Evolve Fundamentals HESI exam
with 100% solution
An elderly client with a fractured left hip is To avoid shearing forces when repositioning, the client
should on strict bedrest. Which nursing measure is be lifted gently across a surface (D). Reddened
areas should essential to the client's nursing care? not be massaged (A) since this may increase the
damage to
already traumatized skin. To control pain and muscle spasms,
A. Massage any reddened areas for at least active range of motion (B) may be limited on the affected
leg. five minutes. The position described in (C) is contraindicated for a
client
B.Encourage active range of motion with a fractured left
hip. exercises on extremities.
C. Position the client laterally, prone, and Correct Answer: D
dorsally in sequence.
D.Gently lift the client when moving into
a desired position.
,The nurse is administering medications The NGT should be flushed before, after and in between each
through a nasogastric tube (NGT) which is medication administered (B). Once all medications are
connected to suction. After ensuring correctadministered, the NGT should be clamped for 20 minutes (A).
tube placement, what action should the (C and D) may be implemented only after the tubing has
been nurse take next? flushed.
A. Clamp the tube for 20 minutes. Correct Answer: B
B.Flush the tube with water.
C. Administer the medications as prescribed.
D.Crush the tablets and dissolve in
sterile water.
A client who is in hospice care complains of The most effective management of pain is achieved using
an increasing amounts of pain. The healthcare around-the-clock schedule that provides
analgesic
provider prescribes an analgesic every four medications on a regular basis (A) and in a timely manner.
hours as needed. Which action should the Analgesics are less effective if pain persists until it is severe,
so nurse implement? an analgesic medication should be administered before
the
client's pain peaks (B). Providing comfort is a priority for the
A. Give an around-the-clock schedule for client who is dying, but sedation that impairs the client's ability
administration of analgesics. to interact and experience the time before life ends should be
B. Administer analgesic medication as minimized
(C). Offering a medication-free period allows the needed when the pain is severe. serum drug level to
fall, which is not an effective method to
C. Provide medication to keep the client manage chronic pain (D).
sedated and unaware of stimuli.
D.Offer a medication-free period so that Correct Answer:
A the client can do daily activities.
When assessing a client with wrist restraints, The priority nursing action is to restore circulation by
the nurse observes that the fingers on the loosening the restraint (A), because blue fingers (cyanosis)
right hand are blue. What action should the indicates decreased circulation. (C and D) are also important
nurse implement first? nursing interventions, but do not have the priority of (A). Pulse
oximetry (B) measures the saturation of hemoglobin with
A. Loosen the right wrist restraint. oxygen and is not indicated in situations where the cyanosis is
B. Apply a pulse oximeter to the right hand. related to
mechanical compression (the restraints).
C. Compare hand color bilaterally.
D.Palpate the right radial pulse. Correct Answer: A
The nurse is assessing the nutritional statusA lactating woman (B) has the greatest need for
additional of several clients. Which client has the protein intake. (A, C, and D) are all conditions
that require greatest nutritional need for additional protein, but do not have the increased
metabolic protein
intake of protein? demands of lactation.
A. A college-age track runner with a Correct Answer: B
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.
,A client is in the radiology department To ensure that a therapeutic level of medication is maintained,
at 0900 when the prescription the nurse should administer the missed dose as soon as
levofloxacin (Levaquin) 500 mg IV q24h possible, and revise the administration schedule accordingly
is scheduled to be administered. The to prevent dangerously increasing the level of the medication
client returns to the in the bloodstream (D). The nurse should document the
unit at 1300. What is the best intervention for reason for the late dose, but (A and C) are not warranted. (B)
the nurse to implement? could result in increased blood levels of the drug.
A. Contact the healthcare provider and Correct Answer: D
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.
While instructing a male client's wife in the The wife is performing the passive ROM correctly, therefore
performance of passive range-of-motion the nurse should acknowledge this fact (A). The joint that is
exercises to his contracted shoulder, the being exercised should be uncovered (B) while the rest of the
nurse observes that she is holding his body should remain covered for warmth and privacy. (C
arm above and below the elbow. What and D) do not provide adequate support to the joint
nursing action should the nurse while still
implement? allowing for joint movement.
A. Acknowledge that she is supporting the Correct Answer: A
arm correctly.
B.Encourage her to keep the joint covered
to maintain warmth.
C. Reinforce the need to grip directly under
the joint for better support.
D.Instruct her to grip directly over the
joint for better motion.
What is the most important reason for Venous return is usually better in the upper extremities.
starting intravenous infusions in the upper Cannulation of the veins in the lower extremities increases the
extremities rather than the lower risk of thrombus formation (B) which, if dislodged, could
extremities of adults? be life-threatening. Superficial veins are often very easy
(A) to
A. It is more difficult to find a superficial find in the feet and legs. Handling a leg or foot with an IV (C)
vein in the feet and ankles. is probably not any more difficult than handling an arm
B.A decreased flow rate could result in or hand. Even if the nurse did believe moving a cannulated
the formation of a thrombosis. leg was more difficult, this is not the most important reason
C. A cannulated extremity is more difficult for
to move when the leg or foot is used. using the upper extremities. Pain (D) is not a consideration.
D.Veins are located deep in the feet and
ankles, resulting in a more painful Correct Answer: B
procedure.
, The nurse observes an unlicensed The most important action is to ensure that an accurate BP
assistive personnel (UAP) taking a reading is obtained. The nurse should reassess the BP with
client's blood the correct size cuff (B). Reassessment should not be
pressure with a cuff that is too small, but the postponed
blood pressure reading obtained is within (A). Though (C and D) are likely indicated, these actions do
the client's usual range. What action is most not have the priority of (B).
important for the nurse to implement?
Correct Answer: B
A. Tell the UAP to use a larger cuff at
the next scheduled assessment.
B.Reassess the client's blood pressure
using a larger cuff.
C. Have the unit educator review
this procedure with the UAPs.
D.Teach the UAP the correct technique for
assessing blood pressure.
Twenty minutes after beginning a heat (D) describes thermal adaptation, which occurs 20 to 30
application, the client states that the heating minutes after heat application. (A and B) provide false
pad no longer feels warm enough. What information. (C) is not based on a knowledge of physiology
is the best response by the nurse? and is an unsafe action that may harm the client.
A. "That means you have derived Correct Answer: D
the maximum benefit, and the heat
can be removed."
B. "Your blood vessels are becoming
dilated and removing the heat from the
site."
C. "We will increase the temperature
5 degrees when the pad no longer
feels warm."
D."The body's receptors adapt over time
as they are exposed to heat."
The nurse is instructing a client with high Limiting saturated fat from animal food sources to no
cholesterol about diet and life style more than 4 ounces per week (C) is an important diet
modification. What comment from the client modification for lowering cholesterol. To be effective in
indicates that the teaching has been reducing
effective? cholesterol, the client should exercise 30 minutes per day, or
at least 4 to 6 times per week (A). Red meat and all proteins
A. "If I exercise at least two times weekly do not need to be eliminated (B) to lower cholesterol, but
for one hour, I will lower my cholesterol." should be restricted to lean cuts of red meat and
B."I need to avoid eating proteins, smaller portions (2-ounce servings). The low density
including red meat." lipoproteins (D) need to decrease rather than increase.
C. "I will limit my intake of beef to 4
ounces per week." Correct Answer: C
D. "My blood level of low
density lipoproteins needs to
increase."
with 100% solution
An elderly client with a fractured left hip is To avoid shearing forces when repositioning, the client
should on strict bedrest. Which nursing measure is be lifted gently across a surface (D). Reddened
areas should essential to the client's nursing care? not be massaged (A) since this may increase the
damage to
already traumatized skin. To control pain and muscle spasms,
A. Massage any reddened areas for at least active range of motion (B) may be limited on the affected
leg. five minutes. The position described in (C) is contraindicated for a
client
B.Encourage active range of motion with a fractured left
hip. exercises on extremities.
C. Position the client laterally, prone, and Correct Answer: D
dorsally in sequence.
D.Gently lift the client when moving into
a desired position.
,The nurse is administering medications The NGT should be flushed before, after and in between each
through a nasogastric tube (NGT) which is medication administered (B). Once all medications are
connected to suction. After ensuring correctadministered, the NGT should be clamped for 20 minutes (A).
tube placement, what action should the (C and D) may be implemented only after the tubing has
been nurse take next? flushed.
A. Clamp the tube for 20 minutes. Correct Answer: B
B.Flush the tube with water.
C. Administer the medications as prescribed.
D.Crush the tablets and dissolve in
sterile water.
A client who is in hospice care complains of The most effective management of pain is achieved using
an increasing amounts of pain. The healthcare around-the-clock schedule that provides
analgesic
provider prescribes an analgesic every four medications on a regular basis (A) and in a timely manner.
hours as needed. Which action should the Analgesics are less effective if pain persists until it is severe,
so nurse implement? an analgesic medication should be administered before
the
client's pain peaks (B). Providing comfort is a priority for the
A. Give an around-the-clock schedule for client who is dying, but sedation that impairs the client's ability
administration of analgesics. to interact and experience the time before life ends should be
B. Administer analgesic medication as minimized
(C). Offering a medication-free period allows the needed when the pain is severe. serum drug level to
fall, which is not an effective method to
C. Provide medication to keep the client manage chronic pain (D).
sedated and unaware of stimuli.
D.Offer a medication-free period so that Correct Answer:
A the client can do daily activities.
When assessing a client with wrist restraints, The priority nursing action is to restore circulation by
the nurse observes that the fingers on the loosening the restraint (A), because blue fingers (cyanosis)
right hand are blue. What action should the indicates decreased circulation. (C and D) are also important
nurse implement first? nursing interventions, but do not have the priority of (A). Pulse
oximetry (B) measures the saturation of hemoglobin with
A. Loosen the right wrist restraint. oxygen and is not indicated in situations where the cyanosis is
B. Apply a pulse oximeter to the right hand. related to
mechanical compression (the restraints).
C. Compare hand color bilaterally.
D.Palpate the right radial pulse. Correct Answer: A
The nurse is assessing the nutritional statusA lactating woman (B) has the greatest need for
additional of several clients. Which client has the protein intake. (A, C, and D) are all conditions
that require greatest nutritional need for additional protein, but do not have the increased
metabolic protein
intake of protein? demands of lactation.
A. A college-age track runner with a Correct Answer: B
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.
,A client is in the radiology department To ensure that a therapeutic level of medication is maintained,
at 0900 when the prescription the nurse should administer the missed dose as soon as
levofloxacin (Levaquin) 500 mg IV q24h possible, and revise the administration schedule accordingly
is scheduled to be administered. The to prevent dangerously increasing the level of the medication
client returns to the in the bloodstream (D). The nurse should document the
unit at 1300. What is the best intervention for reason for the late dose, but (A and C) are not warranted. (B)
the nurse to implement? could result in increased blood levels of the drug.
A. Contact the healthcare provider and Correct Answer: D
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.
While instructing a male client's wife in the The wife is performing the passive ROM correctly, therefore
performance of passive range-of-motion the nurse should acknowledge this fact (A). The joint that is
exercises to his contracted shoulder, the being exercised should be uncovered (B) while the rest of the
nurse observes that she is holding his body should remain covered for warmth and privacy. (C
arm above and below the elbow. What and D) do not provide adequate support to the joint
nursing action should the nurse while still
implement? allowing for joint movement.
A. Acknowledge that she is supporting the Correct Answer: A
arm correctly.
B.Encourage her to keep the joint covered
to maintain warmth.
C. Reinforce the need to grip directly under
the joint for better support.
D.Instruct her to grip directly over the
joint for better motion.
What is the most important reason for Venous return is usually better in the upper extremities.
starting intravenous infusions in the upper Cannulation of the veins in the lower extremities increases the
extremities rather than the lower risk of thrombus formation (B) which, if dislodged, could
extremities of adults? be life-threatening. Superficial veins are often very easy
(A) to
A. It is more difficult to find a superficial find in the feet and legs. Handling a leg or foot with an IV (C)
vein in the feet and ankles. is probably not any more difficult than handling an arm
B.A decreased flow rate could result in or hand. Even if the nurse did believe moving a cannulated
the formation of a thrombosis. leg was more difficult, this is not the most important reason
C. A cannulated extremity is more difficult for
to move when the leg or foot is used. using the upper extremities. Pain (D) is not a consideration.
D.Veins are located deep in the feet and
ankles, resulting in a more painful Correct Answer: B
procedure.
, The nurse observes an unlicensed The most important action is to ensure that an accurate BP
assistive personnel (UAP) taking a reading is obtained. The nurse should reassess the BP with
client's blood the correct size cuff (B). Reassessment should not be
pressure with a cuff that is too small, but the postponed
blood pressure reading obtained is within (A). Though (C and D) are likely indicated, these actions do
the client's usual range. What action is most not have the priority of (B).
important for the nurse to implement?
Correct Answer: B
A. Tell the UAP to use a larger cuff at
the next scheduled assessment.
B.Reassess the client's blood pressure
using a larger cuff.
C. Have the unit educator review
this procedure with the UAPs.
D.Teach the UAP the correct technique for
assessing blood pressure.
Twenty minutes after beginning a heat (D) describes thermal adaptation, which occurs 20 to 30
application, the client states that the heating minutes after heat application. (A and B) provide false
pad no longer feels warm enough. What information. (C) is not based on a knowledge of physiology
is the best response by the nurse? and is an unsafe action that may harm the client.
A. "That means you have derived Correct Answer: D
the maximum benefit, and the heat
can be removed."
B. "Your blood vessels are becoming
dilated and removing the heat from the
site."
C. "We will increase the temperature
5 degrees when the pad no longer
feels warm."
D."The body's receptors adapt over time
as they are exposed to heat."
The nurse is instructing a client with high Limiting saturated fat from animal food sources to no
cholesterol about diet and life style more than 4 ounces per week (C) is an important diet
modification. What comment from the client modification for lowering cholesterol. To be effective in
indicates that the teaching has been reducing
effective? cholesterol, the client should exercise 30 minutes per day, or
at least 4 to 6 times per week (A). Red meat and all proteins
A. "If I exercise at least two times weekly do not need to be eliminated (B) to lower cholesterol, but
for one hour, I will lower my cholesterol." should be restricted to lean cuts of red meat and
B."I need to avoid eating proteins, smaller portions (2-ounce servings). The low density
including red meat." lipoproteins (D) need to decrease rather than increase.
C. "I will limit my intake of beef to 4
ounces per week." Correct Answer: C
D. "My blood level of low
density lipoproteins needs to
increase."
