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Evolve HESI practice Exam Test Questions With
Well Elaborated Solutions
A client with pneumonia has a decrease in oxygen saturation from 94%
to 88% while ambulating. Based on these findings, which intervention
should the nurse implement first? - ...ANSWER✓✓✓Assist the
ambulating client back to the bed.
A client's infusion of normal saline infiltrated earlier today, and
approximately 500 ml of saline infused into the subcutaneous tissue. The
client is now complaining of excruciating arm pain and demanding
"stronger pain medications." What initial action is most important for the
nurse to take? - ...ANSWER✓✓✓Measure the pulse volume and
capillary refill distal to the infiltration.
(Pain and diminished pulse volume are signs of compartment syndrome,
which can progress to complete loss of the peripheral pulse in the
extremity.)
A female client asks the nurse to find someone who can translate into
her native language her concerns about a treatment. Which action should
the nurse take? - ...ANSWER✓✓✓Request and document the name of
the certified translator.
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A female client with a nasogastric tube attached to low suction states
that she is nauseated. The nurse assesses that there has been no drainage
through the nasogastric tube in the last two hours. What action should
the nurse take first? - ...ANSWER✓✓✓Reposition the client on her side
(The immediate priority is to determine if the tube is functioning
correctly, which would then relieve the nausea. Repositioning is the least
invasive.)
A hospitalized male client is receiving nasogastric tube feedings via a
small-bore tube and a continuous pump infusion. He reports that he had
a bad bout of severe coughing a few minutes ago, but feels fine now.
What action is best for the nurse to take? - ...ANSWER✓✓✓After
clearing the tube with 30 ml of air, check the pH of fluid withdrawn
from the tube.
(Coughing, vomiting, and suctioning can precipitate displacement of the
small bore upward into the esophagus. This will help check tube
placement.)
A male client being discharged with a prescription for the
bronchodilator theophylline tells the nurse that he understands he is to
take three doses of the medication each day. Since, at the time of
discharge, timed-release capsules are not available, which dosing
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schedule should the nurse advise the client to follow? -
...ANSWER✓✓✓8 a.m., 4 p.m., and midnight.
(Theophylline should be administered on a regular around-the-clock
schedule. 8,4 and midnight provide the best bronchodilating effect and
reduce the potential for adverse effects.)
A male client tells the nurse that he does not know where he is or what
year it is. What data should the nurse document that is most accurate?
- ...ANSWER✓✓✓is disoriented to place and time.
A nurse is preparing to give medications through a nasogastric feeding
tube. Which nursing action should prevent complications during
administration? - ...ANSWER✓✓✓A) Mix each medication individually
Medications should be mixed separately (A) to prevent clumping.
A postoperative client will need to perform daily dressing changes after
discharge. Which outcome statement best demonstrates the client's
readiness to manage his wound care after discharge? The client -
...ANSWER✓✓✓demonstrates the wound care procedure correctly.
A resident in a skilled nursing facility for short-term rehabilitation after
a hip replacement tells the nurse, "I don't want any more blood taken for
Evolve HESI practice Exam Test Questions With
Well Elaborated Solutions
A client with pneumonia has a decrease in oxygen saturation from 94%
to 88% while ambulating. Based on these findings, which intervention
should the nurse implement first? - ...ANSWER✓✓✓Assist the
ambulating client back to the bed.
A client's infusion of normal saline infiltrated earlier today, and
approximately 500 ml of saline infused into the subcutaneous tissue. The
client is now complaining of excruciating arm pain and demanding
"stronger pain medications." What initial action is most important for the
nurse to take? - ...ANSWER✓✓✓Measure the pulse volume and
capillary refill distal to the infiltration.
(Pain and diminished pulse volume are signs of compartment syndrome,
which can progress to complete loss of the peripheral pulse in the
extremity.)
A female client asks the nurse to find someone who can translate into
her native language her concerns about a treatment. Which action should
the nurse take? - ...ANSWER✓✓✓Request and document the name of
the certified translator.
,2|Page
A female client with a nasogastric tube attached to low suction states
that she is nauseated. The nurse assesses that there has been no drainage
through the nasogastric tube in the last two hours. What action should
the nurse take first? - ...ANSWER✓✓✓Reposition the client on her side
(The immediate priority is to determine if the tube is functioning
correctly, which would then relieve the nausea. Repositioning is the least
invasive.)
A hospitalized male client is receiving nasogastric tube feedings via a
small-bore tube and a continuous pump infusion. He reports that he had
a bad bout of severe coughing a few minutes ago, but feels fine now.
What action is best for the nurse to take? - ...ANSWER✓✓✓After
clearing the tube with 30 ml of air, check the pH of fluid withdrawn
from the tube.
(Coughing, vomiting, and suctioning can precipitate displacement of the
small bore upward into the esophagus. This will help check tube
placement.)
A male client being discharged with a prescription for the
bronchodilator theophylline tells the nurse that he understands he is to
take three doses of the medication each day. Since, at the time of
discharge, timed-release capsules are not available, which dosing
, 3|Page
schedule should the nurse advise the client to follow? -
...ANSWER✓✓✓8 a.m., 4 p.m., and midnight.
(Theophylline should be administered on a regular around-the-clock
schedule. 8,4 and midnight provide the best bronchodilating effect and
reduce the potential for adverse effects.)
A male client tells the nurse that he does not know where he is or what
year it is. What data should the nurse document that is most accurate?
- ...ANSWER✓✓✓is disoriented to place and time.
A nurse is preparing to give medications through a nasogastric feeding
tube. Which nursing action should prevent complications during
administration? - ...ANSWER✓✓✓A) Mix each medication individually
Medications should be mixed separately (A) to prevent clumping.
A postoperative client will need to perform daily dressing changes after
discharge. Which outcome statement best demonstrates the client's
readiness to manage his wound care after discharge? The client -
...ANSWER✓✓✓demonstrates the wound care procedure correctly.
A resident in a skilled nursing facility for short-term rehabilitation after
a hip replacement tells the nurse, "I don't want any more blood taken for
