EVOLVE HESI FUNDAMENTALS EXAM PREPARATION QUESTIONS BANK 200 PRACTICE QUESTIONS COMPLETE WITH VERIFIED ANSWERS AND RATIONALES

EVOLVE HESI FUNDAMENTALS EXAM PREPARATION QUESTIONS BANK 200 PRACTICE QUESTIONS COMPLETE WITH VERIFIED ANSWERS AND RATIONALES 1. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The nurse notes the client's respiratory rate has decreased from 22 to 10 breaths per minute. Which action should the nurse take first? A) Increase the oxygen flow rate to 4 L/min B) Assess the client's level of consciousness C) Notify the healthcare provider immediately D) Document the change in respiratory rate Correct Answer: B) Assess the client's level of consciousness Rationale: The priority action is to assess the client's level of consciousness to determine if the decreased respiratory rate is causing hypoxia or hypercapnia. In COPD clients, oxygen administration can suppress the hypoxic drive, leading to respiratory depression. The nurse must first evaluate the client's neurological status before implementing other interventions. ________________________________________ 2. The nurse is preparing to administer an intramuscular injection to an adult client in the ventrogluteal site. Which action should the nurse implement to correctly locate this site? A) Place the client in a prone position with toes pointing inward B) Use the palm of the hand to locate the greater trochanter C) Position the client supine with the knee flexed D) Locate the site two fingerbreadths below the acromion process Correct Answer: B) Use the palm of the hand to locate the greater trochanter Rationale: To locate the ventrogluteal site, the nurse places the palm of the hand over the greater trochanter, with the index finger pointing to the anterior superior iliac spine and the middle finger pointing to the iliac crest. The injection is given in the V formed between the fingers. This site is preferred because it has no major nerves or blood vessels. ________________________________________ 3. A client is admitted with dehydration and is prescribed intravenous fluids at 125 mL/hour. The nurse notes that the IV site is cool, pale, and edematous. What should the nurse do first? A) Slow the infusion rate to 50 mL/hour B) Apply a warm compress to the site C) Discontinue the IV and restart at a different site D) Document the finding and continue to monitor Correct Answer: C) Discontinue the IV and restart at a different site Rationale: The assessment findings of coolness, pallor, and edema indicate infiltration, meaning the IV fluid is leaking into the surrounding tissue. The nurse should immediately discontinue the IV at that site to prevent further tissue damage and restart it at a different location. Applying warm compresses or slowing the rate does not address the infiltration, and documenting without action is inappropriate. ________________________________________ 4. The nurse is caring for a client who is two days post-operative following abdominal surgery. The client reports feeling constipated and requests a laxative. Which assessment finding would indicate that the nurse should question this request? A) The client has not had a bowel movement in three days B) The client's abdomen is soft and non-distended C) The client has hypoactive bowel sounds in all four quadrants D) The client reports passing flatus earlier in the day Correct Answer: C) The client has hypoactive bowel sounds in all four quadrants Rationale: Hypoactive bowel sounds may indicate an ileus or decreased intestinal motility, which is common post-operatively. Administering laxatives when bowel sounds are hypoactive could be harmful and may lead to complications. A soft, non-distended abdomen and passing flatus are positive signs, and three days without a bowel movement is not immediately concerning post-operatively. ________________________________________ 5. A client with diabetes mellitus is experiencing hypoglycemia. The client is conscious and able to swallow. Which intervention should the nurse implement first? A) Administer 50% dextrose intravenously B) Give the client 4 ounces of orange juice C) Administer glucagon subcutaneously D) Give the client two packets of table sugar Correct Answer: B) Give the client 4 ounces of orange juice Rationale: For a conscious client experiencing hypoglycemia, the first line of treatment is to administer 15 grams of fast-acting carbohydrate, such as 4 ounces of orange juice or regular soda. IV dextrose and