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 o 𝑓 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
messages.downloaded_by
,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 i 𝑓 the
client were exhibiting signs o𝑓 hypotension such as dizziness. This prescribed dose is within the
normal dosage range, as de𝑓ined by the manu𝑓acturer; there 𝑓ore, 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.
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,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 o 𝑓 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 e 𝑓𝑓ectiveness o 𝑓 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 o 𝑓 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?
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, 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 (re 𝑓erred 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 o 𝑓 glucocorticoids in the adrenal cortex.
Clients with Cushing syndrome o𝑓ten develop diabetes mellitus. Monitoring o 𝑓 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 in 𝑓usion 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
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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 o 𝑓 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
messages.downloaded_by
,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 i 𝑓 the
client were exhibiting signs o𝑓 hypotension such as dizziness. This prescribed dose is within the
normal dosage range, as de𝑓ined by the manu𝑓acturer; there 𝑓ore, 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.
messages.downloaded_by
,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 o 𝑓 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 e 𝑓𝑓ectiveness o 𝑓 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 o 𝑓 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?
messages.downloaded_by
, 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 (re 𝑓erred 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 o 𝑓 glucocorticoids in the adrenal cortex.
Clients with Cushing syndrome o𝑓ten develop diabetes mellitus. Monitoring o 𝑓 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 in 𝑓usion 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
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