Evolve HESI Medical Surgical Practice Exam

Evolve HESI Medical Surgical Practice Exam Related

Review Evolve HESI Medical Surgical Practice Exam related questions and content

A nurse checks the residual volume from a client's nasogastric tube feeding before administering an intermittent tube feeding and finds 35 mL of gastric contents. What should the nurse do before administering the prescribed 100 mL of formula to the client?

  • A. Pour the residual volume into the nasogastric tube through a syringe with the plunger removed
  • B. Discard the residual volume properly and record it as output on the client's fluid balance record
  • C. Dilute the residual volume with water and inject it into the nasogastric tube, applying pressure on the plunger
  • D. Mix the residual volume with the formula and pour it into the nasogastric tube, using a syringe without a plunger
Correct Answer: A

Rationale: After checking the residual feeding contents, the nurse should pour the residual volume back into the stomach by removing the syringe bulb or plunger and then pouring the gastric contents, using the syringe, into the nasogastric tube. This helps ensure that the residual volume is reintroduced into the client's gastrointestinal tract. Option B is incorrect because discarding the residual volume without reinstilling it into the stomach can lead to inaccurate medication administration and potential electrolyte imbalances. Option C is incorrect as diluting the residual volume with water and injecting it under pressure can cause aspiration or discomfort for the client. Option D is incorrect because mixing the residual volume with the formula can alter the prescribed dosage and consistency, potentially affecting the client's nutritional intake and causing complications.

You may also like to solve these questions

The nurse assumes care for a patient who is currently receiving a dose of intravenous vancomycin (Vancocin) infusing at 20 mg/min. The nurse notes red blotches on the patient's face, neck, and chest and assesses a blood pressure of 80/55 mm Hg. Which action will the nurse take?

  • A. Request an order for IV epinephrine to treat anaphylactic shock.
  • B. Slow the infusion to 10 mg/min and observe the patient closely.
  • C. Stop the infusion and obtain an order for a BUN and serum creatinine.
  • D. Suspect Stevens-Johnson syndrome and notify the provider immediately.
Correct Answer: B

Rationale: When vancomycin is infused too rapidly, "red man" syndrome may occur; the rate should be 10 mg/min to prevent this. This is a toxic reaction, not an allergic one, so epinephrine is not indicated. Stevens-Johnson syndrome is characterized by a rash and fever. Red man syndrome is not related to renal function.

A client with a diagnosis of hypothermia is being admitted to the hospital by a nurse. Which of the following signs does the nurse anticipate that this client will exhibit?

  • A. Increased heart rate and increased blood pressure
  • B. Increased heart rate and decreased blood pressure
  • C. Decreased heart rate and increased blood pressure
  • D. Decreased heart rate and decreased blood pressure
Correct Answer: D

Rationale: Hypothermia decreases the heart rate and blood pressure due to reduced metabolic needs of the body. With lower metabolic demands, the heart's workload decreases, leading to reductions in both heart rate and blood pressure. Choices A, B, and C are incorrect because hypothermia typically results in a decrease in heart rate and blood pressure, not an increase.

A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test?

  • A. I didn't shampoo my hair.
  • B. I ate breakfast this morning.
  • C. I didn't take my anticonvulsant today.
  • D. It was hard not to drink coffee this morning, but I knew that I couldn't, so I didn't.
Correct Answer: A

Rationale: The correct answer is A. For an EEG, it is essential that the client's hair is clean, without any products like hairspray or gel, to ensure good electrode contact with the scalp. Choice B is not a concern as having breakfast is allowed before the test. Choice C, not taking an anticonvulsant, might be required for certain types of EEGs to capture accurate brain activity. Choice D, not drinking coffee, is not a specific requirement for an EEG preparation.

A nurse plans care for an older adult client. Which interventions should the nurse include in this client's plan of care to promote kidney health? (Select all that apply.)

  • A. Ensure adequate fluid intake.
  • B. Leave the bathroom light on at night.
  • C. Encourage use of the toilet every 6 hours.
  • D. A & B
Correct Answer: D

Rationale: The correct interventions to promote kidney health in an older adult client include ensuring adequate fluid intake to maintain hydration and leaving the bathroom light on at night to promote safe ambulation. Adequate hydration supports kidney function and helps prevent urinary tract infections. Encouraging the use of the toilet every 6 hours is not specific to kidney health and may not be individualized to the client's needs. Providing thorough perineal care after each voiding is important for hygiene but not directly related to promoting kidney health. Assessing for urinary retention and urinary tract infections is crucial but falls under assessment rather than interventions for promoting kidney health specifically.

The nurse is caring for several patients who are receiving antibiotics. Which order will the nurse question?

  • A. Azithromycin (Zithromax) 500 mg IV in 500 mL of fluid
  • B. Azithromycin (Zithromax) 500 mg PO once daily
  • C. Erythromycin 300 mg IM QID
  • D. Erythromycin 300 mg PO QID
Correct Answer: C

Rationale: The nurse should question the order for Erythromycin 300 mg IM QID. Erythromycin and other macrolides should not be given intramuscularly because they cause painful tissue irritation. Options A and B are correct routes for Azithromycin, either intravenously or orally. Option D is a correct route for Erythromycin, which is orally.

Copyright © 2025 Nokea. All rights reserved.