1|Page
EVOLVE HESI FUNDAMENTALS ACTUAL FINAL EXAM BANK |
WITH COMPLETE QUESTIONS AND ANSWERS | 2025/206 LATEST
UPDATED | 100 % RATED AND VERIFIED SOLUTIONS | GET AN A+
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential
to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position. - (ANSWER)To avoid shearing
forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas
should not be massaged (A) since this may increase the damage to already traumatized skin. To
control pain and muscle spasms, active range of motion (B) may be limited on the affected leg.
The position described in (C) is contraindicated for a client with a fractured left hip.
Correct Answer: D
The nurse is administering medications through a nasogastric tube (NGT) which is connected to
suction. After ensuring correct tube placement, what action should the nurse take next?
,2|Page
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water. - (ANSWER)The NGT should be flushed
before, after and in between each medication administered (B). Once all medications are
administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented
only after the tubing has been flushed.
Correct Answer: B
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. - (ANSWER)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
,3|Page
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. - (ANSWER)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).
, 4|Page
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. - (ANSWER)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.
EVOLVE HESI FUNDAMENTALS ACTUAL FINAL EXAM BANK |
WITH COMPLETE QUESTIONS AND ANSWERS | 2025/206 LATEST
UPDATED | 100 % RATED AND VERIFIED SOLUTIONS | GET AN A+
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential
to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position. - (ANSWER)To avoid shearing
forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas
should not be massaged (A) since this may increase the damage to already traumatized skin. To
control pain and muscle spasms, active range of motion (B) may be limited on the affected leg.
The position described in (C) is contraindicated for a client with a fractured left hip.
Correct Answer: D
The nurse is administering medications through a nasogastric tube (NGT) which is connected to
suction. After ensuring correct tube placement, what action should the nurse take next?
,2|Page
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water. - (ANSWER)The NGT should be flushed
before, after and in between each medication administered (B). Once all medications are
administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented
only after the tubing has been flushed.
Correct Answer: B
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. - (ANSWER)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
,3|Page
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. - (ANSWER)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).
, 4|Page
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. - (ANSWER)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.
