EVOLVE MED SURG HESI EXAM
WITH 100% CORRECT ANSWERS
2025/2026
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 answers >>
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 answers >> 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 answers >> Correct Answer: B
Rationale:Stooped posture results in the upper torso becoming
the center of 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
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 answers >> 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 if the client were exhibiting signs of
hypotension such as dizziness. This prescribed dose is within the
normal dosage range, as defined by the manufacturer; therefore,
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 answers >> 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.
D. The client has not had a bowel movement in 2 days and has a
soft abdomen. correct answers >> Correct Answer: A
Rationale: A hard rigid abdomen and elevated WBC is indicative of
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 answers
>> 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.
WITH 100% CORRECT ANSWERS
2025/2026
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 answers >>
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 answers >> 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 answers >> Correct Answer: B
Rationale:Stooped posture results in the upper torso becoming
the center of 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
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 answers >> 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 if the client were exhibiting signs of
hypotension such as dizziness. This prescribed dose is within the
normal dosage range, as defined by the manufacturer; therefore,
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 answers >> 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.
D. The client has not had a bowel movement in 2 days and has a
soft abdomen. correct answers >> Correct Answer: A
Rationale: A hard rigid abdomen and elevated WBC is indicative of
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 answers
>> 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.
