EVOLVE HESI FUNDAMENTALS ACTUAL
EXAM 2024/2025 EXPERT VERIFIED WITH
DETAILED ANSWERS AND RATIONALES|
GUARANTEED PASS
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure
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33 is essential to the client's nursing care?
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A. Massage any reddened areas for at least five minutes. 33 33 33 33 33 33 33 33
B. Encourage active range of motion exercises on extremities. 33 33 33 33 33 33 33
C. Position the client laterally, prone, and dorsally in sequence.
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D. Gently lift the client when moving into a desired position. - ANSWER>>To
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33 avoid shearing forces when repositioning, the client should be lifted gently
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33 across a surface (D). Reddened areas should not be massaged (A) since this may
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33 increase the damage to already traumatized skin. To control pain and muscle
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33 spasms, active range of motion (B) may be limited on the affected leg. The
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33 position described in (C) is contraindicated for a client with a fractured left hip.
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Correct Answer: D 33 33
The nurse is administering medications through a nasogastric tube (NGT) which is
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33 connected to suction. After ensuring correct tube placement, what action should
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33 the nurse take next?
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A. Clamp the tube for 20 minutes. 33 33 33 33 33
B. Flush the tube with water. 33 33 33 33
,C. Administer the medications as prescribed.
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D. Crush the tablets and dissolve in sterile water. - ANSWER>>The NGT should be
33 33 33 33 33 33 33 33 33 33 33 33 33
33 flushed before, after and in between each medication administered (B). Once all
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medications are administered, the NGT should be clamped for 20 minutes (A). (C
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33 and D) may be implemented only after the tubing has been flushed.
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Correct Answer: B 33 33
A client who is in hospice care complains of increasing amounts of pain. The
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33 healthcare provider prescribes an analgesic every four hours as needed. Which
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33 action should the nurse implement? 33 33 33 33
A. Give an around-the-clock schedule for administration of analgesics.
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B. Administer analgesic medication as needed when the pain is severe.
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C. Provide medication to keep the client sedated and unaware of stimuli.
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D. Offer a medication-free period so that the client can do daily activities. -
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33 ANSWER>>The most effective management of pain is achieved using an 33 33 33 33 33 33 33 33 33
33 around-the-clock schedule that provides analgesic medications on a regular 33 33 33 33 33 33 33 33
basis (A) and in a timely manner. Analgesics are less effective if pain persists until it
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is severe, so an analgesic medication should be administered before the client's
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33 pain peaks (B). Providing comfort is a priority for the client who is dying, but
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33 sedation that impairs the client's ability to interact and experience the time before
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33 life ends should be minimized (C). Offering a medication-free period allows the
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33 serum drug level to fall, which is not an effective method to manage chronic pain
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33 (D).
Correct Answer: A 33 33
When assessing a client with wrist restraints, the nurse observes that the fingers
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33 on the right hand are blue. What action should the nurse implement first?
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A. Loosen the right wrist restraint.
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,B. Apply a pulse oximeter to the right hand.
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C. Compare hand color bilaterally.
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D. Palpate the right radial pulse. - ANSWER>>The priority nursing action is to
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33 restore circulation by loosening the restraint (A), because blue fingers (cyanosis)
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33 indicates decreased circulation. (C and D) are also important nursing
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33 interventions, but do not have the priority of (A). Pulse oximetry (B) measures the
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33 saturation of hemoglobin with oxygen and is not indicated in situations where the
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33 cyanosis is related to mechanical compression (the restraints).
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Correct Answer: A 33 33
The nurse is assessing the nutritional status of several clients. Which client has the
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33 greatest nutritional need for additional intake of protein?
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A. A college-age track runner with a sprained ankle.
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B. A lactating woman nursing her 3-day-old infant.
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C. A school-aged child with Type 2 diabetes.
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D. An elderly man being treated for a peptic ulcer. - ANSWER>>A lactating
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33 woman (B) has the greatest need for additional protein intake. (A, C, and D) are all
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33 conditions that require protein, but do not have the increased metabolic protein
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33 demands of lactation. 33 33
Correct Answer: B 33 33
A client is in the radiology department at 0900 when the prescription levofloxacin
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33 (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to
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the unit at 1300. What is the best intervention for the nurse to implement?
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A. Contact the healthcare provider and complete a medication variance form.
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B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
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, C. Notify the charge nurse and complete an incident report to explain the missed
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dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at
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33 1300. - ANSWER>>To ensure that a therapeutic level of medication is maintained,
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33 the nurse should administer the missed dose as soon as possible, and revise the
33 33 33 33 33 33 33 33 33 33 33 33 33
33 administration schedule accordingly to prevent dangerously increasing the level 33 33 33 33 33 33 33 33
33 of the medication in the bloodstream (D). The nurse should document the reason
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for the late dose, but (A and C) are not warranted. (B) could result in increased
33 33 33 33 33 33 33 33 33 33 33 33 33 33 33 33
33 blood levels of the drug. 33 33 33 33
Correct Answer: D 33 33
While instructing a male client's wife in the performance of passive range-of-
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33 motion exercises to his contracted shoulder, the nurse observes that she is
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33 holding his arm above and below the elbow. What nursing action should the
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33 nurse implement? 33
A. Acknowledge that she is supporting the arm correctly.
33 33 33 33 33 33 33 33
B. Encourage her to keep the joint covered to maintain warmth.
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C. Reinforce the need to grip directly under the joint for better support.
33 33 33 33 33 33 33 33 33 33 33 33
D. Instruct her to grip directly over the joint for better motion. - ANSWER>>The
33 33 33 33 33 33 33 33 33 33 33 33 33
33 wife is performing the passive ROM correctly, therefore the nurse should
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33 acknowledge this fact (A). The joint that is being exercised should be uncovered 33 33 33 33 33 33 33 33 33 33 33 33
(B) while the rest of the body should remain covered for warmth and privacy. (C
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33 and D) do not provide adequate support to the joint while still allowing for joint
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33 movement.
Correct Answer: A 33 33
What is the most important reason for starting intravenous infusions in the upper
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33 extremities rather than the lower extremities of adults? 33 33 33 33 33 33 33
EXAM 2024/2025 EXPERT VERIFIED WITH
DETAILED ANSWERS AND RATIONALES|
GUARANTEED PASS
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure
33 33 33 33 33 33 33 33 33 33 33 33 33 33
33 is essential to the client's nursing care?
33 33 33 33 33 33
A. Massage any reddened areas for at least five minutes. 33 33 33 33 33 33 33 33
B. Encourage active range of motion exercises on extremities. 33 33 33 33 33 33 33
C. Position the client laterally, prone, and dorsally in sequence.
33 33 33 33 33 33 33 33
D. Gently lift the client when moving into a desired position. - ANSWER>>To
33 33 33 33 33 33 33 33 33 33 33
33 avoid shearing forces when repositioning, the client should be lifted gently
33 33 33 33 33 33 33 33 33 33
33 across a surface (D). Reddened areas should not be massaged (A) since this may
33 33 33 33 33 33 33 33 33 33 33 33 33
33 increase the damage to already traumatized skin. To control pain and muscle
33 33 33 33 33 33 33 33 33 33 33
33 spasms, active range of motion (B) may be limited on the affected leg. The
33 33 33 33 33 33 33 33 33 33 33 33 33
33 position described in (C) is contraindicated for a client with a fractured left hip.
33 33 33 33 33 33 33 33 33 33 33 33 33
Correct Answer: D 33 33
The nurse is administering medications through a nasogastric tube (NGT) which is
33 33 33 33 33 33 33 33 33 33 33
33 connected to suction. After ensuring correct tube placement, what action should
33 33 33 33 33 33 33 33 33 33
33 the nurse take next?
33 33 33
A. Clamp the tube for 20 minutes. 33 33 33 33 33
B. Flush the tube with water. 33 33 33 33
,C. Administer the medications as prescribed.
33 33 33 33 33
D. Crush the tablets and dissolve in sterile water. - ANSWER>>The NGT should be
33 33 33 33 33 33 33 33 33 33 33 33 33
33 flushed before, after and in between each medication administered (B). Once all
33 33 33 33 33 33 33 33 33 33 33
medications are administered, the NGT should be clamped for 20 minutes (A). (C
33 33 33 33 33 33 33 33 33 33 33 33 33
33 and D) may be implemented only after the tubing has been flushed.
33 33 33 33 33 33 33 33 33 33 33
Correct Answer: B 33 33
A client who is in hospice care complains of increasing amounts of pain. The
33 33 33 33 33 33 33 33 33 33 33 33 33
33 healthcare provider prescribes an analgesic every four hours as needed. Which
33 33 33 33 33 33 33 33 33 33
33 action should the nurse implement? 33 33 33 33
A. Give an around-the-clock schedule for administration of analgesics.
33 33 33 33 33 33 33 33
B. Administer analgesic medication as needed when the pain is severe.
33 33 33 33 33 33 33 33 33 33
C. Provide medication to keep the client sedated and unaware of stimuli.
33 33 33 33 33 33 33 33 33 33 33
D. Offer a medication-free period so that the client can do daily activities. -
33 33 33 33 33 33 33 33 33 33 33 33 33
33 ANSWER>>The most effective management of pain is achieved using an 33 33 33 33 33 33 33 33 33
33 around-the-clock schedule that provides analgesic medications on a regular 33 33 33 33 33 33 33 33
basis (A) and in a timely manner. Analgesics are less effective if pain persists until it
33 33 33 33 33 33 33 33 33 33 33 33 33 33 33
is severe, so an analgesic medication should be administered before the client's
33 33 33 33 33 33 33 33 33 33 33 33
33 pain peaks (B). Providing comfort is a priority for the client who is dying, but
33 33 33 33 33 33 33 33 33 33 33 33 33 33
33 sedation that impairs the client's ability to interact and experience the time before
33 33 33 33 33 33 33 33 33 33 33 33
33 life ends should be minimized (C). Offering a medication-free period allows the
33 33 33 33 33 33 33 33 33 33 33
33 serum drug level to fall, which is not an effective method to manage chronic pain
33 33 33 33 33 33 33 33 33 33 33 33 33 33
33 (D).
Correct Answer: A 33 33
When assessing a client with wrist restraints, the nurse observes that the fingers
33 33 33 33 33 33 33 33 33 33 33 33
33 on the right hand are blue. What action should the nurse implement first?
33 33 33 33 33 33 33 33 33 33 33 33
A. Loosen the right wrist restraint.
33 33 33 33 33
,B. Apply a pulse oximeter to the right hand.
33 33 33 33 33 33 33 33
C. Compare hand color bilaterally.
33 33 33 33
D. Palpate the right radial pulse. - ANSWER>>The priority nursing action is to
33 33 33 33 33 33 33 33 33 33 33 33
33 restore circulation by loosening the restraint (A), because blue fingers (cyanosis)
33 33 33 33 33 33 33 33 33 33
33 indicates decreased circulation. (C and D) are also important nursing
33 33 33 33 33 33 33 33 33
33 interventions, but do not have the priority of (A). Pulse oximetry (B) measures the
33 33 33 33 33 33 33 33 33 33 33 33 33
33 saturation of hemoglobin with oxygen and is not indicated in situations where the
33 33 33 33 33 33 33 33 33 33 33 33
33 cyanosis is related to mechanical compression (the restraints).
33 33 33 33 33 33 33
Correct Answer: A 33 33
The nurse is assessing the nutritional status of several clients. Which client has the
33 33 33 33 33 33 33 33 33 33 33 33 33
33 greatest nutritional need for additional intake of protein?
33 33 33 33 33 33 33
A. A college-age track runner with a sprained ankle.
33 33 33 33 33 33 33 33
B. A lactating woman nursing her 3-day-old infant.
33 33 33 33 33 33 33
C. A school-aged child with Type 2 diabetes.
33 33 33 33 33 33 33
D. An elderly man being treated for a peptic ulcer. - ANSWER>>A lactating
33 33 33 33 33 33 33 33 33 33 33 33
33 woman (B) has the greatest need for additional protein intake. (A, C, and D) are all
33 33 33 33 33 33 33 33 33 33 33 33 33 33 33
33 conditions that require protein, but do not have the increased metabolic protein
33 33 33 33 33 33 33 33 33 33 33
33 demands of lactation. 33 33
Correct Answer: B 33 33
A client is in the radiology department at 0900 when the prescription levofloxacin
33 33 33 33 33 33 33 33 33 33 33 33
33 (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to
33 33 33 33 33 33 33 33 33 33 33 33 33
the unit at 1300. What is the best intervention for the nurse to implement?
33 33 33 33 33 33 33 33 33 33 33 33 33 33
A. Contact the healthcare provider and complete a medication variance form.
33 33 33 33 33 33 33 33 33 33
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
33 33 33 33 33 33 33 33 33 33 33 33 33
, C. Notify the charge nurse and complete an incident report to explain the missed
33 33 33 33 33 33 33 33 33 33 33 33 33
dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at
33 33 33 33 33 33 33 33 33 33 33 33 33 33
33 1300. - ANSWER>>To ensure that a therapeutic level of medication is maintained,
33 33 33 33 33 33 33 33 33 33 33
33 the nurse should administer the missed dose as soon as possible, and revise the
33 33 33 33 33 33 33 33 33 33 33 33 33
33 administration schedule accordingly to prevent dangerously increasing the level 33 33 33 33 33 33 33 33
33 of the medication in the bloodstream (D). The nurse should document the reason
33 33 33 33 33 33 33 33 33 33 33 33
for the late dose, but (A and C) are not warranted. (B) could result in increased
33 33 33 33 33 33 33 33 33 33 33 33 33 33 33 33
33 blood levels of the drug. 33 33 33 33
Correct Answer: D 33 33
While instructing a male client's wife in the performance of passive range-of-
33 33 33 33 33 33 33 33 33 33 33
33 motion exercises to his contracted shoulder, the nurse observes that she is
33 33 33 33 33 33 33 33 33 33 33
33 holding his arm above and below the elbow. What nursing action should the
33 33 33 33 33 33 33 33 33 33 33 33
33 nurse implement? 33
A. Acknowledge that she is supporting the arm correctly.
33 33 33 33 33 33 33 33
B. Encourage her to keep the joint covered to maintain warmth.
33 33 33 33 33 33 33 33 33 33
C. Reinforce the need to grip directly under the joint for better support.
33 33 33 33 33 33 33 33 33 33 33 33
D. Instruct her to grip directly over the joint for better motion. - ANSWER>>The
33 33 33 33 33 33 33 33 33 33 33 33 33
33 wife is performing the passive ROM correctly, therefore the nurse should
33 33 33 33 33 33 33 33 33 33
33 acknowledge this fact (A). The joint that is being exercised should be uncovered 33 33 33 33 33 33 33 33 33 33 33 33
(B) while the rest of the body should remain covered for warmth and privacy. (C
33 33 33 33 33 33 33 33 33 33 33 33 33 33
33 and D) do not provide adequate support to the joint while still allowing for joint
33 33 33 33 33 33 33 33 33 33 33 33 33 33
33 movement.
Correct Answer: A 33 33
What is the most important reason for starting intravenous infusions in the upper
33 33 33 33 33 33 33 33 33 33 33 33
33 extremities rather than the lower extremities of adults? 33 33 33 33 33 33 33
