Evolve HESI practice Exam
Three days following surgery, a male client observes his colostomy for the first time. He
becomes quite upset and tells the nurse that it is much bigger than he expected. What
is the best response by the nurse? - Correct Answer-Instruct the client that the stoma
will become smaller when the initial swelling diminishes.
(Postoperative swelling causes enlargement of the stoma. The nurse can teach the
client that the stoma will become smaller when the swelling is diminished. This will help
reduce the anxiety and promote colostomy acceptance.)
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix
20 mg/2 ml. How many milliliters should the nurse administer? - Correct Answer-1.5ml
Which assessment data would provide the most accurate determination of proper
placement of a nasogastric tube? - Correct Answer-Examining a chest x-ray obtained
after the tubing was inserted.
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution
at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60
gtt/ml, how many drops per minute should the client receive? - Correct Answer-124
gtt/min.
At the time of the first dressing change, the client refuses to look at her mastectomy
incision. The nurse tells the client that the incision is healing well, but the client refuses
to talk about it. What would be an appropriate response to this client's silence? - Correct
Answer-It is OK if you don't want to talk about your surgery. I will be available when you
are ready.
(It displays sensitivity and understanding without judging the patient)
Examination of a client complaining of itching on his right arm reveals a rash made up of
multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should
the nurse record this finding? - Correct Answer-Localized red rash comprised of flat
areas, pinpoint to 0.5 cm in diameter.
The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in
8 mg per ml. How many ml should the nurse administer? - Correct Answer-0.5 ml.
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? -
Correct Answer-After clearing the tube with 30 ml of air, check the pH of fluid withdrawn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 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? - Correct Answer-
Give the missed dose at 1300 and change the schedule to administer daily at 1300.
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? - Correct Answer-Give an around-the-clock schedule for
administration of analgesics.
After completing an assessment and determining that a client has a problem, which
action should the nurse perform next? - Correct Answer-determine the etiology of the
problem
What is the most important reason for starting intravenous infusions in the upper
extremities rather than the lower extremities of adults? - Correct Answer-A decreased
flow rate could result in the formation of a thrombosis.
The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the
floor when she talks to the nurse. What action should the nurse take? - Correct Answer-
Continue asking the mother questions about the child.
Which intervention is most important for the nurse to implement for a male client who is
experiencing urinary retention? - Correct Answer-Assess for bladder distention.
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern
should the nurse have for planning care in terms of the client's beliefs? - Correct
Answer-Blood transfusions are forbidden.
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? - Correct
Answer-Acknowledge that she is supporting the arm correctly.
An elderly male client who is unresponsive following a cerebral vascular accident (CVA)
is receiving bolus enteral feedings though a gastrostomy tube. What is the best client
position for administration of the bolus tube feedings? - Correct Answer-Fowler's.
Three days following surgery, a male client observes his colostomy for the first time. He
becomes quite upset and tells the nurse that it is much bigger than he expected. What
is the best response by the nurse? - Correct Answer-Instruct the client that the stoma
will become smaller when the initial swelling diminishes.
(Postoperative swelling causes enlargement of the stoma. The nurse can teach the
client that the stoma will become smaller when the swelling is diminished. This will help
reduce the anxiety and promote colostomy acceptance.)
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix
20 mg/2 ml. How many milliliters should the nurse administer? - Correct Answer-1.5ml
Which assessment data would provide the most accurate determination of proper
placement of a nasogastric tube? - Correct Answer-Examining a chest x-ray obtained
after the tubing was inserted.
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution
at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60
gtt/ml, how many drops per minute should the client receive? - Correct Answer-124
gtt/min.
At the time of the first dressing change, the client refuses to look at her mastectomy
incision. The nurse tells the client that the incision is healing well, but the client refuses
to talk about it. What would be an appropriate response to this client's silence? - Correct
Answer-It is OK if you don't want to talk about your surgery. I will be available when you
are ready.
(It displays sensitivity and understanding without judging the patient)
Examination of a client complaining of itching on his right arm reveals a rash made up of
multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should
the nurse record this finding? - Correct Answer-Localized red rash comprised of flat
areas, pinpoint to 0.5 cm in diameter.
The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in
8 mg per ml. How many ml should the nurse administer? - Correct Answer-0.5 ml.
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? -
Correct 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 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? - Correct Answer-
Give the missed dose at 1300 and change the schedule to administer daily at 1300.
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? - Correct Answer-Give an around-the-clock schedule for
administration of analgesics.
After completing an assessment and determining that a client has a problem, which
action should the nurse perform next? - Correct Answer-determine the etiology of the
problem
What is the most important reason for starting intravenous infusions in the upper
extremities rather than the lower extremities of adults? - Correct Answer-A decreased
flow rate could result in the formation of a thrombosis.
The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the
floor when she talks to the nurse. What action should the nurse take? - Correct Answer-
Continue asking the mother questions about the child.
Which intervention is most important for the nurse to implement for a male client who is
experiencing urinary retention? - Correct Answer-Assess for bladder distention.
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern
should the nurse have for planning care in terms of the client's beliefs? - Correct
Answer-Blood transfusions are forbidden.
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? - Correct
Answer-Acknowledge that she is supporting the arm correctly.
An elderly male client who is unresponsive following a cerebral vascular accident (CVA)
is receiving bolus enteral feedings though a gastrostomy tube. What is the best client
position for administration of the bolus tube feedings? - Correct Answer-Fowler's.
