EVOLVE HESI FUNDAMENTALS ACTUAL
EXAM 2024/2025 EXPERT VERIFIED WITH
DETAILED ANSWERS AND RATIONALES|
GUARANTEED PASS
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is
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essential to the client's nursing care?
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A. Massage any reddened areas for at least five minutes. L L L L L L L L
B. Encourage active range of motion exercises on extremities. L L L L L L L
C. Position the client laterally, prone, and dorsally in sequence.
L L L L L L L L
D. Gently lift the client when moving into a desired position. - ANSWER>>To avoid
L L L L L L L L L L L L
shearing forces when repositioning, the client should be lifted gently across a
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surface (D). Reddened areas should not be massaged (A) since this may increase the
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damage to already traumatized skin. To control pain and muscle spasms, active
L L L L L L L L L L L L
range of motion (B) may be limited on the affected leg. The position described in (C)
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is contraindicated for a client with a fractured left hip.
L L L L L L L L L L
Correct Answer: D L L
The nurse is administering medications through a nasogastric tube (NGT) which is
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connected to suction. After ensuring correct tube placement, what action should
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the nurse take next?
L L L L
A. Clamp the tube for 20 minutes. L L L L L
B. Flush the tube with water.
L L L L
,C. Administer the medications as prescribed.
L L L L L
D. Crush the tablets and dissolve in sterile water. - ANSWER>>The NGT should be
L L L L L L L L L L L L L
flushed before, after and in between each medication administered (B). Once all
L L L L L L L L L L L L
medications are administered, the NGT should be clamped for 20 minutes (A). (C and
L L L L L L L L L L L L L L
D) may be implemented only after the tubing has been flushed.
L L L L L L L L L L L
Correct Answer: B L L
A client who is in hospice care complains of increasing amounts of pain. The
L L L L L L L L L L L L L
healthcare provider prescribes an analgesic every four hours as needed. Which action
L L L L L L L L L L L L
should the nurse implement?
L L L L
A. Give an around-the-clock schedule for administration of analgesics.
L L L L L L L L
B. Administer analgesic medication as needed when the pain is severe.
L L L L L L L L L L
C. Provide medication to keep the client sedated and unaware of stimuli.
L L L L L L L L L L L
D. Offer a medication-free period so that the client can do daily activities. -
L L L L L L L L L L L L L
ANSWER>>The most effective management of pain is achieved using an
L L L L L L L L L L
around-the-clock schedule that provides analgesic medications on a regular
L L L L L L L L L
basis (A) and in a timely manner. Analgesics are less effective if pain persists until it is
L L L L L L L L L L L L L L L L
severe, so an analgesic medication should be administered before the client's pain
L L L L L L L L L L L L
peaks (B). Providing comfort is a priority for the client who is dying, but sedation that
L L L L L L L L L L L L L L L L
impairs the client's ability to interact and experience the time before life ends should
L L L L L L L L L L L L L L
be minimized (C). Offering a medication-free period allows the serum drug level to
L L L L L L L L L L L L L
fall, which is not an effective method to manage chronic pain (D).
L L L L L L L L L L L L
Correct Answer: A L L
When assessing a client with wrist restraints, the nurse observes that the fingers on
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the right hand are blue. What action should the nurse implement first?
L L L L L L L L L L L L
A. Loosen the right wrist restraint.
L L L L L
,B. Apply a pulse oximeter to the right hand.
L L L L L L L L
C. Compare hand color bilaterally.
L L L L
D. Palpate the right radial pulse. - ANSWER>>The priority nursing action is to restore
L L L L L L L L L L L L L
circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates
L L L L L L L L L L L
decreased circulation. (C and D) are also important nursing interventions, but do not
L L L L L L L L L L L L L
have the priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin
L L L L L L L L L L L L L
with oxygen and is not indicated in situations where the cyanosis is related to
L L L L L L L L L L L L L L
mechanical compression (the restraints).
L L L L
Correct Answer: A L L
The nurse is assessing the nutritional status of several clients. Which client has the
L L L L L L L L L L L L L
greatest nutritional need for additional intake of protein?
L L L L L L L L
A. A college-age track runner with a sprained ankle.
L L L L L L L L
B. A lactating woman nursing her 3-day-old infant.
L L L L L L L
C. A school-aged child with Type 2 diabetes.
L L L L L L L
D. An elderly man being treated for a peptic ulcer. - ANSWER>>A lactating woman
L L L L L L L L L L L L L
(B) has the greatest need for additional protein intake. (A, C, and D) are all conditions
L L L L L L L L L L L L L L L L
that require protein, but do not have the increased metabolic protein demands of
L L L L L L L L L L L L L
lactation.
L
Correct Answer: B L L
A client is in the radiology department at 0900 when the prescription levofloxacin
L L L L L L L L L L L L
(Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the
L L L L L L L L L L L L L L L
unit at 1300. What is the best intervention for the nurse to implement?
L L L L L L L L L L L L L
A. Contact the healthcare provider and complete a medication variance form.
L L L L L L L L L L
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
L L L L L L L L L L L L L
, C. Notify the charge nurse and complete an incident report to explain the missed
L L L L L L L L L L L L L
dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.
L L L L L L L L L L L L L L L
- ANSWER>>To ensure that a therapeutic level of medication is maintained, the
L L L L L L L L L L L L
nurse should administer the missed dose as soon as possible, and revise the
L L L L L L L L L L L L L
administration schedule accordingly to prevent dangerously increasing the level of
L L L L L L L L L L
the medication in the bloodstream (D). The nurse should document the reason for
L L L L L L L L L L L L L
the late dose, but (A and C) are not warranted. (B) could result in increased blood
L L L L L L L L L L L L L L L L
levels of the drug.
L L L L
Correct Answer: D L L
While instructing a male client's wife in the performance of passive range-of- motion
L L L L L L L L L L L L
exercises to his contracted shoulder, the nurse observes that she is holding his arm
L L L L L L L L L L L L L L
above and below the elbow. What nursing action should the nurse implement?
L L L L L L L L L L L L
A. Acknowledge that she is supporting the arm correctly.
L L L L L L L L
B. Encourage her to keep the joint covered to maintain warmth.
L L L L L L L L L L
C. Reinforce the need to grip directly under the joint for better support.
L L L L L L L L L L L L
D. Instruct her to grip directly over the joint for better motion. - ANSWER>>The wife is
L L L L L L L L L L L L L L L
performing the passive ROM correctly, therefore the nurse should acknowledge this
L L L L L L L L L L L
fact (A). The joint that is being exercised should be uncovered
L L L L L L L L L L L
(B) while the rest of the body should remain covered for warmth and privacy. (C and
L L L L L L L L L L L L L L L
D) do not provide adequate support to the joint while still allowing for joint
L L L L L L L L L L L L L L
movement.
L
Correct Answer: A L L
What is the most important reason for starting intravenous infusions in the upper
L L L L L L L L L L L L
extremities rather than the lower extremities of adults?
L L L L L L L L
EXAM 2024/2025 EXPERT VERIFIED WITH
DETAILED ANSWERS AND RATIONALES|
GUARANTEED PASS
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is
L L L L L L L L L L L L L L L
essential to the client's nursing care?
L L L L L L
A. Massage any reddened areas for at least five minutes. L L L L L L L L
B. Encourage active range of motion exercises on extremities. L L L L L L L
C. Position the client laterally, prone, and dorsally in sequence.
L L L L L L L L
D. Gently lift the client when moving into a desired position. - ANSWER>>To avoid
L L L L L L L L L L L L
shearing forces when repositioning, the client should be lifted gently across a
L L L L L L L L L L L L
surface (D). Reddened areas should not be massaged (A) since this may increase the
L L L L L L L L L L L L L L
damage to already traumatized skin. To control pain and muscle spasms, active
L L L L L L L L L L L L
range of motion (B) may be limited on the affected leg. The position described in (C)
L L L L L L L L L L L L L L L L
is contraindicated for a client with a fractured left hip.
L L L L L L L L L L
Correct Answer: D L L
The nurse is administering medications through a nasogastric tube (NGT) which is
L L L L L L L L L L L
connected to suction. After ensuring correct tube placement, what action should
L L L L L L L L L L L
the nurse take next?
L L L L
A. Clamp the tube for 20 minutes. L L L L L
B. Flush the tube with water.
L L L L
,C. Administer the medications as prescribed.
L L L L L
D. Crush the tablets and dissolve in sterile water. - ANSWER>>The NGT should be
L L L L L L L L L L L L L
flushed before, after and in between each medication administered (B). Once all
L L L L L L L L L L L L
medications are administered, the NGT should be clamped for 20 minutes (A). (C and
L L L L L L L L L L L L L L
D) may be implemented only after the tubing has been flushed.
L L L L L L L L L L L
Correct Answer: B L L
A client who is in hospice care complains of increasing amounts of pain. The
L L L L L L L L L L L L L
healthcare provider prescribes an analgesic every four hours as needed. Which action
L L L L L L L L L L L L
should the nurse implement?
L L L L
A. Give an around-the-clock schedule for administration of analgesics.
L L L L L L L L
B. Administer analgesic medication as needed when the pain is severe.
L L L L L L L L L L
C. Provide medication to keep the client sedated and unaware of stimuli.
L L L L L L L L L L L
D. Offer a medication-free period so that the client can do daily activities. -
L L L L L L L L L L L L L
ANSWER>>The most effective management of pain is achieved using an
L L L L L L L L L L
around-the-clock schedule that provides analgesic medications on a regular
L L L L L L L L L
basis (A) and in a timely manner. Analgesics are less effective if pain persists until it is
L L L L L L L L L L L L L L L L
severe, so an analgesic medication should be administered before the client's pain
L L L L L L L L L L L L
peaks (B). Providing comfort is a priority for the client who is dying, but sedation that
L L L L L L L L L L L L L L L L
impairs the client's ability to interact and experience the time before life ends should
L L L L L L L L L L L L L L
be minimized (C). Offering a medication-free period allows the serum drug level to
L L L L L L L L L L L L L
fall, which is not an effective method to manage chronic pain (D).
L L L L L L L L L L L L
Correct Answer: A L L
When assessing a client with wrist restraints, the nurse observes that the fingers on
L L L L L L L L L L L L L
the right hand are blue. What action should the nurse implement first?
L L L L L L L L L L L L
A. Loosen the right wrist restraint.
L L L L L
,B. Apply a pulse oximeter to the right hand.
L L L L L L L L
C. Compare hand color bilaterally.
L L L L
D. Palpate the right radial pulse. - ANSWER>>The priority nursing action is to restore
L L L L L L L L L L L L L
circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates
L L L L L L L L L L L
decreased circulation. (C and D) are also important nursing interventions, but do not
L L L L L L L L L L L L L
have the priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin
L L L L L L L L L L L L L
with oxygen and is not indicated in situations where the cyanosis is related to
L L L L L L L L L L L L L L
mechanical compression (the restraints).
L L L L
Correct Answer: A L L
The nurse is assessing the nutritional status of several clients. Which client has the
L L L L L L L L L L L L L
greatest nutritional need for additional intake of protein?
L L L L L L L L
A. A college-age track runner with a sprained ankle.
L L L L L L L L
B. A lactating woman nursing her 3-day-old infant.
L L L L L L L
C. A school-aged child with Type 2 diabetes.
L L L L L L L
D. An elderly man being treated for a peptic ulcer. - ANSWER>>A lactating woman
L L L L L L L L L L L L L
(B) has the greatest need for additional protein intake. (A, C, and D) are all conditions
L L L L L L L L L L L L L L L L
that require protein, but do not have the increased metabolic protein demands of
L L L L L L L L L L L L L
lactation.
L
Correct Answer: B L L
A client is in the radiology department at 0900 when the prescription levofloxacin
L L L L L L L L L L L L
(Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the
L L L L L L L L L L L L L L L
unit at 1300. What is the best intervention for the nurse to implement?
L L L L L L L L L L L L L
A. Contact the healthcare provider and complete a medication variance form.
L L L L L L L L L L
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
L L L L L L L L L L L L L
, C. Notify the charge nurse and complete an incident report to explain the missed
L L L L L L L L L L L L L
dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.
L L L L L L L L L L L L L L L
- ANSWER>>To ensure that a therapeutic level of medication is maintained, the
L L L L L L L L L L L L
nurse should administer the missed dose as soon as possible, and revise the
L L L L L L L L L L L L L
administration schedule accordingly to prevent dangerously increasing the level of
L L L L L L L L L L
the medication in the bloodstream (D). The nurse should document the reason for
L L L L L L L L L L L L L
the late dose, but (A and C) are not warranted. (B) could result in increased blood
L L L L L L L L L L L L L L L L
levels of the drug.
L L L L
Correct Answer: D L L
While instructing a male client's wife in the performance of passive range-of- motion
L L L L L L L L L L L L
exercises to his contracted shoulder, the nurse observes that she is holding his arm
L L L L L L L L L L L L L L
above and below the elbow. What nursing action should the nurse implement?
L L L L L L L L L L L L
A. Acknowledge that she is supporting the arm correctly.
L L L L L L L L
B. Encourage her to keep the joint covered to maintain warmth.
L L L L L L L L L L
C. Reinforce the need to grip directly under the joint for better support.
L L L L L L L L L L L L
D. Instruct her to grip directly over the joint for better motion. - ANSWER>>The wife is
L L L L L L L L L L L L L L L
performing the passive ROM correctly, therefore the nurse should acknowledge this
L L L L L L L L L L L
fact (A). The joint that is being exercised should be uncovered
L L L L L L L L L L L
(B) while the rest of the body should remain covered for warmth and privacy. (C and
L L L L L L L L L L L L L L L
D) do not provide adequate support to the joint while still allowing for joint
L L L L L L L L L L L L L L
movement.
L
Correct Answer: A L L
What is the most important reason for starting intravenous infusions in the upper
L L L L L L L L L L L L
extremities rather than the lower extremities of adults?
L L L L L L L L
