Evolve Fundamentals HESI Questions and
Answers 100% Solved
When assessing a client with wrist restraints, the nurse observes that the fingers on the right
hand are blue. What action should the nurse implement first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse. The priority nursing action is to restore circulation by
loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C
and D) are also important nursing interventions, but do not have the priority of (A). Pulse
oximetry (B) measures the saturation of hemoglobin with oxygen and is not indicated in
situations where the cyanosis is related to mechanical compression (the restraints).
Correct Answer: A
The nurse is assessing the nutritional status of several clients. Which client has the greatest
nutritional need for additional intake of protein?
,A. A college-age track runner with a 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 lactating woman (B) has the greatest
need for additional protein intake. (A, C, and D) are all conditions that require protein, but do
not have the increased metabolic protein demands of lactation.
Correct Answer: B
A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin)
500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is
the best intervention for the nurse to implement?
A. Contact the healthcare provider and 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. To
ensure that a therapeutic level of medication is maintained, the nurse should administer the
missed dose as soon as possible, and revise the administration schedule accordingly to prevent
dangerously increasing the level of the medication in the bloodstream (D). The nurse should
document the reason for the late dose, but (A and C) are not warranted. (B) could result in
increased blood levels of the drug.
Correct Answer: D
While instructing a male client's wife in the performance of passive range-of-motion exercises to
his contracted shoulder, the nurse observes that she is holding his arm above and below the
elbow. What nursing action should the nurse implement?
A. Acknowledge that she is supporting the 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. The wife is performing
the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that
is being exercised should be uncovered (B) while the rest of the body should remain covered for
, warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing
for joint movement.
Correct Answer: A
What is the most important reason for starting intravenous infusions in the upper extremities
rather than the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result in the formation of a thrombosis.
C. A cannulated extremity is more difficult to move when the leg or foot is used.
D. Veins are located deep in the feet and ankles, resulting in a more painful procedure.
Venous return is usually better in the upper extremities. Cannulation of the veins in the
lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-
threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg
or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if
the nurse did believe moving a cannulated leg was more difficult, this is not the most important
reason for using the upper extremities. Pain (D) is not a consideration.
Answers 100% Solved
When assessing a client with wrist restraints, the nurse observes that the fingers on the right
hand are blue. What action should the nurse implement first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse. The priority nursing action is to restore circulation by
loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C
and D) are also important nursing interventions, but do not have the priority of (A). Pulse
oximetry (B) measures the saturation of hemoglobin with oxygen and is not indicated in
situations where the cyanosis is related to mechanical compression (the restraints).
Correct Answer: A
The nurse is assessing the nutritional status of several clients. Which client has the greatest
nutritional need for additional intake of protein?
,A. A college-age track runner with a 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 lactating woman (B) has the greatest
need for additional protein intake. (A, C, and D) are all conditions that require protein, but do
not have the increased metabolic protein demands of lactation.
Correct Answer: B
A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin)
500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is
the best intervention for the nurse to implement?
A. Contact the healthcare provider and 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. To
ensure that a therapeutic level of medication is maintained, the nurse should administer the
missed dose as soon as possible, and revise the administration schedule accordingly to prevent
dangerously increasing the level of the medication in the bloodstream (D). The nurse should
document the reason for the late dose, but (A and C) are not warranted. (B) could result in
increased blood levels of the drug.
Correct Answer: D
While instructing a male client's wife in the performance of passive range-of-motion exercises to
his contracted shoulder, the nurse observes that she is holding his arm above and below the
elbow. What nursing action should the nurse implement?
A. Acknowledge that she is supporting the 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. The wife is performing
the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that
is being exercised should be uncovered (B) while the rest of the body should remain covered for
, warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing
for joint movement.
Correct Answer: A
What is the most important reason for starting intravenous infusions in the upper extremities
rather than the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result in the formation of a thrombosis.
C. A cannulated extremity is more difficult to move when the leg or foot is used.
D. Veins are located deep in the feet and ankles, resulting in a more painful procedure.
Venous return is usually better in the upper extremities. Cannulation of the veins in the
lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-
threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg
or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if
the nurse did believe moving a cannulated leg was more difficult, this is not the most important
reason for using the upper extremities. Pain (D) is not a consideration.
