1
HESI MED SURG EVOLVE EXAM LATEST UPDATES -2025/2026-
ACTUAL QUESTIONS WITH VERIFIED ANSWERS ALREADY
GRADED A+ GUARANTEED SUCCESS
A client is placed on a mechanical ventilator following a cerebral hemorrhage, and
vecuronium bromide, 0.04 mg/kg every 12 hours IV, is prescribed. What is the
priority nursing diagnosis for this client?
A. Impaired communication related to paralysis of skeletal muscles
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
A
Rationale:To increase the client's tolerance of endotracheal intubation and/or
mechanical ventilation, a skeletal muscle relaxant such as vecuronium is usually
prescribed. Option A is a serious outcome because the client cannot communicate
his or her needs. Although this client might also experience option D, it is not a
priority when compared with option A. Infection is not related to increased
intracranial pressure. The respirator will ensure that the lungs are expanded, so
option C is incorrect.
The nurse receives the client's next scheduled bag of TPN labeled with the
additive NPH insulin. Which action should the nurse implement?
A. Hang the solution at the current rate.
B. Refrigerate the solution until needed.
, 2
C.Prepare the solution with new tubing.
D.Return the solution to the pharmacy.
D
Rationale: Only regular insulin is administered by the IV route, so the TPN solution
containing NPH insulin should be returned to the pharmacy. Options A, B, and C
are not indicated because the solution should not be administered.
A postoperative client receives a Schedule II opioid analgesic for pain. Which
assessment finding requires the most immediate intervention by the nurse?
A. Hypoactive bowel sounds with abdominal distention
B. Client reports continued pain of 8 on a 10-point scale
C. Respiratory rate of 12 breaths/min, with O2 saturation of 85%
D. Client reports nausea after receiving the medication
C
Rationale: Administration of a Schedule II opioid analgesic can result in
respiratory depression, which requires immediate intervention by the nurse to
prevent respiratory arrest. Options A, B, and D require action by the nurse but are
of less priority than option C.
A family member was taught to suction a client's tracheostomy prior to the
client's discharge from the hospital. Which observation by the nurse indicates that
the family member is capable of correctly performing the suctioning technique?
, 3
A. Turns on the continuous wall suction to 190 mm Hg.
B. Inserts the catheter until resistance or coughing occurs.
C. Withdraws the catheter while maintaining suctioning.
D. Reclears the tracheostomy after suctioning the mouth.
B
Rationale:Option B indicates correct technique for performing suctioning. Suction
pressure should be between 80 and 120 mm Hg, not 190 mm Hg. The catheter
should be withdrawn 1 to 2 cm at a time with intermittent, not continuous,
suction. Option D introduces pathogens unnecessarily into the tracheobronchial
tree.
A client is diagnosed with an acute small bowel obstruction. Which assessment
finding requires the most immediate intervention by the nurse?
A. Fever of 102° F
B. Blood pressure of 150/90 mm Hg
C. Abdominal cramping
D. Dry mucous membranes
A
Rationale:A sudden increase in temperature is an indicator of peritonitis. The
nurse should notify the health care provider immediately. Options B, C, and D are
also findings that require intervention by the nurse but are of less priority than
option A. Option B may indicate a hypertensive condition but is not as acute a
condition as peritonitis. Option C is an expected finding in clients with small bowel
obstruction and may require medication. Option D indicates probable fluid
volume deficit, which requires fluid volume replacement.
, 4
In assessing a client diagnosed with primary aldosteronism, the nurse expects the
laboratory test results to indicate a decreased serum level of which substance?
A. Sodium
B. Phosphate
C. Potassium
D. Glucose
C
Rationale: Clients with primary aldosteronism exhibit a profound decline in serum
levels of potassium; hypokalemia; hypertension is the most prominent and
universal sign. The serum sodium level is normal or elevated, depending on the
amount of water resorbed with the sodium. Option B is influenced by parathyroid
hormone (PTH). Option D is not affected by primary aldosteronism.
During assessment of a client in the intensive care unit, the nurse notes that the
client's breath sounds are clear on auscultation, but jugular vein distention and
muffled heart sounds are present. Which intervention should the nurse
implement?
A. Prepare the client for a pericardial tap.
B. Administer intravenous furosemide (Lasix).
C. Assist the client to cough and breathe deeply.
D. Instruct the client to restrict oral fluid intake.
A
Rationale: The client is exhibiting symptoms of cardiac tamponade, a collection of
fluid in the pericardial sac that results in a reduction in cardiac output, which is a
HESI MED SURG EVOLVE EXAM LATEST UPDATES -2025/2026-
ACTUAL QUESTIONS WITH VERIFIED ANSWERS ALREADY
GRADED A+ GUARANTEED SUCCESS
A client is placed on a mechanical ventilator following a cerebral hemorrhage, and
vecuronium bromide, 0.04 mg/kg every 12 hours IV, is prescribed. What is the
priority nursing diagnosis for this client?
A. Impaired communication related to paralysis of skeletal muscles
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
A
Rationale:To increase the client's tolerance of endotracheal intubation and/or
mechanical ventilation, a skeletal muscle relaxant such as vecuronium is usually
prescribed. Option A is a serious outcome because the client cannot communicate
his or her needs. Although this client might also experience option D, it is not a
priority when compared with option A. Infection is not related to increased
intracranial pressure. The respirator will ensure that the lungs are expanded, so
option C is incorrect.
The nurse receives the client's next scheduled bag of TPN labeled with the
additive NPH insulin. Which action should the nurse implement?
A. Hang the solution at the current rate.
B. Refrigerate the solution until needed.
, 2
C.Prepare the solution with new tubing.
D.Return the solution to the pharmacy.
D
Rationale: Only regular insulin is administered by the IV route, so the TPN solution
containing NPH insulin should be returned to the pharmacy. Options A, B, and C
are not indicated because the solution should not be administered.
A postoperative client receives a Schedule II opioid analgesic for pain. Which
assessment finding requires the most immediate intervention by the nurse?
A. Hypoactive bowel sounds with abdominal distention
B. Client reports continued pain of 8 on a 10-point scale
C. Respiratory rate of 12 breaths/min, with O2 saturation of 85%
D. Client reports nausea after receiving the medication
C
Rationale: Administration of a Schedule II opioid analgesic can result in
respiratory depression, which requires immediate intervention by the nurse to
prevent respiratory arrest. Options A, B, and D require action by the nurse but are
of less priority than option C.
A family member was taught to suction a client's tracheostomy prior to the
client's discharge from the hospital. Which observation by the nurse indicates that
the family member is capable of correctly performing the suctioning technique?
, 3
A. Turns on the continuous wall suction to 190 mm Hg.
B. Inserts the catheter until resistance or coughing occurs.
C. Withdraws the catheter while maintaining suctioning.
D. Reclears the tracheostomy after suctioning the mouth.
B
Rationale:Option B indicates correct technique for performing suctioning. Suction
pressure should be between 80 and 120 mm Hg, not 190 mm Hg. The catheter
should be withdrawn 1 to 2 cm at a time with intermittent, not continuous,
suction. Option D introduces pathogens unnecessarily into the tracheobronchial
tree.
A client is diagnosed with an acute small bowel obstruction. Which assessment
finding requires the most immediate intervention by the nurse?
A. Fever of 102° F
B. Blood pressure of 150/90 mm Hg
C. Abdominal cramping
D. Dry mucous membranes
A
Rationale:A sudden increase in temperature is an indicator of peritonitis. The
nurse should notify the health care provider immediately. Options B, C, and D are
also findings that require intervention by the nurse but are of less priority than
option A. Option B may indicate a hypertensive condition but is not as acute a
condition as peritonitis. Option C is an expected finding in clients with small bowel
obstruction and may require medication. Option D indicates probable fluid
volume deficit, which requires fluid volume replacement.
, 4
In assessing a client diagnosed with primary aldosteronism, the nurse expects the
laboratory test results to indicate a decreased serum level of which substance?
A. Sodium
B. Phosphate
C. Potassium
D. Glucose
C
Rationale: Clients with primary aldosteronism exhibit a profound decline in serum
levels of potassium; hypokalemia; hypertension is the most prominent and
universal sign. The serum sodium level is normal or elevated, depending on the
amount of water resorbed with the sodium. Option B is influenced by parathyroid
hormone (PTH). Option D is not affected by primary aldosteronism.
During assessment of a client in the intensive care unit, the nurse notes that the
client's breath sounds are clear on auscultation, but jugular vein distention and
muffled heart sounds are present. Which intervention should the nurse
implement?
A. Prepare the client for a pericardial tap.
B. Administer intravenous furosemide (Lasix).
C. Assist the client to cough and breathe deeply.
D. Instruct the client to restrict oral fluid intake.
A
Rationale: The client is exhibiting symptoms of cardiac tamponade, a collection of
fluid in the pericardial sac that results in a reduction in cardiac output, which is a
