Evolve HESI Practice
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and Rationales | Graded A+
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Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive Rationales
Included
, A 6-month-old infant with congestive heart failure (CHF) is Apical heart rate of 60.
receiving digoxin elixir. Which observation by the nurse
warrants immediate intervention? A heart rate of 60 (A) is much lower than normal for a 6-month-old and warrants
Apical heart rate of 60. immediate intervention. The normal heart rate for a 6-month-old is 80 to 150 BPM
Sweating across the forehead. when awake, and a rate of 70 while sleeping is considered within normal limits. (B
Doesn't suck well. and C) are expected symptoms of heart failure in an infant. (D) is within normal
Respiratory rate of 30 breaths per minute. limits for an infant.
The nurse is teaching the parents of a 5-year-old with Administer aerosol therapy followed by postural drainage before meals.
cystic fibrosis about respiratory treatments. Which
statement indicates to the nurse that the parents Postural drainage for a child with cystic fibrosis is most effective when performed
understand? after nebulization and before meals (C) or at least 1 hour after eating to prevent
Perform postural drainage before starting aerosol therapy. nausea and vomiting. Postural drainage uses gravity to promote mucous removal
Give respiratory treatments when the child is coughing a after nebulization (A) treatments which open the airways. Pulmonary toileting or
lot. respiratory treatments should be given 3 to 4 times daily, not episodically (B and D).
Administer aerosol therapy followed by postural drainage
before meals.
Ensure respiratory therapy is done daily during any
respiratory infection.
A female teenager is taking oral tetracycline HCL Use sunscreen when lying by the pool.
(Achromycin V) for acne vulgaris. What is the most
important instruction for the nurse to include in this client's Photosensitivity is a common side effect of tetracycline HCL (Achromycin V)
teaching plan? therapy. Severe sunburn can occur with minimal sun exposure and clients should
Use sunscreen when lying by the pool. be instructed to avoid sunlight and to use sunscreen (A). (B and D) are not related
Cleanse the skin at least 4 times a day. to tetracycline HCL (Achromycin V) therapy. (C) should be avoided because dairy
Take the medication with a glass of milk. products interfere with the absorption of tetracyclines.
Menstrual periods may become irregular.
What preoperative nursing intervention should be included Observe for projectile vomiting.
in the plan of care for an infant with pyloric stenosis?
Monitor for signs of metabolic acidosis. Projectile vomiting (D), which contributes to metabolic alkalosis (A), is the classic
Estimate the quantity of diarrhea stools. sign of pyloric stenosis. (B) is not indicated. (C) is dangerous, due to the potential
Place in a supine position after feeding. for aspiration with frequent vomiting.
Observe for projectile vomiting.
An infant is born with a ventricular septal defect (VSD) and Prevent the return of oxygenated blood to the lungs.
surgery is planned to correct the defect. The nurse
recognizes that surgical correction is designed to achieve Closure of VSDs stops oxygenated blood from being shunted from the left ventricle
which outcome? to the right ventricle (C). VSDs are acyanotic defects, which means that no
Stop the flow of unoxygenated blood into systemic unoxygenated blood enters the systemic circulation (A and B). (D) is common with
circulation. Tetrology of Fallot, which is a cyanotic defect.
Increase the flow of unoxygenated blood to the lungs.
Prevent the return of oxygenated blood to the lungs.
Reduce peripheral tissue hypoxia and nailbed clubbing
A 3-week-old newborn is brought to the clinic for follow-up A. Monitor the the infant's weight and number of wet diapers per day.
after a home birth. The mother reports that her child bottle B. Increase the infant's intake per feeding by 1 to 2 ounces per week.
feeds for 5 minutes only and then falls asleep. The nurse D. Allow the infant to rest and refeed on demand or every 2 hours.
auscultates a loud murmur characteristic of a ventricular E. Use a softer nipple or increase the size of the nipple opening.
septal defect (VSD), and finds the newborn is acyanotic
with a respiratory rate of 64 breaths per minute. What Antibiotic prophylaxis is recommended for infants with VSDs, but should not be
instruction should the nurse provide the mother to ensure mixed in a bottle of formula (C) because it is difficult to ensure that the total dose is
the infant is receiving adequate intake? (Select all that consumed.
apply.)
A. Monitor the the infant's weight and number of wet They should be monitored for weight gain and at least 6 wet diapers per day (A). A
diapers per day. one-month old infant should ingest 2 to 4 ounces of formula per feeding and
B. Increase the infant's intake per feeding by 1 to 2 ounces progress to about 30 ounces per day by 4-months of age (B)
per week.
C. Mix the dose of prophylactic antibiotic in a full bottle of
formula.
D. Allow the infant to rest and refeed on demand or every
2 hours.
E. Use a softer nipple or increase the size of the nipple
opening.
Questions | Comprehensive
Study Guide with Answers
and Rationales | Graded A+
| Guaranteed Success
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive Rationales
Included
, A 6-month-old infant with congestive heart failure (CHF) is Apical heart rate of 60.
receiving digoxin elixir. Which observation by the nurse
warrants immediate intervention? A heart rate of 60 (A) is much lower than normal for a 6-month-old and warrants
Apical heart rate of 60. immediate intervention. The normal heart rate for a 6-month-old is 80 to 150 BPM
Sweating across the forehead. when awake, and a rate of 70 while sleeping is considered within normal limits. (B
Doesn't suck well. and C) are expected symptoms of heart failure in an infant. (D) is within normal
Respiratory rate of 30 breaths per minute. limits for an infant.
The nurse is teaching the parents of a 5-year-old with Administer aerosol therapy followed by postural drainage before meals.
cystic fibrosis about respiratory treatments. Which
statement indicates to the nurse that the parents Postural drainage for a child with cystic fibrosis is most effective when performed
understand? after nebulization and before meals (C) or at least 1 hour after eating to prevent
Perform postural drainage before starting aerosol therapy. nausea and vomiting. Postural drainage uses gravity to promote mucous removal
Give respiratory treatments when the child is coughing a after nebulization (A) treatments which open the airways. Pulmonary toileting or
lot. respiratory treatments should be given 3 to 4 times daily, not episodically (B and D).
Administer aerosol therapy followed by postural drainage
before meals.
Ensure respiratory therapy is done daily during any
respiratory infection.
A female teenager is taking oral tetracycline HCL Use sunscreen when lying by the pool.
(Achromycin V) for acne vulgaris. What is the most
important instruction for the nurse to include in this client's Photosensitivity is a common side effect of tetracycline HCL (Achromycin V)
teaching plan? therapy. Severe sunburn can occur with minimal sun exposure and clients should
Use sunscreen when lying by the pool. be instructed to avoid sunlight and to use sunscreen (A). (B and D) are not related
Cleanse the skin at least 4 times a day. to tetracycline HCL (Achromycin V) therapy. (C) should be avoided because dairy
Take the medication with a glass of milk. products interfere with the absorption of tetracyclines.
Menstrual periods may become irregular.
What preoperative nursing intervention should be included Observe for projectile vomiting.
in the plan of care for an infant with pyloric stenosis?
Monitor for signs of metabolic acidosis. Projectile vomiting (D), which contributes to metabolic alkalosis (A), is the classic
Estimate the quantity of diarrhea stools. sign of pyloric stenosis. (B) is not indicated. (C) is dangerous, due to the potential
Place in a supine position after feeding. for aspiration with frequent vomiting.
Observe for projectile vomiting.
An infant is born with a ventricular septal defect (VSD) and Prevent the return of oxygenated blood to the lungs.
surgery is planned to correct the defect. The nurse
recognizes that surgical correction is designed to achieve Closure of VSDs stops oxygenated blood from being shunted from the left ventricle
which outcome? to the right ventricle (C). VSDs are acyanotic defects, which means that no
Stop the flow of unoxygenated blood into systemic unoxygenated blood enters the systemic circulation (A and B). (D) is common with
circulation. Tetrology of Fallot, which is a cyanotic defect.
Increase the flow of unoxygenated blood to the lungs.
Prevent the return of oxygenated blood to the lungs.
Reduce peripheral tissue hypoxia and nailbed clubbing
A 3-week-old newborn is brought to the clinic for follow-up A. Monitor the the infant's weight and number of wet diapers per day.
after a home birth. The mother reports that her child bottle B. Increase the infant's intake per feeding by 1 to 2 ounces per week.
feeds for 5 minutes only and then falls asleep. The nurse D. Allow the infant to rest and refeed on demand or every 2 hours.
auscultates a loud murmur characteristic of a ventricular E. Use a softer nipple or increase the size of the nipple opening.
septal defect (VSD), and finds the newborn is acyanotic
with a respiratory rate of 64 breaths per minute. What Antibiotic prophylaxis is recommended for infants with VSDs, but should not be
instruction should the nurse provide the mother to ensure mixed in a bottle of formula (C) because it is difficult to ensure that the total dose is
the infant is receiving adequate intake? (Select all that consumed.
apply.)
A. Monitor the the infant's weight and number of wet They should be monitored for weight gain and at least 6 wet diapers per day (A). A
diapers per day. one-month old infant should ingest 2 to 4 ounces of formula per feeding and
B. Increase the infant's intake per feeding by 1 to 2 ounces progress to about 30 ounces per day by 4-months of age (B)
per week.
C. Mix the dose of prophylactic antibiotic in a full bottle of
formula.
D. Allow the infant to rest and refeed on demand or every
2 hours.
E. Use a softer nipple or increase the size of the nipple
opening.
