Evolve HESI practice Exam
Questions with Accurate Answers
A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due
to a fracture resulting from a fall. In reviewing hip precautions with the client,
which instruction should the nurse include in this client's teaching plan? correct
answers Place a pillow between your knees while lying in bed to prevent hip
dislocation.
A client is in the radiology department at 0900 when the prescription levofloxacin
(Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to
the unit at 1300. What is the best intervention for the nurse to implement?
correct answers Give the missed dose at 1300 and change the schedule to
administer daily at 1300.
A client is receiving a cephalosporin antibiotic IV and complains of pain and
irritation at the infusion site. The nurse observes erythema, swelling, and a red
streak along the vessel above the IV access site. Which action should the nurse
take at this time? correct answers Initiate an alternate site for the IV infusion of
the medication.
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4
hours. At what rate should the nurse set the client's intravenous infusion pump?
correct answers 63 ml/hour.
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation
arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to
administer the IVPB dose over 20 minutes. For how many ml/hr should the
infusion pump be set to deliver the secondary infusion? correct answers 150
,A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal
saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-
hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are
clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7
mEq/L. Which action is most important for the nurse to implement? correct
answers Document in the medical record that these normal findings are expected
outcomes
The results are all within normal range.(C) No changes are needed.
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next
day. What question is most important for the nurse to include during the
preoperative assessment? correct answers What vitamin and mineral
supplements do you take?
(Vitamin and mineral supplements may impact medications used during the
procedure.)
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern
should the nurse have for planning care in terms of the client's beliefs? correct
answers Blood transfusions are forbidden.
A client who is in hospice care complains of increasing amounts of pain. The
healthcare provider prescribes an analgesic every four hours as needed. Which
action should the nurse implement? correct answers Give an around-the-clock
schedule for administration of analgesics.
A client with acute hemorrhagic anemia is to receive four units of packed RBCs
(red blood cells) as rapidly as possible. Which intervention is most important for
, the nurse to implement? correct answers Ensure the accuracy of the blood type
match.
A client with chronic renal failure selects a scrambled egg for his breakfast. What
action should the nurse take? correct answers Commend the client for selecting a
high biologic value protein.
(Foods such as eggs and milk are high in biologic proteins which are allowed
because they are complete proteins and supply the essential amino acids
necessary growth and cellular repair.)
A client with pneumonia has a decrease in oxygen saturation from 94% to 88%
while ambulating. Based on these findings, which intervention should the nurse
implement first? correct answers Assist the ambulating client back to the bed.
A client's infusion of normal saline infiltrated earlier today, and approximately 500
ml of saline infused into the subcutaneous tissue. The client is now complaining of
excruciating arm pain and demanding "stronger pain medications." What initial
action is most important for the nurse to take? correct answers Measure the
pulse volume and capillary refill distal to the infiltration.
(Pain and diminished pulse volume are signs of compartment syndrome, which
can progress to complete loss of the peripheral pulse in the extremity.)
A female client asks the nurse to find someone who can translate into her native
language her concerns about a treatment. Which action should the nurse take?
correct answers Request and document the name of the certified translator.
Questions with Accurate Answers
A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due
to a fracture resulting from a fall. In reviewing hip precautions with the client,
which instruction should the nurse include in this client's teaching plan? correct
answers Place a pillow between your knees while lying in bed to prevent hip
dislocation.
A client is in the radiology department at 0900 when the prescription levofloxacin
(Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to
the unit at 1300. What is the best intervention for the nurse to implement?
correct answers Give the missed dose at 1300 and change the schedule to
administer daily at 1300.
A client is receiving a cephalosporin antibiotic IV and complains of pain and
irritation at the infusion site. The nurse observes erythema, swelling, and a red
streak along the vessel above the IV access site. Which action should the nurse
take at this time? correct answers Initiate an alternate site for the IV infusion of
the medication.
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4
hours. At what rate should the nurse set the client's intravenous infusion pump?
correct answers 63 ml/hour.
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation
arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to
administer the IVPB dose over 20 minutes. For how many ml/hr should the
infusion pump be set to deliver the secondary infusion? correct answers 150
,A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal
saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-
hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are
clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7
mEq/L. Which action is most important for the nurse to implement? correct
answers Document in the medical record that these normal findings are expected
outcomes
The results are all within normal range.(C) No changes are needed.
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next
day. What question is most important for the nurse to include during the
preoperative assessment? correct answers What vitamin and mineral
supplements do you take?
(Vitamin and mineral supplements may impact medications used during the
procedure.)
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern
should the nurse have for planning care in terms of the client's beliefs? correct
answers Blood transfusions are forbidden.
A client who is in hospice care complains of increasing amounts of pain. The
healthcare provider prescribes an analgesic every four hours as needed. Which
action should the nurse implement? correct answers Give an around-the-clock
schedule for administration of analgesics.
A client with acute hemorrhagic anemia is to receive four units of packed RBCs
(red blood cells) as rapidly as possible. Which intervention is most important for
, the nurse to implement? correct answers Ensure the accuracy of the blood type
match.
A client with chronic renal failure selects a scrambled egg for his breakfast. What
action should the nurse take? correct answers Commend the client for selecting a
high biologic value protein.
(Foods such as eggs and milk are high in biologic proteins which are allowed
because they are complete proteins and supply the essential amino acids
necessary growth and cellular repair.)
A client with pneumonia has a decrease in oxygen saturation from 94% to 88%
while ambulating. Based on these findings, which intervention should the nurse
implement first? correct answers Assist the ambulating client back to the bed.
A client's infusion of normal saline infiltrated earlier today, and approximately 500
ml of saline infused into the subcutaneous tissue. The client is now complaining of
excruciating arm pain and demanding "stronger pain medications." What initial
action is most important for the nurse to take? correct answers Measure the
pulse volume and capillary refill distal to the infiltration.
(Pain and diminished pulse volume are signs of compartment syndrome, which
can progress to complete loss of the peripheral pulse in the extremity.)
A female client asks the nurse to find someone who can translate into her native
language her concerns about a treatment. Which action should the nurse take?
correct answers Request and document the name of the certified translator.
