Evolve HESI EXAM A+ GRADE ASSURED COMPLETE SOLUTIONS AND VERIFIED ANSWERS

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Exam Solution vc




Evolve HESI 2026 A+ GRADE ASSURED COMPLETE SOLU vc vc vc vc vc vc vc




TIONS AND VERIFIED ANSWERS (10F65) vc vc vc vc




QUESTION 1 vc




A 6-month-
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old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observati
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on by the nurse warrants immediate intervention? Apical heart rate of 60. Sweating acro
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ss the forehead. Doesn't suck well. Respiratory rate of 30 breaths per minute.
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ANSWER

Apical heart rate of 60. A heart rate of 60 (
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A) is much lower than normal for a 6-month-
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old and warrants immediate intervention. The normal heart rate for a 6-month-
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old is 80 to 150 BPM when awake, and a rate of 70 while sleeping is considered within normal limits. (B
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and
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C) are expected symptoms of heart failure in an infant. (
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D) is within normal limits for an infant.
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QUESTION 2 vc




A female teenager is taking oral tetracycline HCL (Achromycin V) for acne vulgaris. What
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is the most important instruction for the nurse to include in this client's teaching plan?
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Use sunscreen when lying by the pool. Cleanse the skin at least 4 times a day. Take the m
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edication with a glass of milk. Menstrual periods may become irregular.
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ANSWER

Use sunscreen when lying by the pool. Photosensitivity is a common side effect of tetracycline HCL (Ach
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romycin V) therapy. Severe sunburn can occur with minimal sun exposure and clients should be instruct
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ed to avoid sunlight and to use sunscreen (A). (B and
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D) are not related to tetracycline HCL (Achromycin V) therapy. (
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C) should be avoided because dairy products interfere with the absorption of tetracyclines.
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QUESTION 3 vc

,What preoperative nursing intervention should be included in the plan of care for an inf
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ant with pyloric stenosis? Monitor for signs of metabolic acidosis. Estimate the quantity
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of diarrhea stools. Place in a supine position after feeding. Observe for projectile vomitin
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g.
ANSWER

Observe for projectile vomiting. Projectile vomiting (D), which contributes to metabolic alkalosis (A), is t
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he classic sign of pyloric stenosis. (
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B) is not indicated. (
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C) is dangerous, due to the potential for aspiration with frequent vomiting.
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QUESTION 4 vc




Preoperative nursing care for a child with Wilms' tumor should include which interventi vc vc vc vc vc vc vc vc vc vc vc vc



on? Gently percuss the abdomen for evidence of trapped air. Observe the abdomen for a
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ny noticeable discolorations. Apply cold compresses to the abdomen to reduce edema. P
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ut a sign on the bed reading, "DO NOT PALPATE ABDOMEN."
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ANSWER

Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN." Prevention of abdominal palpation (
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D) minimizes the risk of rupturing the encapsulated tumor and subsequent metastasis. (
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A) is unnecessary, and this action could traumatize the tumor in the same manner as palpation. (B and
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C) are incorrect since the abdomen is not discolored and cold compresses are not indicated.
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QUESTION 5 vc




The nurse is assessing an 8-month-
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old child who has a medical diagnosis of Tetrology of Fallot. Which symptom is this client
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most likely to exhibit? Bradycardia. Machinery murmur. Weak pedal pulses. Clubbed fin
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gers.
ANSWER

Clubbed fingers. Tetrology of Fallot, a cyanotic heart defect, causes clubbing of fingers and toes (
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D) due to tissue hypoxia. Tachycardia, not (A), is a manifestation of congenital heart disease. (
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B) is a classic sign of ventricular septal defect. (
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C) is characteristic of coarctation of the aorta.
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QUESTION 6 vc




Surgery is being delayed for an infant with undescended testes. In collaboration with the
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healthcare provider and the family, which prescription should the nurse anticipate? A tr
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ial of adrenocorticotrophic hormone injections. Frequent stimulation of the cremasteric
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reflex. A trial of human chorionic gonadotrophic hormone. Frequent warm baths to gentl
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y dilate the scrotal area.
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ANSWER

, A trial of human chorionic gonadotrophic hormone. A trial of HCG (human chorionic gonadotrophic hor
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mone) ( vc



C) may aid in testicular descent, but does not replace surgical repair for true undescended testes. Undes
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cended testes (cryptorchidism) may be found in the inguinal canal due to exaggerated cremasteric refle
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x. ( vc



A) is not indicated. Stimulation of the cremasteric reflex causes the testes to ascend rather than descend
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in the scrotum (B). (
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D) may relax the cremasteric muscle, but may not cause the testes to descend.
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QUESTION 7 vc




A preschool-
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age child who is hospitalized for hypospadias repair is most strongly influenced by whic
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h behavior? Ability to communicate verbally. Response to separation from family. Concer
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n for body integrity. Socialization with other children.
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ANSWER

Concern for body integrity. The preschooler's major stressor is concern for his body integrity (C). He fea
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rs that his "insides will leak out." A child undergoing surgery to his genitalia is even more concerned ab
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out body integrity. The preschooler is quite verbal, so comprehension of the words he uses or hears ma
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y be inaccurate, while his imagination and fears may fantasize the reality (A). (
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B) is a concern for all children, but of most concern to the toddler. (
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D) is not a prime concern in this situation.
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QUESTION 8 vc




A six-month-
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old returns from surgery with elbow restraints in place. What nursing care should be inc
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luded when caring for any restrained child? Keep restraints on at all times. Remove restr
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aints one at a time and provide range of motion exercises. Remove all restraints simulta
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neously and provide play activities. Renew the healthcare provider's prescription for res
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traints every 72 hours. vc vc vc




ANSWER

Remove restraints one at a time and provide range of motion exercises. Removing restraints one at a ti
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me ( vc



B) is safer than removing all of them at once (C). The child needs to exercise and should not be kept in r
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estraints at all times (A). The renewal of the healthcare provider's prescription varies with hospitals (D)
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, and it does not really answer the question.
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QUESTION 9 vc




All of the following interventions can be used to evaluate the effectiveness of nursing an
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d medical interventions used to treat diarrhea. Which intervention is least useful in the
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nurse's evaluation of a 20-month- vc vc vc vc