EVOLVE HESI FUNDAMENTALS
PRACTICE EXAM
A44hospitalized44male44client44is44receiving44nasogastric44tube44feedings44via44a44small-
bore44tube44and44a44continuous44pump44infusion.44He44reports44that44he44had44a44bad44
bout44of44severe44coughing44a44few44minutes44ago,44but44feels44fine44now.44What44actio
n44is44best44for44the44nurse44to44take?44-44answer--
After44clearing44the44tube44with443044ml44of44air,44check44the44pH44of44fluid44withdrawn44f
rom44the44tube.
A44client44is44in44the44radiology44department44at44090044when44the44prescription44levoflo
xacin44(Levaquin)4450044mg44IV44q24h44is44scheduled44to44be44administered.44The44clie
nt44returns44to44the44unit44at441300.44What44is44the44best44intervention44for44the44nurse44
to44implement?44-44answer--
Give44the44missed44dose44at44130044and44change44the44schedule44to44administer44daily4
4at441300.
A44client44who44is44in44hospice44care44complains44of44increasing44amounts44of44pain.44T
he44healthcare44provider44prescribes44an44analgesic44every44four44hours44as44needed.44
Which44action44should44the44nurse44implement?44-44answer--Give44an44around-the-
clock44schedule44for44administration44of44analgesics.
After44completing44an44assessment44and44determining44that44a44client44has44a44problem
,44which44action44should44the44nurse44perform44next?44-44answer--
determine44the44etiology44of44the44problem
What44is44the44most44important44reason44for44starting44intravenous44infusions44in44the44
upper44extremities44rather44than44the44lower44extremities44of44adults?44-44answer--
A44decreased44flow44rate44could44result44in44the44formation44of44a44thrombosis.
The44nurse44notices44that44the44mother44of44a449-year-
old44Vietnamese44child44always44looks44at44the44floor44when44she44talks44to44the44nurse.
44What44action44should44the44nurse44take?44-44answer--
Continue44asking44the44mother44questions44about44the44child.
, Which44intervention44is44most44important44for44the44nurse44to44implement44for44a44male4
4client44who44is44experiencing44urinary44retention?44-44answer--
Assess44for44bladder44distention.
A44client44who44is44a44Jehovah's44Witness44is44admitted44to44the44nursing44unit.44Which4
4concern44should44the44nurse44have44for44planning44care44in44terms44of44the44client's44b
eliefs?44-44answer--Blood44transfusions44are44forbidden.
While44instructing44a44male44client's44wife44in44the44performance44of44passive44range-of-
motion44exercises44to44his44contracted44shoulder,44the44nurse44observes44that44she44is44
holding44his44arm44above44and44below44the44elbow.44What44nursing44action44should44th
e44nurse44implement?44-44answer--
Acknowledge44that44she44is44supporting44the44arm44correctly.
An44elderly44male44client44who44is44unresponsive44following44a44cerebral44vascular44acci
dent44(CVA)44is44receiving44bolus44enteral44feedings44though44a44gastrostomy44tube.44
What44is44the44best44client44position44for44administration44of44the44bolus44tube44feedings
?44-44answer--Fowler's.
An44adult44male44client44with44a44history44of44hypertension44tells44the44nurse44that44he44i
s44tired44of44taking44antihypertensive44medications44and44is44going44to44try44spiritual44m
editation44instead.44What44should44be44the44nurse's44first44response?44-44answer--
It44is44important44that44you44continue44your44medication44while44learning44to44meditate.
A44client44is44to44receive44cimetidine44(Tagamet)4430044mg44q6h44IVPB.44The44preparati
on44arrives44from44the44pharmacy44diluted44in445044ml44of440.9%44NaCl.44The44nurse44pl
ans44to44administer44the44IVPB44dose44over442044minutes.44For44how44many44ml/
hr44should44the44infusion44pump44be44set44to44deliver44the44secondary44infusion?44-
44answer--150
The44nurse44is44completing44a44mental44assessment44for44a44client44who44is44demonstra
ting44slow44thought44processes,44personality44changes,44and44emotional44lability.44Whic
h44area44of44the44brain44controls44these44neuro-cognitive44functions?44-44answer--
Frontal44lobe
A44client44is44receiving44a44cephalosporin44antibiotic44IV44and44complains44of44pain44and
44irritation44at44the44infusion44site.44The44nurse44observes44erythema,44swelling,44and44a
44red44streak44along44the44vessel44above44the44IV44access44site.44Which44action44should
44the44nurse44take44at44this44time?44-44answer--
Initiate44an44alternate44site44for44the44IV44infusion44of44the44medication.
A44female44client44asks44the44nurse44to44find44someone44who44can44translate44into44her4
4native44language44her44concerns44about44a44treatment.44Which44action44should44the44n
urse44take?44-44answer--
Request44and44document44the44name44of44the44certified44translator.
PRACTICE EXAM
A44hospitalized44male44client44is44receiving44nasogastric44tube44feedings44via44a44small-
bore44tube44and44a44continuous44pump44infusion.44He44reports44that44he44had44a44bad44
bout44of44severe44coughing44a44few44minutes44ago,44but44feels44fine44now.44What44actio
n44is44best44for44the44nurse44to44take?44-44answer--
After44clearing44the44tube44with443044ml44of44air,44check44the44pH44of44fluid44withdrawn44f
rom44the44tube.
A44client44is44in44the44radiology44department44at44090044when44the44prescription44levoflo
xacin44(Levaquin)4450044mg44IV44q24h44is44scheduled44to44be44administered.44The44clie
nt44returns44to44the44unit44at441300.44What44is44the44best44intervention44for44the44nurse44
to44implement?44-44answer--
Give44the44missed44dose44at44130044and44change44the44schedule44to44administer44daily4
4at441300.
A44client44who44is44in44hospice44care44complains44of44increasing44amounts44of44pain.44T
he44healthcare44provider44prescribes44an44analgesic44every44four44hours44as44needed.44
Which44action44should44the44nurse44implement?44-44answer--Give44an44around-the-
clock44schedule44for44administration44of44analgesics.
After44completing44an44assessment44and44determining44that44a44client44has44a44problem
,44which44action44should44the44nurse44perform44next?44-44answer--
determine44the44etiology44of44the44problem
What44is44the44most44important44reason44for44starting44intravenous44infusions44in44the44
upper44extremities44rather44than44the44lower44extremities44of44adults?44-44answer--
A44decreased44flow44rate44could44result44in44the44formation44of44a44thrombosis.
The44nurse44notices44that44the44mother44of44a449-year-
old44Vietnamese44child44always44looks44at44the44floor44when44she44talks44to44the44nurse.
44What44action44should44the44nurse44take?44-44answer--
Continue44asking44the44mother44questions44about44the44child.
, Which44intervention44is44most44important44for44the44nurse44to44implement44for44a44male4
4client44who44is44experiencing44urinary44retention?44-44answer--
Assess44for44bladder44distention.
A44client44who44is44a44Jehovah's44Witness44is44admitted44to44the44nursing44unit.44Which4
4concern44should44the44nurse44have44for44planning44care44in44terms44of44the44client's44b
eliefs?44-44answer--Blood44transfusions44are44forbidden.
While44instructing44a44male44client's44wife44in44the44performance44of44passive44range-of-
motion44exercises44to44his44contracted44shoulder,44the44nurse44observes44that44she44is44
holding44his44arm44above44and44below44the44elbow.44What44nursing44action44should44th
e44nurse44implement?44-44answer--
Acknowledge44that44she44is44supporting44the44arm44correctly.
An44elderly44male44client44who44is44unresponsive44following44a44cerebral44vascular44acci
dent44(CVA)44is44receiving44bolus44enteral44feedings44though44a44gastrostomy44tube.44
What44is44the44best44client44position44for44administration44of44the44bolus44tube44feedings
?44-44answer--Fowler's.
An44adult44male44client44with44a44history44of44hypertension44tells44the44nurse44that44he44i
s44tired44of44taking44antihypertensive44medications44and44is44going44to44try44spiritual44m
editation44instead.44What44should44be44the44nurse's44first44response?44-44answer--
It44is44important44that44you44continue44your44medication44while44learning44to44meditate.
A44client44is44to44receive44cimetidine44(Tagamet)4430044mg44q6h44IVPB.44The44preparati
on44arrives44from44the44pharmacy44diluted44in445044ml44of440.9%44NaCl.44The44nurse44pl
ans44to44administer44the44IVPB44dose44over442044minutes.44For44how44many44ml/
hr44should44the44infusion44pump44be44set44to44deliver44the44secondary44infusion?44-
44answer--150
The44nurse44is44completing44a44mental44assessment44for44a44client44who44is44demonstra
ting44slow44thought44processes,44personality44changes,44and44emotional44lability.44Whic
h44area44of44the44brain44controls44these44neuro-cognitive44functions?44-44answer--
Frontal44lobe
A44client44is44receiving44a44cephalosporin44antibiotic44IV44and44complains44of44pain44and
44irritation44at44the44infusion44site.44The44nurse44observes44erythema,44swelling,44and44a
44red44streak44along44the44vessel44above44the44IV44access44site.44Which44action44should
44the44nurse44take44at44this44time?44-44answer--
Initiate44an44alternate44site44for44the44IV44infusion44of44the44medication.
A44female44client44asks44the44nurse44to44find44someone44who44can44translate44into44her4
4native44language44her44concerns44about44a44treatment.44Which44action44should44the44n
urse44take?44-44answer--
Request44and44document44the44name44of44the44certified44translator.
