Evolve Fundamentals HESI UPDATED
ACTUAL Questions and CORRECT
Answers
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential
to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position. - CORRECT ANSWER -To
avoid shearing forces when repositioning, the client should be lifted gently across a surface (D).
Reddened areas should not be massaged (A) since this may increase the damage to already
traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited
on the affected leg. The position described in (C) is contraindicated for a client with a fractured
left hip.
Correct Answer: D
The nurse is administering medications through a nasogastric tube (NGT) which is connected to
suction. After ensuring correct tube placement, what action should the nurse take next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water. - CORRECT ANSWER -The NGT
should be flushed before, after and in between each medication administered (B). Once all
medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be
implemented only after the tubing has been flushed.
Correct Answer: B
,A client who is in hospice care complains of increasing amounts of pain. The healthcare provider
prescribes an analgesic every four hours as needed. Which action should the nurse implement?
A. Give an around-the-clock schedule for administration of analgesics.
B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities. - CORRECT
ANSWER -The most effective management of pain is achieved using an around-the-clock
schedule that provides analgesic medications on a regular basis (A) and in a timely manner.
Analgesics are less effective if pain persists until it is severe, so an analgesic medication should
be administered before the client's pain peaks (B). Providing comfort is a priority for the client
who is dying, but sedation that impairs the client's ability to interact and experience the time
before life ends should be minimized (C). Offering a medication-free period allows the serum
drug level to fall, which is not an effective method to manage chronic pain (D).
Correct Answer: A
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. - CORRECT ANSWER -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. - CORRECT ANSWER -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. -
CORRECT ANSWER -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. - CORRECT ANSWER -
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. -
CORRECT ANSWER -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.
Correct Answer: B
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with
a cuff that is too small, but the blood pressure reading obtained is within the client's usual range.
What action is most important for the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
ACTUAL Questions and CORRECT
Answers
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential
to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position. - CORRECT ANSWER -To
avoid shearing forces when repositioning, the client should be lifted gently across a surface (D).
Reddened areas should not be massaged (A) since this may increase the damage to already
traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited
on the affected leg. The position described in (C) is contraindicated for a client with a fractured
left hip.
Correct Answer: D
The nurse is administering medications through a nasogastric tube (NGT) which is connected to
suction. After ensuring correct tube placement, what action should the nurse take next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water. - CORRECT ANSWER -The NGT
should be flushed before, after and in between each medication administered (B). Once all
medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be
implemented only after the tubing has been flushed.
Correct Answer: B
,A client who is in hospice care complains of increasing amounts of pain. The healthcare provider
prescribes an analgesic every four hours as needed. Which action should the nurse implement?
A. Give an around-the-clock schedule for administration of analgesics.
B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities. - CORRECT
ANSWER -The most effective management of pain is achieved using an around-the-clock
schedule that provides analgesic medications on a regular basis (A) and in a timely manner.
Analgesics are less effective if pain persists until it is severe, so an analgesic medication should
be administered before the client's pain peaks (B). Providing comfort is a priority for the client
who is dying, but sedation that impairs the client's ability to interact and experience the time
before life ends should be minimized (C). Offering a medication-free period allows the serum
drug level to fall, which is not an effective method to manage chronic pain (D).
Correct Answer: A
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. - CORRECT ANSWER -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. - CORRECT ANSWER -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. -
CORRECT ANSWER -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. - CORRECT ANSWER -
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. -
CORRECT ANSWER -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.
Correct Answer: B
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with
a cuff that is too small, but the blood pressure reading obtained is within the client's usual range.
What action is most important for the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
