EVOLVE HESI PHARM EXAM NEWEST
COMPLETE QUESTIONS AND CORRECT
VERIFIED ANSWERS(DETAILED
ANSWERS)|ALREADY GRADED A+
Which disaster management intervention by the nurse is an example of primary prevention?
A.Emergency department triage
B.Follow-up care for psychological problems
C.Education of rescue workers in first aid
D.Treatment of clients who are injured C
Rationale:
Primary prevention is aimed at preventing disease or injury. Training rescue workers prior to a
disaster is an example of minimizing or preventing injury (C). (A) is an example of secondary
prevention. (B) is an example of tertiary prevention. (D) is an example of secondary prevention.
The nurse is caring for a client who is experiencing severe pain. The expected outcome the
nurse writes for the client reads, "The client will state my pain is less than 2 within 45 minutes
after pain medication has been administered." Formulating the expected outcome is an
example of which step in the nursing process?
A.Assessment
B.Planning
C.Implementation
D.Evaluation B
Rationale:
Planning (B) allows the nurse to set goals for care and elicit the expected outcome by identifying
appropriate nursing actions. Assessment, implementation, and evaluation are part of the care
for the client but are not the appropriate actions for formulating the expected outcome (A, C,
and D).
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,The nurse is planning the care for a client who is admitted with syndrome of inappropriate
antidiuretic hormone secretion (SIADH). Which intervention(s) should the nurse include in this
client's plan of care? (Select all that apply.)
A.Salt-free diet
B.Quiet environment
C.Deep tendon reflex assessments
D.Neurologic checks
E.Daily weights B,C,D,E
Rationale:
Correct responses are (B, C, D, and E). SAIDH results in water retention and dilutional
hyponatremia, which causes neurologic changes when serum sodium levels are less than 115
mEq/L. The nurse should maintain a quiet environment (B) to prevent overstimulation and
assess deep tendon reflexes (C) and perform neurologic checks (D) to monitor for neurologic
deterioration. Daily weights (E) should be monitored to assess for fluid overload. (A) would
contribute to dilutional hyponatremia.
A client in the psychiatric setting with an anxiety disorder reports chest pain. Which action
should the nurse take first?
A.Administer an antianxiety medication PRN.
B.Assess the client's vital signs.
C.Notify the primary health care provider.
D.Determine coping mechanisms used in the past. B
Rationale:
Although increased heart rate, palpitations, and chest pain may be caused by anxiety, it is
important that the nurse assess the patient and rule out physiologic causes (B).
Nonpharmacologic measures should be taken first (A). (C and D) may be considered but are not
as high priority as the initial physiologic assessment.
The charge nurse observes a student nurse enter the room of a client who is prescribed
airborne precautions. The application of which personal protective equipment by the student
indicates a correct understanding of this precaution?
A.Surgical mask, clean gloves, and gown
2|Page
,B.Properly fitted N95 respirator or mask
C.Sterile gloves and gown
D.Goggles, clean gloves, and gown B
Rationale:
The use of personal protective equipment (PPE) for airborne precautions includes a properly
prefitted N95 respirator or mask (B). (A, C and D) do not provide the appropriate respiratory
equipment for airborne precautions. A surgical mask is used for preventing transmission of
droplet precautions.
The nurse empties a client's urinary drainage from an indwelling Foley catheter. Which finding
should be reported to the primary health care provider?
A.Ammonia odor is noted when the catheter is emptied.
B.240 mL of urinary output is produced in 12 hours.
C.A 16-French catheter was used for an adult female.
D.Drainage system is hanging below the level of the bladder. B
Rationale:
An expected finding is between 400 and 750 mL in 12 hours = average of 30 mL/hr (B).
Ammonia odor is an expected finding (A). Size 14- to 18-French catheters are common sizes
used in the adult female (C). Below the level of the bladder is the correct position for the
drainage bag (D).
An adult female who presents at the mental clinic trembling and crying becomes distressed
when the nurse attempts to conduct an assessment. She complains about the number of
questions that are being asked, which she is convinced are going to cause her to have a heart
attack. What action should the nurse take?
A.Take the client's blood pressure and reassure her that questioning will not cause a heart
attack.
B.Explain that treatment is based on information obtained in the assessment.
C.Encourage the client to relax so that she can provide the information requested.
D.Empower the client to share her story of why she is here at the mental health clinic. D
Rationale:
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, The client is exhibiting signs of moderate anxiety, which include voice tremors, shakiness,
somatic complaints, and selective inattention. (D) is the best method for addressing this client's
level of anxiety by creating a shared understanding of the client's concerns. Although
assessment of her blood pressure (A) might be a worthwhile intervention, reassuring her that
questioning will not cause a heart attack (A) is argumentative. (B) suggests that treatment
cannot be provided without the information, which is manipulative. Asking the client to relax (C)
is likely to increase her anxiety.
Which information is most concerning to the nurse when caring for an older client with bilateral
cataracts?
A.States having difficulty with color perception
B.Presents with opacity of the lens upon assessment
C.Complains of seeing a cobweb-type structure in the visual field
D.Reports the need to use a magnifying glass to see small print C
Rationale:
Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment, which
constitutes a medical emergency. Clients with cataracts are at increased risk for retinal
detachment (C). Distorted color perception (A), opacity of the lens (B), and gradual vision loss
(D) are expected signs and symptom of cataracts, but do not need immediate attention.
Which intervention(s) should be performed by the nurse when caring for a woman in the fourth
stage of labor? (Select all that apply.)
A.Maintain bed rest for the first 6 hours after delivery.
B.Palpate and massage the fundus to maintain firmness.
C.Have client empty bladder if fundus is above umbilicus.
D.Check perineal pad for color and consistency of lochia.
E.Apply ice pack or witch hazel compresses to the perineum. B,D,E
Rationale:
The fundus should be palpated and massaged frequently to prevent hemorrhage (B). The lochia
should be assessed to detect for hemorrhage (D) and ice packs and witch hazel can decrease
edema and discomfort (E). Bed rest is only recommended for the first 2 hours (A). A full bladder
is suspected if the fundus is deviated to the right or left of the umbilicus (C).
4|Page
COMPLETE QUESTIONS AND CORRECT
VERIFIED ANSWERS(DETAILED
ANSWERS)|ALREADY GRADED A+
Which disaster management intervention by the nurse is an example of primary prevention?
A.Emergency department triage
B.Follow-up care for psychological problems
C.Education of rescue workers in first aid
D.Treatment of clients who are injured C
Rationale:
Primary prevention is aimed at preventing disease or injury. Training rescue workers prior to a
disaster is an example of minimizing or preventing injury (C). (A) is an example of secondary
prevention. (B) is an example of tertiary prevention. (D) is an example of secondary prevention.
The nurse is caring for a client who is experiencing severe pain. The expected outcome the
nurse writes for the client reads, "The client will state my pain is less than 2 within 45 minutes
after pain medication has been administered." Formulating the expected outcome is an
example of which step in the nursing process?
A.Assessment
B.Planning
C.Implementation
D.Evaluation B
Rationale:
Planning (B) allows the nurse to set goals for care and elicit the expected outcome by identifying
appropriate nursing actions. Assessment, implementation, and evaluation are part of the care
for the client but are not the appropriate actions for formulating the expected outcome (A, C,
and D).
1|Page
,The nurse is planning the care for a client who is admitted with syndrome of inappropriate
antidiuretic hormone secretion (SIADH). Which intervention(s) should the nurse include in this
client's plan of care? (Select all that apply.)
A.Salt-free diet
B.Quiet environment
C.Deep tendon reflex assessments
D.Neurologic checks
E.Daily weights B,C,D,E
Rationale:
Correct responses are (B, C, D, and E). SAIDH results in water retention and dilutional
hyponatremia, which causes neurologic changes when serum sodium levels are less than 115
mEq/L. The nurse should maintain a quiet environment (B) to prevent overstimulation and
assess deep tendon reflexes (C) and perform neurologic checks (D) to monitor for neurologic
deterioration. Daily weights (E) should be monitored to assess for fluid overload. (A) would
contribute to dilutional hyponatremia.
A client in the psychiatric setting with an anxiety disorder reports chest pain. Which action
should the nurse take first?
A.Administer an antianxiety medication PRN.
B.Assess the client's vital signs.
C.Notify the primary health care provider.
D.Determine coping mechanisms used in the past. B
Rationale:
Although increased heart rate, palpitations, and chest pain may be caused by anxiety, it is
important that the nurse assess the patient and rule out physiologic causes (B).
Nonpharmacologic measures should be taken first (A). (C and D) may be considered but are not
as high priority as the initial physiologic assessment.
The charge nurse observes a student nurse enter the room of a client who is prescribed
airborne precautions. The application of which personal protective equipment by the student
indicates a correct understanding of this precaution?
A.Surgical mask, clean gloves, and gown
2|Page
,B.Properly fitted N95 respirator or mask
C.Sterile gloves and gown
D.Goggles, clean gloves, and gown B
Rationale:
The use of personal protective equipment (PPE) for airborne precautions includes a properly
prefitted N95 respirator or mask (B). (A, C and D) do not provide the appropriate respiratory
equipment for airborne precautions. A surgical mask is used for preventing transmission of
droplet precautions.
The nurse empties a client's urinary drainage from an indwelling Foley catheter. Which finding
should be reported to the primary health care provider?
A.Ammonia odor is noted when the catheter is emptied.
B.240 mL of urinary output is produced in 12 hours.
C.A 16-French catheter was used for an adult female.
D.Drainage system is hanging below the level of the bladder. B
Rationale:
An expected finding is between 400 and 750 mL in 12 hours = average of 30 mL/hr (B).
Ammonia odor is an expected finding (A). Size 14- to 18-French catheters are common sizes
used in the adult female (C). Below the level of the bladder is the correct position for the
drainage bag (D).
An adult female who presents at the mental clinic trembling and crying becomes distressed
when the nurse attempts to conduct an assessment. She complains about the number of
questions that are being asked, which she is convinced are going to cause her to have a heart
attack. What action should the nurse take?
A.Take the client's blood pressure and reassure her that questioning will not cause a heart
attack.
B.Explain that treatment is based on information obtained in the assessment.
C.Encourage the client to relax so that she can provide the information requested.
D.Empower the client to share her story of why she is here at the mental health clinic. D
Rationale:
3|Page
, The client is exhibiting signs of moderate anxiety, which include voice tremors, shakiness,
somatic complaints, and selective inattention. (D) is the best method for addressing this client's
level of anxiety by creating a shared understanding of the client's concerns. Although
assessment of her blood pressure (A) might be a worthwhile intervention, reassuring her that
questioning will not cause a heart attack (A) is argumentative. (B) suggests that treatment
cannot be provided without the information, which is manipulative. Asking the client to relax (C)
is likely to increase her anxiety.
Which information is most concerning to the nurse when caring for an older client with bilateral
cataracts?
A.States having difficulty with color perception
B.Presents with opacity of the lens upon assessment
C.Complains of seeing a cobweb-type structure in the visual field
D.Reports the need to use a magnifying glass to see small print C
Rationale:
Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment, which
constitutes a medical emergency. Clients with cataracts are at increased risk for retinal
detachment (C). Distorted color perception (A), opacity of the lens (B), and gradual vision loss
(D) are expected signs and symptom of cataracts, but do not need immediate attention.
Which intervention(s) should be performed by the nurse when caring for a woman in the fourth
stage of labor? (Select all that apply.)
A.Maintain bed rest for the first 6 hours after delivery.
B.Palpate and massage the fundus to maintain firmness.
C.Have client empty bladder if fundus is above umbilicus.
D.Check perineal pad for color and consistency of lochia.
E.Apply ice pack or witch hazel compresses to the perineum. B,D,E
Rationale:
The fundus should be palpated and massaged frequently to prevent hemorrhage (B). The lochia
should be assessed to detect for hemorrhage (D) and ice packs and witch hazel can decrease
edema and discomfort (E). Bed rest is only recommended for the first 2 hours (A). A full bladder
is suspected if the fundus is deviated to the right or left of the umbilicus (C).
4|Page
