EVOLVE HESI PRACTICE QUESTIONS
WITH 100% CORRECT ANSWERS
A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin
elixir. Which observation by the nurse warrants immediate intervention?
Apical heart rate of 60.
Sweating across the forehead.
Doesn't suck well.
Respiratory rate of 30 breaths per minute. - Correct Answer-Apical heart
rate of 60.
A heart rate of 60 (A) is much lower than normal for a 6-month-old and
warrants immediate intervention. The normal heart rate for a 6-month-old is
80 to 150 BPM when awake, and a rate of 70 while sleeping is considered
within normal limits. (B and C) are expected symptoms of heart failure in an
infant. (D) is within normal limits for an infant.
The nurse is teaching the parents of a 5-year-old with cystic fibrosis about
respiratory treatments. Which statement indicates to the nurse that the
parents understand?
Perform postural drainage before starting aerosol therapy.
Give respiratory treatments when the child is coughing a lot.
Administer aerosol therapy followed by postural drainage before meals.
Ensure respiratory therapy is done daily during any respiratory infection. -
Correct Answer-Administer aerosol therapy followed by postural drainage
before meals.
Postural drainage for a child with cystic fibrosis is most effective when
performed after nebulization and before meals (C) or at least 1 hour after
eating to prevent nausea and vomiting. Postural drainage uses gravity to
promote mucous removal after nebulization (A) treatments which open the
airways. Pulmonary toileting or respiratory treatments should be given 3 to 4
times daily, not episodically (B and D).
,A female teenager is taking oral tetracycline HCL (Achromycin V) for acne
vulgaris. What is the most important instruction for the nurse to include in
this client's teaching plan?
Use sunscreen when lying by the pool.
Cleanse the skin at least 4 times a day.
Take the medication with a glass of milk.
Menstrual periods may become irregular. - Correct Answer-Use sunscreen
when lying by the pool.
Photosensitivity is a common side effect of tetracycline HCL (Achromycin V)
therapy. Severe sunburn can occur with minimal sun exposure and clients
should be instructed to avoid sunlight and to use sunscreen (A). (B and D)
are not related to tetracycline HCL (Achromycin V) therapy. (C) should be
avoided because dairy products interfere with the absorption of
tetracyclines.
What preoperative nursing intervention should be included in the plan of
care for an infant with pyloric stenosis?
Monitor for signs of metabolic acidosis.
Estimate the quantity of diarrhea stools.
Place in a supine position after feeding.
Observe for projectile vomiting. - Correct Answer-Observe for projectile
vomiting.
Projectile vomiting (D), which contributes to metabolic alkalosis (A), is the
classic sign of pyloric stenosis. (B) is not indicated. (C) is dangerous, due to
the potential for aspiration with frequent vomiting.
An infant is born with a ventricular septal defect (VSD) and surgery is
planned to correct the defect. The nurse recognizes that surgical correction
is designed to achieve which outcome?
Stop the flow of unoxygenated blood into systemic circulation.
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 - Correct Answer-
Prevent the return of oxygenated blood to the lungs.
Closure of VSDs stops oxygenated blood from being shunted from the left
ventricle to the right ventricle (C). VSDs are acyanotic defects, which means
,that no unoxygenated blood enters the systemic circulation (A and B). (D) is
common with Tetrology of Fallot, which is a cyanotic defect.
A 3-week-old newborn is brought to the clinic for follow-up after a home
birth. The mother reports that her child bottle feeds for 5 minutes only and
then falls asleep. The nurse auscultates a loud murmur characteristic of a
ventricular septal defect (VSD), and finds the newborn is acyanotic with a
respiratory rate of 64 breaths per minute. What instruction should the nurse
provide the mother to ensure the infant is receiving adequate intake? (Select
all that apply.)
A. Monitor the the infant's weight and number of wet diapers per day.
B. Increase the infant's intake per feeding by 1 to 2 ounces 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. - Correct
Answer-A. Monitor the the infant's weight and number of wet diapers per
day.
B. Increase the infant's intake per feeding by 1 to 2 ounces per week.
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.
Antibiotic prophylaxis is recommended for infants with VSDs, but should not
be mixed in a bottle of formula (C) because it is difficult to ensure that the
total dose is consumed.
They should be monitored for weight gain and at least 6 wet diapers per day
(A). A one-month old infant should ingest 2 to 4 ounces of formula per
feeding and progress to about 30 ounces per day by 4-months of age (B)
Preoperative nursing care for a child with Wilms' tumor should include which
intervention?
Gently percuss the abdomen for evidence of trapped air.
Observe the abdomen for any noticeable discolorations.
Apply cold compresses to the abdomen to reduce edema.
Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN." - Correct
Answer-Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN."
Prevention of abdominal palpation (D) minimizes the risk of rupturing the
encapsulated tumor and subsequent metastasis. (A) is unnecessary, and this
action could traumatize the tumor in the same manner as palpation. (B and
, C) are incorrect since the abdomen is not discolored and cold compresses
are not indicated.
At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse
that a female adolescent client with acute glomerulonephritis has a blood
pressure of 210/110. The 4 a.m. blood pressure reading was 170/88. The
client reports to the UAP that she is upset because her boyfriend did not visit
last night. What action should the nurse take first?
Give the client her 9 a.m. prescription for an oral diuretic early.
Administer PRN prescription of nifedipine (Procardia) sublingually.
Notify the healthcare provider and inform the nursing supervisor of the
client's condition.
Attempt to calm the client and retake the blood pressure in thirty minutes. -
Correct Answer-Administer PRN prescription of nifedipine (Procardia)
sublingually.
Sublingual Procardia (B) lowers blood pressure very quickly, and this should
be done first. (A) may also be done, but oral diuretics do not work as rapidly
as the sublingual antihypertensive. When notifying the healthcare provider,
the first thing he/she will want to know is if the PRN antihypertensive has
been administered (C). (D) does not consider the seriousness of this finding.
The nurse should stay with the client until the blood pressure is reduced.
The nurse is assessing an 8-month-old child who has a medical diagnosis of
Tetrology of Fallot. Which symptom is this client most likely to exhibit?
Bradycardia.
Machinery murmur.
Weak pedal pulses.
Clubbed fingers. - Correct Answer-Clubbed fingers.
Tetrology of Fallot, a cyanotic heart defect, causes clubbing of fingers and
toes (D) due to tissue hypoxia. Tachycardia, not (A), is a manifestation of
congenital heart disease. (B) is a classic sign of ventricular septal defect. (C)
is characteristic of coarctation of the aorta.
Surgery is being delayed for an infant with undescended testes. In
collaboration with the healthcare provider and the family, which prescription
should the nurse anticipate?
A trial of adrenocorticotrophic hormone injections.
Frequent stimulation of the cremasteric reflex.
WITH 100% CORRECT ANSWERS
A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin
elixir. Which observation by the nurse warrants immediate intervention?
Apical heart rate of 60.
Sweating across the forehead.
Doesn't suck well.
Respiratory rate of 30 breaths per minute. - Correct Answer-Apical heart
rate of 60.
A heart rate of 60 (A) is much lower than normal for a 6-month-old and
warrants immediate intervention. The normal heart rate for a 6-month-old is
80 to 150 BPM when awake, and a rate of 70 while sleeping is considered
within normal limits. (B and C) are expected symptoms of heart failure in an
infant. (D) is within normal limits for an infant.
The nurse is teaching the parents of a 5-year-old with cystic fibrosis about
respiratory treatments. Which statement indicates to the nurse that the
parents understand?
Perform postural drainage before starting aerosol therapy.
Give respiratory treatments when the child is coughing a lot.
Administer aerosol therapy followed by postural drainage before meals.
Ensure respiratory therapy is done daily during any respiratory infection. -
Correct Answer-Administer aerosol therapy followed by postural drainage
before meals.
Postural drainage for a child with cystic fibrosis is most effective when
performed after nebulization and before meals (C) or at least 1 hour after
eating to prevent nausea and vomiting. Postural drainage uses gravity to
promote mucous removal after nebulization (A) treatments which open the
airways. Pulmonary toileting or respiratory treatments should be given 3 to 4
times daily, not episodically (B and D).
,A female teenager is taking oral tetracycline HCL (Achromycin V) for acne
vulgaris. What is the most important instruction for the nurse to include in
this client's teaching plan?
Use sunscreen when lying by the pool.
Cleanse the skin at least 4 times a day.
Take the medication with a glass of milk.
Menstrual periods may become irregular. - Correct Answer-Use sunscreen
when lying by the pool.
Photosensitivity is a common side effect of tetracycline HCL (Achromycin V)
therapy. Severe sunburn can occur with minimal sun exposure and clients
should be instructed to avoid sunlight and to use sunscreen (A). (B and D)
are not related to tetracycline HCL (Achromycin V) therapy. (C) should be
avoided because dairy products interfere with the absorption of
tetracyclines.
What preoperative nursing intervention should be included in the plan of
care for an infant with pyloric stenosis?
Monitor for signs of metabolic acidosis.
Estimate the quantity of diarrhea stools.
Place in a supine position after feeding.
Observe for projectile vomiting. - Correct Answer-Observe for projectile
vomiting.
Projectile vomiting (D), which contributes to metabolic alkalosis (A), is the
classic sign of pyloric stenosis. (B) is not indicated. (C) is dangerous, due to
the potential for aspiration with frequent vomiting.
An infant is born with a ventricular septal defect (VSD) and surgery is
planned to correct the defect. The nurse recognizes that surgical correction
is designed to achieve which outcome?
Stop the flow of unoxygenated blood into systemic circulation.
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 - Correct Answer-
Prevent the return of oxygenated blood to the lungs.
Closure of VSDs stops oxygenated blood from being shunted from the left
ventricle to the right ventricle (C). VSDs are acyanotic defects, which means
,that no unoxygenated blood enters the systemic circulation (A and B). (D) is
common with Tetrology of Fallot, which is a cyanotic defect.
A 3-week-old newborn is brought to the clinic for follow-up after a home
birth. The mother reports that her child bottle feeds for 5 minutes only and
then falls asleep. The nurse auscultates a loud murmur characteristic of a
ventricular septal defect (VSD), and finds the newborn is acyanotic with a
respiratory rate of 64 breaths per minute. What instruction should the nurse
provide the mother to ensure the infant is receiving adequate intake? (Select
all that apply.)
A. Monitor the the infant's weight and number of wet diapers per day.
B. Increase the infant's intake per feeding by 1 to 2 ounces 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. - Correct
Answer-A. Monitor the the infant's weight and number of wet diapers per
day.
B. Increase the infant's intake per feeding by 1 to 2 ounces per week.
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.
Antibiotic prophylaxis is recommended for infants with VSDs, but should not
be mixed in a bottle of formula (C) because it is difficult to ensure that the
total dose is consumed.
They should be monitored for weight gain and at least 6 wet diapers per day
(A). A one-month old infant should ingest 2 to 4 ounces of formula per
feeding and progress to about 30 ounces per day by 4-months of age (B)
Preoperative nursing care for a child with Wilms' tumor should include which
intervention?
Gently percuss the abdomen for evidence of trapped air.
Observe the abdomen for any noticeable discolorations.
Apply cold compresses to the abdomen to reduce edema.
Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN." - Correct
Answer-Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN."
Prevention of abdominal palpation (D) minimizes the risk of rupturing the
encapsulated tumor and subsequent metastasis. (A) is unnecessary, and this
action could traumatize the tumor in the same manner as palpation. (B and
, C) are incorrect since the abdomen is not discolored and cold compresses
are not indicated.
At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse
that a female adolescent client with acute glomerulonephritis has a blood
pressure of 210/110. The 4 a.m. blood pressure reading was 170/88. The
client reports to the UAP that she is upset because her boyfriend did not visit
last night. What action should the nurse take first?
Give the client her 9 a.m. prescription for an oral diuretic early.
Administer PRN prescription of nifedipine (Procardia) sublingually.
Notify the healthcare provider and inform the nursing supervisor of the
client's condition.
Attempt to calm the client and retake the blood pressure in thirty minutes. -
Correct Answer-Administer PRN prescription of nifedipine (Procardia)
sublingually.
Sublingual Procardia (B) lowers blood pressure very quickly, and this should
be done first. (A) may also be done, but oral diuretics do not work as rapidly
as the sublingual antihypertensive. When notifying the healthcare provider,
the first thing he/she will want to know is if the PRN antihypertensive has
been administered (C). (D) does not consider the seriousness of this finding.
The nurse should stay with the client until the blood pressure is reduced.
The nurse is assessing an 8-month-old child who has a medical diagnosis of
Tetrology of Fallot. Which symptom is this client most likely to exhibit?
Bradycardia.
Machinery murmur.
Weak pedal pulses.
Clubbed fingers. - Correct Answer-Clubbed fingers.
Tetrology of Fallot, a cyanotic heart defect, causes clubbing of fingers and
toes (D) due to tissue hypoxia. Tachycardia, not (A), is a manifestation of
congenital heart disease. (B) is a classic sign of ventricular septal defect. (C)
is characteristic of coarctation of the aorta.
Surgery is being delayed for an infant with undescended testes. In
collaboration with the healthcare provider and the family, which prescription
should the nurse anticipate?
A trial of adrenocorticotrophic hormone injections.
Frequent stimulation of the cremasteric reflex.
