RN HESI EVOLVE FUNDAMENTALS EXAM - EXAMINATION
COMPLETE QUESTIONS AND DETAILED SOLUTIONS
LATEST UPDATE THIS YEAR JUST RELEASED
Question 1: Which assessment data would provide the most
accurate determination of proper placement of a nasogastric tube?
A. Aspirating gastric contents to assure a pH value of 4 or less.
B. Hearing air pass in the stomach after injecting air into the tubing.
C. Examining a chest x-ray obtained after the tubing was inserted.
D. Checking the remaining length of tubing to ensure that the correct
length was inserted
Answer:
C. Both (A and B) are methods used to determine proper placement of the NG
tubing. However, the best indicator that the tubing is properly placed is (C).
(D) is not an indicator of proper placement.
Question 2: The nurse is caring for a client who is receiving
24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr.
When initially assessing the client, the nurse notes that the TPN
solution has run out and the next TPN solution is not available.
What immediate action should the nurse take?
A. Infuse normal saline at a keep vein open rate.
B. Discontinue the IV and flush the port with heparin.
C. Infuse 10 percent dextrose and water at 54 ml/hr.
D. Obtain a stat blood glucose level and notify the healthcare
provider.
Answer:
, C. TPN is discontinued gradually to allow the client to adjust to decreased
levels of glucose. Administering 10% dextrose in water at the prescribed rate
(C) will keep the client from experiencing hypoglycemia until the next TPN
solution is available. The client could experience a hypoglycemic reaction if
the current level of glucose (A) is not maintained or if the TPN is discontinued
abruptly (B). There is no reason to obtain a stat blood glucose level (D) and
the healthcare provider cannot do anything about this situation.
Question 3: When assisting an 82-year-old client to ambulate, it is
important for the nurse to realize that the center of gravity for an
elderly person is the
A. Arms.
B. Upper torso.
C. Head.
D. Feet.
Answer:
B. The center of gravity for adults is the hips. However, as the person grows
older, a stooped posture is common because of the changes from
osteoporosis and normal bone degeneration, and the knees, hips, and elbows
flex. This stooped posture results in the upper torso (B) becoming the center
of gravity for older persons. Although (A) is a part, or an extension of the
upper torso, this is not the best and most complete answer.
Question 4: In developing a plan of care for a client with dementia,
the nurse should remember that confusion in the elderly
A. is to be expected, and progresses with age.
B. often follows relocation to new surroundings.
C. is a result of irreversible brain pathology.
D. can be prevented with adequate sleep.
Answer:
, B. Relocation (B) often results in confusion among elderly clients--moving is
stressful for anyone. (A) is a stereotypical judgment. Stress in the elderly
often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a
prevention (D) for confusion.
Question 5: An elderly male client who suffered a cerebral vascular
accident is receiving tube feedings via a gastrostomy tube. The
nurse knows that the best position for this client during
administration of the feedings is
A. prone.
B. Fowler's.
C. Sims'.
D. supine.
Answer:
B. The client should be positioned in a semi-sitting or Fowler's (B) position
during feeding, in order to decrease the chance of aspiration. A gastrostomy
tube, often referred to as a PEG tube, is inserted directly into the stomach
through an incision in the abdomen and is used when long-term tube feedings
are needed. In (A and/or C) positions, the client would be lying on his
abdomen and on the tubing. In (D), the client would be lying flat on his back
which would increase the chance of aspiration.
Question 6: The nurse notices that the mother a 9-year-old
Vietnamese child always looks at the floor when she talks to the
nurse. What action should the nurse take?
A. Talk directly to the child instead of the mother.
B. Continue asking the mother questions about the child.
C. Ask another nurse to interview the mother now.
D. Tell the mother politely to look at you when answering
Answer:
, B. - Eye contact is a culturally influenced form of non-verbal communication.
In some non-Western cultures, such as the Vietnamese culture, a client or
family member may avoid eye contact as a form of respect, so the nurse
should continue to ask the mother questions about the child (B). (A, C, and D)
are not indicated.
Question 7: When conducting an admission assessment, the nurse
should ask the client about the use of complimentary healing
practices. Which statement is accurate regarding the use of these
practices?
A. Complimentary healing practices interfere with the efficacy of the
medical model of treatment.
B. Conventional medications are likely to interact with folk remedies
and cause adverse effects.
C. Many complimentary healing practices can be used in conjunction
with conventional practices.
D. Conventional medical practices will ultimately replace the use of
complimentary healing practices.
Answer:
C. Conventional approaches to health care can be depersonalizing and often
fail to take into consideration all aspects of an individual, including body,
mind, and spirit. Often complimentary healing practices can be used in
conjunction with conventional medical practices (C), rather than interfering (A)
with conventional practices, causing adverse effects (B), or replacing
conventional medical care (D).
Question 8: A young mother of three children complains of
increased anxiety during her annual physical exam. What
information should the nurse obtain first?
A. Sexual activity patterns.
B. Nutritional history.
C. Leisure activities.
COMPLETE QUESTIONS AND DETAILED SOLUTIONS
LATEST UPDATE THIS YEAR JUST RELEASED
Question 1: Which assessment data would provide the most
accurate determination of proper placement of a nasogastric tube?
A. Aspirating gastric contents to assure a pH value of 4 or less.
B. Hearing air pass in the stomach after injecting air into the tubing.
C. Examining a chest x-ray obtained after the tubing was inserted.
D. Checking the remaining length of tubing to ensure that the correct
length was inserted
Answer:
C. Both (A and B) are methods used to determine proper placement of the NG
tubing. However, the best indicator that the tubing is properly placed is (C).
(D) is not an indicator of proper placement.
Question 2: The nurse is caring for a client who is receiving
24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr.
When initially assessing the client, the nurse notes that the TPN
solution has run out and the next TPN solution is not available.
What immediate action should the nurse take?
A. Infuse normal saline at a keep vein open rate.
B. Discontinue the IV and flush the port with heparin.
C. Infuse 10 percent dextrose and water at 54 ml/hr.
D. Obtain a stat blood glucose level and notify the healthcare
provider.
Answer:
, C. TPN is discontinued gradually to allow the client to adjust to decreased
levels of glucose. Administering 10% dextrose in water at the prescribed rate
(C) will keep the client from experiencing hypoglycemia until the next TPN
solution is available. The client could experience a hypoglycemic reaction if
the current level of glucose (A) is not maintained or if the TPN is discontinued
abruptly (B). There is no reason to obtain a stat blood glucose level (D) and
the healthcare provider cannot do anything about this situation.
Question 3: When assisting an 82-year-old client to ambulate, it is
important for the nurse to realize that the center of gravity for an
elderly person is the
A. Arms.
B. Upper torso.
C. Head.
D. Feet.
Answer:
B. The center of gravity for adults is the hips. However, as the person grows
older, a stooped posture is common because of the changes from
osteoporosis and normal bone degeneration, and the knees, hips, and elbows
flex. This stooped posture results in the upper torso (B) becoming the center
of gravity for older persons. Although (A) is a part, or an extension of the
upper torso, this is not the best and most complete answer.
Question 4: In developing a plan of care for a client with dementia,
the nurse should remember that confusion in the elderly
A. is to be expected, and progresses with age.
B. often follows relocation to new surroundings.
C. is a result of irreversible brain pathology.
D. can be prevented with adequate sleep.
Answer:
, B. Relocation (B) often results in confusion among elderly clients--moving is
stressful for anyone. (A) is a stereotypical judgment. Stress in the elderly
often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a
prevention (D) for confusion.
Question 5: An elderly male client who suffered a cerebral vascular
accident is receiving tube feedings via a gastrostomy tube. The
nurse knows that the best position for this client during
administration of the feedings is
A. prone.
B. Fowler's.
C. Sims'.
D. supine.
Answer:
B. The client should be positioned in a semi-sitting or Fowler's (B) position
during feeding, in order to decrease the chance of aspiration. A gastrostomy
tube, often referred to as a PEG tube, is inserted directly into the stomach
through an incision in the abdomen and is used when long-term tube feedings
are needed. In (A and/or C) positions, the client would be lying on his
abdomen and on the tubing. In (D), the client would be lying flat on his back
which would increase the chance of aspiration.
Question 6: The nurse notices that the mother a 9-year-old
Vietnamese child always looks at the floor when she talks to the
nurse. What action should the nurse take?
A. Talk directly to the child instead of the mother.
B. Continue asking the mother questions about the child.
C. Ask another nurse to interview the mother now.
D. Tell the mother politely to look at you when answering
Answer:
, B. - Eye contact is a culturally influenced form of non-verbal communication.
In some non-Western cultures, such as the Vietnamese culture, a client or
family member may avoid eye contact as a form of respect, so the nurse
should continue to ask the mother questions about the child (B). (A, C, and D)
are not indicated.
Question 7: When conducting an admission assessment, the nurse
should ask the client about the use of complimentary healing
practices. Which statement is accurate regarding the use of these
practices?
A. Complimentary healing practices interfere with the efficacy of the
medical model of treatment.
B. Conventional medications are likely to interact with folk remedies
and cause adverse effects.
C. Many complimentary healing practices can be used in conjunction
with conventional practices.
D. Conventional medical practices will ultimately replace the use of
complimentary healing practices.
Answer:
C. Conventional approaches to health care can be depersonalizing and often
fail to take into consideration all aspects of an individual, including body,
mind, and spirit. Often complimentary healing practices can be used in
conjunction with conventional medical practices (C), rather than interfering (A)
with conventional practices, causing adverse effects (B), or replacing
conventional medical care (D).
Question 8: A young mother of three children complains of
increased anxiety during her annual physical exam. What
information should the nurse obtain first?
A. Sexual activity patterns.
B. Nutritional history.
C. Leisure activities.
