Evolve HESI Fundamentals Practice
Exam
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a
continuous pump infusion. He reports that he had a bad bout of severe coughing a few
minutes ago, but feels fine now. What action is best for the nurse to take? - ANSAfter
clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
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? - ANSGive the missed dose at 1300 and
change the schedule to administer daily at 1300.
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? - ANSGive an around-the-clock schedule for administration of analgesics.
After completing an assessment and determining that a client has a problem, which action
should the nurse perform next? - ANSdetermine the etiology of the problem
What is the most important reason for starting intravenous infusions in the upper extremities
rather than the lower extremities of adults? - ANSA decreased flow rate could result in the
formation of a thrombosis.
The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor
when she talks to the nurse. What action should the nurse take? - ANSContinue asking the
mother questions about the child.
Which intervention is most important for the nurse to implement for a male client who is
experiencing urinary retention? - ANSAssess for bladder distention.
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? - ANSBlood transfusions are
forbidden.
While instructing a male client's wife in the performance of passive range-of-motion
exercises to his contracted shoulder, the nurse observes that she is holding his arm above
and below the elbow. What nursing action should the nurse implement? - ANSAcknowledge
that she is supporting the arm correctly.
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is
receiving bolus enteral feedings though a gastrostomy tube. What is the best client position
for administration of the bolus tube feedings? - ANSFowler's.
, An adult male client with a history of hypertension tells the nurse that he is tired of taking
antihypertensive medications and is going to try spiritual meditation instead. What should be
the nurse's first response? - ANSIt is important that you continue your medication while
learning to meditate.
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? - ANS150
The nurse is completing a mental assessment for a client who is demonstrating slow thought
processes, personality changes, and emotional lability. Which area of the brain controls
these neuro-cognitive functions? - ANSFrontal lobe
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? - ANSInitiate an
alternate site for the IV infusion of the medication.
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? - ANSRequest and
document the name of the certified translator.
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? - ANSPlace a pillow between your knees while
lying in bed to prevent hip dislocation.
An elderly resident of a long-term care facility is no longer able to perform self-care and is
becoming progressively weaker. The resident previously requested that no resuscitative
efforts be performed, and the family requests hospice care. What action should the nurse
implement first? - ANSNotify the healthcare provider of the family's request.
A young mother of three children complains of increased anxiety during her annual physical
exam. What information should the nurse obtain first? - ANSNutritional history.
The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The
infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer
approximately how many drops per minute? - ANS21
Three days following surgery, a male client observes his colostomy for the first time. He
becomes quite upset and tells the nurse that it is much bigger than he expected. What is the
best response by the nurse? - ANSInstruct the client that the stoma will become smaller
when the initial swelling diminishes.
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20
mg/2 ml. How many milliliters should the nurse administer? - ANS1.5ml
Exam
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a
continuous pump infusion. He reports that he had a bad bout of severe coughing a few
minutes ago, but feels fine now. What action is best for the nurse to take? - ANSAfter
clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
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? - ANSGive the missed dose at 1300 and
change the schedule to administer daily at 1300.
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? - ANSGive an around-the-clock schedule for administration of analgesics.
After completing an assessment and determining that a client has a problem, which action
should the nurse perform next? - ANSdetermine the etiology of the problem
What is the most important reason for starting intravenous infusions in the upper extremities
rather than the lower extremities of adults? - ANSA decreased flow rate could result in the
formation of a thrombosis.
The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor
when she talks to the nurse. What action should the nurse take? - ANSContinue asking the
mother questions about the child.
Which intervention is most important for the nurse to implement for a male client who is
experiencing urinary retention? - ANSAssess for bladder distention.
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? - ANSBlood transfusions are
forbidden.
While instructing a male client's wife in the performance of passive range-of-motion
exercises to his contracted shoulder, the nurse observes that she is holding his arm above
and below the elbow. What nursing action should the nurse implement? - ANSAcknowledge
that she is supporting the arm correctly.
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is
receiving bolus enteral feedings though a gastrostomy tube. What is the best client position
for administration of the bolus tube feedings? - ANSFowler's.
, An adult male client with a history of hypertension tells the nurse that he is tired of taking
antihypertensive medications and is going to try spiritual meditation instead. What should be
the nurse's first response? - ANSIt is important that you continue your medication while
learning to meditate.
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? - ANS150
The nurse is completing a mental assessment for a client who is demonstrating slow thought
processes, personality changes, and emotional lability. Which area of the brain controls
these neuro-cognitive functions? - ANSFrontal lobe
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? - ANSInitiate an
alternate site for the IV infusion of the medication.
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? - ANSRequest and
document the name of the certified translator.
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? - ANSPlace a pillow between your knees while
lying in bed to prevent hip dislocation.
An elderly resident of a long-term care facility is no longer able to perform self-care and is
becoming progressively weaker. The resident previously requested that no resuscitative
efforts be performed, and the family requests hospice care. What action should the nurse
implement first? - ANSNotify the healthcare provider of the family's request.
A young mother of three children complains of increased anxiety during her annual physical
exam. What information should the nurse obtain first? - ANSNutritional history.
The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The
infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer
approximately how many drops per minute? - ANS21
Three days following surgery, a male client observes his colostomy for the first time. He
becomes quite upset and tells the nurse that it is much bigger than he expected. What is the
best response by the nurse? - ANSInstruct the client that the stoma will become smaller
when the initial swelling diminishes.
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20
mg/2 ml. How many milliliters should the nurse administer? - ANS1.5ml
