Evolve HESI practice Exam
The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per
ml. How many ml should the nurse administer? - ANS 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? - ANS 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with 30 ml of air, check the pH of fluid withdrawn from the tube.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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS Fowler's.
An adult male client with a history of hypertension tells the nurse that he is tired of taking
antihypertensive medications and is going to try spiritual meditation instead. What should be the
nurse's first response? - ANS It is important that you continue your medication while learning to
meditate.
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the
pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20
minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?
- ANS 150
The nurse is completing a mental assessment for a client who is demonstrating slow thought
processes, personality changes, and emotional lability. Which area of the brain controls these
neuro-cognitive functions? - ANS Frontal lobe
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the
infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above
the IV access site. Which action should the nurse take at this time? - ANS Initiate an alternate
site for the IV infusion of the medication.
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? - ANS Request and
document the name of the certified translator.
A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture
resulting from a fall. In reviewing hip precautions with the client, which instruction should the
nurse include in this client's teaching plan? - ANS Place a pillow between your knees while
lying in bed to prevent hip dislocation.
An elderly resident of a long-term care facility is no longer able to perform self-care and is
becoming progressively weaker. The resident previously requested that no resuscitative efforts
be performed, and the family requests hospice care. What action should the nurse implement
first? - ANS Notify the healthcare provider of the family's request.
A young mother of three children complains of increased anxiety during her annual physical
exam. What information should the nurse obtain first? - ANS Nutritional history.
The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per
ml. How many ml should the nurse administer? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS Fowler's.
An adult male client with a history of hypertension tells the nurse that he is tired of taking
antihypertensive medications and is going to try spiritual meditation instead. What should be the
nurse's first response? - ANS It is important that you continue your medication while learning to
meditate.
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the
pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20
minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?
- ANS 150
The nurse is completing a mental assessment for a client who is demonstrating slow thought
processes, personality changes, and emotional lability. Which area of the brain controls these
neuro-cognitive functions? - ANS Frontal lobe
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the
infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above
the IV access site. Which action should the nurse take at this time? - ANS Initiate an alternate
site for the IV infusion of the medication.
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? - ANS Request and
document the name of the certified translator.
A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture
resulting from a fall. In reviewing hip precautions with the client, which instruction should the
nurse include in this client's teaching plan? - ANS Place a pillow between your knees while
lying in bed to prevent hip dislocation.
An elderly resident of a long-term care facility is no longer able to perform self-care and is
becoming progressively weaker. The resident previously requested that no resuscitative efforts
be performed, and the family requests hospice care. What action should the nurse implement
first? - ANS Notify the healthcare provider of the family's request.
A young mother of three children complains of increased anxiety during her annual physical
exam. What information should the nurse obtain first? - ANS Nutritional history.
