.NPO except for oral antidiabetic agent
C.Novolin N insulin subcutaneously twice daily
D.Regular insulin subcutaneously per sliding scale ---------CORRECT ANSWER--------
---------Correct Answer: D
Rationale: Regular insulin dosing based on the client's blood glucose levels
(sliding scale) is the best method to achieve control of the client's blood glucose
while the client is NPO and coping with the major stress of surgery. Option A
, increases the risk of vomiting and aspiration. Options B and C provide less
precise control of the blood glucose level.
The nurse in the emergency room assesses a client with a head trauma and notes
a Glasgow Coma Scale (GCS) score of 5. What actions will the nurse take to ensure
the client's safety? (Select all that apply.)
A. Place the client in the supine position.
B. Assess airway and suction secretions as needed.
C.Change the client's position every 2 hours.
D. Avoid mouth care, to avoid stimulating a seizure.
E. Monitor for drainage from the ears. ---------CORRECT ANSWER-----------------
Correct Answer: B,C,E
Rationale: The client should be at least sitting at a 45 degree angle to avoid
aspiration and increased intracranial pressure. Provide frequent mouth care as
the client is unable to do so at this time. The remaining actions are appropriate
for the client with a GCS score of 5.
For the client undergoing hemodialysis, the nurse suspects the client has an air
embolism. What symptoms lead the nurse to this conclusion? (Select all that
apply.)
A. Dyspnea
B. B/P 168/92 mm Hg
