EVOLVE Hesi Fundamentals Actual Exam
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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. - . . 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.
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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. - . .
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?
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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. - . . 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?
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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. - . . 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.