Evolve Fundamentals HESI/ Exam Questions &
Detailed Solutions.
Terms in this set (265)
An elderly client with a To avoid shearing forces when repositioning, the client
fractured left hip is on strict should be lifted gently across a surface (D). Reddened areas
bedrest. Which nursing should not be massaged (A) since this may increase the
measure is essential to the damage to already traumatized skin. To control pain and
client's nursing care? muscle spasms, active range of motion (B) may be limited
on the affected leg. The position described in (C) is
A. Massage any contraindicated for a client with a fractured left hip.
reddened
areas for at least five Correct Answer: D
minutes.
B. Encourage active
rangeof motion exercises on
extremities.
C. Position the
clientlaterally, prone, and
dorsally in sequence. D.
Gently lift the client when
moving into a desired
position.
,The nurse is administering The NGT should be flushed before, after and in between each
medications through a medication administered (B). Once all medications are
nasogastric tube (NGT) administered, the NGT should be clamped for 20 minutes (A).
which is connected to (C and D) may be implemented only after the tubing has been
suction. After ensuring flushed.
correct tube placement,
what action should the Correct Answer: B
nurse take next?
A. Clamp the tube for
20minutes.
B. Flush the tube
withwater.
C. Administer
themedications as
prescribed. D. Crush the
tablets and dissolve in sterile
water.
,A client who is in hospice The most effective management of pain is achieved using an
care complains of increasing around-the-clock schedule that provides analgesic
amounts of pain. The medications on a regular basis (A) and in a timely manner.
healthcare provider Analgesics are less effective if pain persists until it is severe,
prescribes an analgesic every so an analgesic medication should be administered before the
four hours as needed. Which client's pain peaks (B). Providing comfort is a priority for the
action should the nurse client who is dying, but sedation that impairs the client's
implement? ability to interact and experience the time before life ends
should be minimized (C). Offering a medication-free period
A. Give an around-the- allows the serum drug level to fall, which is not an effective
clock schedule for method to manage chronic pain (D).
administration of
analgesics. Correct Answer: A
B. Administer
analgesicmedication as
needed when the pain is
severe.
C. Provide medication
tokeep the client sedated
and unaware of stimuli.
D. Offer a medication-
freeperiod so that the client
can do daily activities.
, When assessing a client with The priority nursing action is to restore circulation by
wrist restraints, the nurse loosening the restraint (A), because blue fingers (cyanosis)
observes that the fingers on indicates decreased circulation. (C and D) are also important
the right hand are blue. What nursing interventions, but do not have the priority of (A).
action should the nurse Pulse oximetry (B) measures the saturation of hemoglobin
implement first? with oxygen and is not indicated in situations where the
cyanosis is related to mechanical compression (the
A. Loosen the right restraints).
wristrestraint.
B. Apply a pulse Correct Answer: A
oximeterto the right hand.
C. Compare hand
colorbilaterally.
D. Palpate the right
radialpulse.
A lactating woman (B) has the greatest need for additional
The nurse is assessing the
protein intake. (A, C, and D) are all conditions that require
nutritional status of several
protein, but do not have the increased metabolic protein
clients. Which client has the
demands of lactation.
greatest nutritional need for
additional intake of protein?
Correct Answer: B
A. A college-age
trackrunner with a
sprained ankle.
B. A lactating
womannursing her 3-day-
old infant.
C. A school-aged
childwith Type 2 diabetes.
D. An elderly man
beingtreated for a peptic
ulcer.
Detailed Solutions.
Terms in this set (265)
An elderly client with a To avoid shearing forces when repositioning, the client
fractured left hip is on strict should be lifted gently across a surface (D). Reddened areas
bedrest. Which nursing should not be massaged (A) since this may increase the
measure is essential to the damage to already traumatized skin. To control pain and
client's nursing care? muscle spasms, active range of motion (B) may be limited
on the affected leg. The position described in (C) is
A. Massage any contraindicated for a client with a fractured left hip.
reddened
areas for at least five Correct Answer: D
minutes.
B. Encourage active
rangeof motion exercises on
extremities.
C. Position the
clientlaterally, prone, and
dorsally in sequence. D.
Gently lift the client when
moving into a desired
position.
,The nurse is administering The NGT should be flushed before, after and in between each
medications through a medication administered (B). Once all medications are
nasogastric tube (NGT) administered, the NGT should be clamped for 20 minutes (A).
which is connected to (C and D) may be implemented only after the tubing has been
suction. After ensuring flushed.
correct tube placement,
what action should the Correct Answer: B
nurse take next?
A. Clamp the tube for
20minutes.
B. Flush the tube
withwater.
C. Administer
themedications as
prescribed. D. Crush the
tablets and dissolve in sterile
water.
,A client who is in hospice The most effective management of pain is achieved using an
care complains of increasing around-the-clock schedule that provides analgesic
amounts of pain. The medications on a regular basis (A) and in a timely manner.
healthcare provider Analgesics are less effective if pain persists until it is severe,
prescribes an analgesic every so an analgesic medication should be administered before the
four hours as needed. Which client's pain peaks (B). Providing comfort is a priority for the
action should the nurse client who is dying, but sedation that impairs the client's
implement? ability to interact and experience the time before life ends
should be minimized (C). Offering a medication-free period
A. Give an around-the- allows the serum drug level to fall, which is not an effective
clock schedule for method to manage chronic pain (D).
administration of
analgesics. Correct Answer: A
B. Administer
analgesicmedication as
needed when the pain is
severe.
C. Provide medication
tokeep the client sedated
and unaware of stimuli.
D. Offer a medication-
freeperiod so that the client
can do daily activities.
, When assessing a client with The priority nursing action is to restore circulation by
wrist restraints, the nurse loosening the restraint (A), because blue fingers (cyanosis)
observes that the fingers on indicates decreased circulation. (C and D) are also important
the right hand are blue. What nursing interventions, but do not have the priority of (A).
action should the nurse Pulse oximetry (B) measures the saturation of hemoglobin
implement first? with oxygen and is not indicated in situations where the
cyanosis is related to mechanical compression (the
A. Loosen the right restraints).
wristrestraint.
B. Apply a pulse Correct Answer: A
oximeterto the right hand.
C. Compare hand
colorbilaterally.
D. Palpate the right
radialpulse.
A lactating woman (B) has the greatest need for additional
The nurse is assessing the
protein intake. (A, C, and D) are all conditions that require
nutritional status of several
protein, but do not have the increased metabolic protein
clients. Which client has the
demands of lactation.
greatest nutritional need for
additional intake of protein?
Correct Answer: B
A. A college-age
trackrunner with a
sprained ankle.
B. A lactating
womannursing her 3-day-
old infant.
C. A school-aged
childwith Type 2 diabetes.
D. An elderly man
beingtreated for a peptic
ulcer.
