Evolve Fundamentals HESI TEST
UPDATED QUESTION AND ANSWERS
,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?
A. Give an around-the-clock schedule for administration of analgesics.
B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities. - CORRECT
ANSWERS-The most effective management of pain is achieved using an around-the-clock
schedule that provides analgesic medications on a regular basis (A) and in a timely manner.
Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be
administered before the client's pain peaks (B). Providing comfort is a priority for the client who
is dying, but sedation that impairs the client's ability to interact and experience the time before
life ends should be minimized (C). Offering a medication-free period allows the serum drug
level to fall, which is not an effective method to manage chronic pain (D).
Correct Answer: A
When assessing a client with wrist restraints, the nurse observes that the fingers on the right
hand are blue. What action should the nurse implement first?
,A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse. - CORRECT ANSWERS-The priority nursing action is to
restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates
decreased circulation. (C and D) are also important nursing interventions, but do not have the
priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin with oxygen and is
not indicated in situations where the cyanosis is related to mechanical compression (the
restraints).
Correct Answer: A
The nurse is assessing the nutritional status of several clients. Which client has the greatest
nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
, D. An elderly man being treated for a peptic ulcer. - CORRECT ANSWERS-A lactating woman
(B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that
require protein, but do not have the increased metabolic protein demands of lactation.
Correct Answer: B
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?
A. Contact the healthcare provider and complete a medication variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
C. Notify the charge nurse and complete an incident report to explain the missed dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. -
CORRECT ANSWERS-To ensure that a therapeutic level of medication is maintained, the nurse
should administer the missed dose as soon as possible, and revise the administration schedule
accordingly to prevent dangerously increasing the level of the medication in the bloodstream
(D). The nurse should document the reason for the late dose, but (A and C) are not warranted.
(B) could result in increased blood levels of the drug.
UPDATED QUESTION AND ANSWERS
,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?
A. Give an around-the-clock schedule for administration of analgesics.
B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities. - CORRECT
ANSWERS-The most effective management of pain is achieved using an around-the-clock
schedule that provides analgesic medications on a regular basis (A) and in a timely manner.
Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be
administered before the client's pain peaks (B). Providing comfort is a priority for the client who
is dying, but sedation that impairs the client's ability to interact and experience the time before
life ends should be minimized (C). Offering a medication-free period allows the serum drug
level to fall, which is not an effective method to manage chronic pain (D).
Correct Answer: A
When assessing a client with wrist restraints, the nurse observes that the fingers on the right
hand are blue. What action should the nurse implement first?
,A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse. - CORRECT ANSWERS-The priority nursing action is to
restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates
decreased circulation. (C and D) are also important nursing interventions, but do not have the
priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin with oxygen and is
not indicated in situations where the cyanosis is related to mechanical compression (the
restraints).
Correct Answer: A
The nurse is assessing the nutritional status of several clients. Which client has the greatest
nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
, D. An elderly man being treated for a peptic ulcer. - CORRECT ANSWERS-A lactating woman
(B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that
require protein, but do not have the increased metabolic protein demands of lactation.
Correct Answer: B
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?
A. Contact the healthcare provider and complete a medication variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
C. Notify the charge nurse and complete an incident report to explain the missed dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. -
CORRECT ANSWERS-To ensure that a therapeutic level of medication is maintained, the nurse
should administer the missed dose as soon as possible, and revise the administration schedule
accordingly to prevent dangerously increasing the level of the medication in the bloodstream
(D). The nurse should document the reason for the late dose, but (A and C) are not warranted.
(B) could result in increased blood levels of the drug.
