EVOLVE HESI PHARM STUDY SHEET EXAM 2026
QUESTIONS WITH ANSWERS VERIFIED ANSWER
COLLECTION
▶ The nurse is admitting an older adult with decompensated congestive heart failure.
The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea.
The nurse should question which doctor's order?
A) KCl 20 mEq PO two times per day
B) Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
C) Oxygen via face mask at 8 L/min
D) Furosemide (Lasix) 20 mg PO now Answer: B
A patient with decompensated heart failure has extracellular fluid volume (ECV) excess.
The IV of 0.9% NaCl is normal saline, which should be questioned because it would
expand ECV and place an additional load on the failing heart. Diuretics such as
furosemide are appropriate to decrease the ECV during heart failure. Increasing the
potassium intake with KCl is appropriate, because furosemide increases potassium
excretion. Oxygen administration is appropriate in this situation of near pulmonary
edema from ECV excess.
▶ The priority nursing intervention for a patient suspected to be hypothermic would be
to:
A) hydrate with intravenous (IV) fluids.
B) remove wet clothes.
C) assess vital signs.
D) provide a warm blanket. Answer: B
The first thing to do with a patient suspected to be hypothermic is to remove wet
clothes, because heat loss is five times greater when clothing is wet. Assessing vital
signs is important, but the wet clothes should be removed first. Hydration is very
important with hyperthermia and the associated danger of dehydration, but there is not
a similar risk with hypothermia. A warm blanket over wet clothes would not be an
effective warming strategy.
▶ The nurse admitting a patient to the emergency department on a very hot summer
day would suspect hyperthermia when the patient demonstrates:
A) slow capillary refill.
B) red, sweaty skin.
C) low pulse rate.
D) decreased respirations. Answer: B
,With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm
or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate
increases with hyperthermia. With hypothermia there is slow capillary refill.
▶ Why does the nurse always ask the client his or her pain level after taking routine
vital signs?
A) To follow McCaffery's guidelines on pain management
B) To ensure that pain assessment occurs on a regular basis
C) To determine the need for more frequent vital sign measurement
D) To determine whether pain is influencing blood pressure and heart rate Answer: B
Making pain the fifth vital sign allows more frequent and accurate assessment, which
can contribute to better pain management.
▶ The nurse observes skin tenting on the back of the older adult client's hand. Which
action by the nurse is most appropriate?
A) Examine dependent body areas.
B) Notify the physician.
C) Document the finding and continue to monitor.
D) Assess turgor on the client's forehead. Answer: D
Skin turgor cannot be accurately assessed on an older adult client's hands because of
age-related loss of tissue elasticity in this area. Areas that more accurately show skin
turgor status on an older client include the skin of the forehead, chest, and abdomen.
These should also be assessed, rather than merely examining dependent body areas.
Further assessment is needed rather than only documenting, monitoring, and notifying
the physician.
▶ The nurse is assessing a client who has undergone a transurethral resection of the
prostate (TURP). Which assessment finding requires immediate action by the nurse?
A) Having the urge to void continuously while the catheter is inserted
B) Passing small blood clots after catheter removal
C) Having bright red drainage with multiple blood clots
D) Experiencing urinary frequency after catheter removal Answer: C
A client who undergoes a TURP is at risk for bleeding during the first 24 hours after
surgery. Passage of small blood clots and tissue debris, urinary frequency and leakage,
and the urge to void continuously while the client still has the catheter inserted are all
considered to be expected complications of the procedure. They will resolve as the
client continues to recover and the catheter is removed. However, the presence of
bright red blood with clots indicates arterial bleeding and should be reported to the
provider.
,▶ Which finding puts a client at greatest risk for wound infection?
A) Presence of a deep wound
B) Coexisting medical conditions
C) Immune compromised status
D) Severely reddened skin Answer: C
A compromised immune system puts a client at greatest risk for infection. Although all
the other options might increase the client's susceptibility, the one with the greatest
potential impact is being immune compromised.
▶ The nurse is assessing a client with an early onset of multiple sclerosis (MS). Which
clinical manifestations does the nurse expect to see?
A) Nystagmus & Diplopia
B) Hyperresponsive reflexes
C) Excessive somnolence
D) Heat intolerance Answer: A
Early signs and symptoms of MS include changes in motor skills, vision, and sensation.
The other manifestations are later signs of MS.
▶ The nurse determines that a client has a Braden Scale score of 9. Which is the
nurse's best intervention related to this assessment?
A) Increase the client's fluid intake.
B) Consult with the health care provider.
C) Reassess the client in 3 days.
D) Document the finding per protocol. Answer: B
A score of 11 or less on the Braden Scale indicates severe risk for pressure ulcer
development in terms of decreased sensory perception, exposure to moisture,
decreased independent activity, decreased mobility, poor nutrition, and chronic
exposure to friction and shear. The nurse needs to consult with the health care provider
to relay this information and to obtain more aggressive skin protection measures than
are currently provided.
▶ While planning care for a patient experiencing fatigue due to chemotherapy, which of
the following is the most appropriate nursing intervention?
A) Completing all nursing care in the evening when the patient is more rested
B) Completing all nursing care in the morning so the patient can rest the remainder of
the day
C) Limiting visitors, thus promoting the maximal amount of hours for sleep
D) Prioritization and administration of nursing care throughout the day Answer: D
, Pacing activities throughout the day conserves energy, and nursing care should be
paced as well. Fatigue is a common side effect of cancer and treatment; and while
adequate sleep is important, an increase in the number of hours slept will not resolve
the fatigue. Restriction of visitors does not promote healthy coping and can result in
feelings of isolation.
▶ A diabetic client has numbness and reduced sensation. Which intervention does the
nurse teach this client to prevent injury?
A) "Use a bath thermometer to test the water temperature."
B) "Examine your feet daily using a mirror."
C) "Wear white socks instead of colored socks."
D) "Rotate your insulin injection sites." Answer: A
Clients with diminished sensory perception can easily experience a burn injury when
bath water is too hot. Instead of checking the temperature of the water by feeling it, they
should use a thermometer. Examining the feet daily does not prevent injury, although
daily foot examinations are important to find problems so they can be addressed.
Rotating insulin and wearing white socks also will not prevent injury.
▶ Which client does the nurse assess to be at greatest risk for pressure ulcer
development?
A) Client who requires assistance with ambulation
B) Incontinent client with limited mobility
C) Client with hypertension on multiple medications
D) Client who has pneumonia Answer: B
Being immobile and being incontinent are two significant risk factors for the
development of pressure ulcers. Clients with pneumonia and hypertension do not have
specific risk factors. The client who needs assistance with ambulation might be at
moderate risk if he or she does not move about much, but having two risk factors makes
the last option the person at highest risk.
▶ The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail
older patient; the nursing assistant understands the instruction when she agrees to:
A) bathe and dry the skin vigorously to stimulate circulation.
B) limit intake of fluid and offer frequent snacks.
C) turn the patient at least every 2 hours.
D) keep the head of the bed elevated 30 degrees. Answer: C
The patient should be turned at least every 2 hours as permanent damage can occur in
2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning
schedule, the patient must be turned more frequently. Limiting fluids will prevent
QUESTIONS WITH ANSWERS VERIFIED ANSWER
COLLECTION
▶ The nurse is admitting an older adult with decompensated congestive heart failure.
The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea.
The nurse should question which doctor's order?
A) KCl 20 mEq PO two times per day
B) Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
C) Oxygen via face mask at 8 L/min
D) Furosemide (Lasix) 20 mg PO now Answer: B
A patient with decompensated heart failure has extracellular fluid volume (ECV) excess.
The IV of 0.9% NaCl is normal saline, which should be questioned because it would
expand ECV and place an additional load on the failing heart. Diuretics such as
furosemide are appropriate to decrease the ECV during heart failure. Increasing the
potassium intake with KCl is appropriate, because furosemide increases potassium
excretion. Oxygen administration is appropriate in this situation of near pulmonary
edema from ECV excess.
▶ The priority nursing intervention for a patient suspected to be hypothermic would be
to:
A) hydrate with intravenous (IV) fluids.
B) remove wet clothes.
C) assess vital signs.
D) provide a warm blanket. Answer: B
The first thing to do with a patient suspected to be hypothermic is to remove wet
clothes, because heat loss is five times greater when clothing is wet. Assessing vital
signs is important, but the wet clothes should be removed first. Hydration is very
important with hyperthermia and the associated danger of dehydration, but there is not
a similar risk with hypothermia. A warm blanket over wet clothes would not be an
effective warming strategy.
▶ The nurse admitting a patient to the emergency department on a very hot summer
day would suspect hyperthermia when the patient demonstrates:
A) slow capillary refill.
B) red, sweaty skin.
C) low pulse rate.
D) decreased respirations. Answer: B
,With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm
or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate
increases with hyperthermia. With hypothermia there is slow capillary refill.
▶ Why does the nurse always ask the client his or her pain level after taking routine
vital signs?
A) To follow McCaffery's guidelines on pain management
B) To ensure that pain assessment occurs on a regular basis
C) To determine the need for more frequent vital sign measurement
D) To determine whether pain is influencing blood pressure and heart rate Answer: B
Making pain the fifth vital sign allows more frequent and accurate assessment, which
can contribute to better pain management.
▶ The nurse observes skin tenting on the back of the older adult client's hand. Which
action by the nurse is most appropriate?
A) Examine dependent body areas.
B) Notify the physician.
C) Document the finding and continue to monitor.
D) Assess turgor on the client's forehead. Answer: D
Skin turgor cannot be accurately assessed on an older adult client's hands because of
age-related loss of tissue elasticity in this area. Areas that more accurately show skin
turgor status on an older client include the skin of the forehead, chest, and abdomen.
These should also be assessed, rather than merely examining dependent body areas.
Further assessment is needed rather than only documenting, monitoring, and notifying
the physician.
▶ The nurse is assessing a client who has undergone a transurethral resection of the
prostate (TURP). Which assessment finding requires immediate action by the nurse?
A) Having the urge to void continuously while the catheter is inserted
B) Passing small blood clots after catheter removal
C) Having bright red drainage with multiple blood clots
D) Experiencing urinary frequency after catheter removal Answer: C
A client who undergoes a TURP is at risk for bleeding during the first 24 hours after
surgery. Passage of small blood clots and tissue debris, urinary frequency and leakage,
and the urge to void continuously while the client still has the catheter inserted are all
considered to be expected complications of the procedure. They will resolve as the
client continues to recover and the catheter is removed. However, the presence of
bright red blood with clots indicates arterial bleeding and should be reported to the
provider.
,▶ Which finding puts a client at greatest risk for wound infection?
A) Presence of a deep wound
B) Coexisting medical conditions
C) Immune compromised status
D) Severely reddened skin Answer: C
A compromised immune system puts a client at greatest risk for infection. Although all
the other options might increase the client's susceptibility, the one with the greatest
potential impact is being immune compromised.
▶ The nurse is assessing a client with an early onset of multiple sclerosis (MS). Which
clinical manifestations does the nurse expect to see?
A) Nystagmus & Diplopia
B) Hyperresponsive reflexes
C) Excessive somnolence
D) Heat intolerance Answer: A
Early signs and symptoms of MS include changes in motor skills, vision, and sensation.
The other manifestations are later signs of MS.
▶ The nurse determines that a client has a Braden Scale score of 9. Which is the
nurse's best intervention related to this assessment?
A) Increase the client's fluid intake.
B) Consult with the health care provider.
C) Reassess the client in 3 days.
D) Document the finding per protocol. Answer: B
A score of 11 or less on the Braden Scale indicates severe risk for pressure ulcer
development in terms of decreased sensory perception, exposure to moisture,
decreased independent activity, decreased mobility, poor nutrition, and chronic
exposure to friction and shear. The nurse needs to consult with the health care provider
to relay this information and to obtain more aggressive skin protection measures than
are currently provided.
▶ While planning care for a patient experiencing fatigue due to chemotherapy, which of
the following is the most appropriate nursing intervention?
A) Completing all nursing care in the evening when the patient is more rested
B) Completing all nursing care in the morning so the patient can rest the remainder of
the day
C) Limiting visitors, thus promoting the maximal amount of hours for sleep
D) Prioritization and administration of nursing care throughout the day Answer: D
, Pacing activities throughout the day conserves energy, and nursing care should be
paced as well. Fatigue is a common side effect of cancer and treatment; and while
adequate sleep is important, an increase in the number of hours slept will not resolve
the fatigue. Restriction of visitors does not promote healthy coping and can result in
feelings of isolation.
▶ A diabetic client has numbness and reduced sensation. Which intervention does the
nurse teach this client to prevent injury?
A) "Use a bath thermometer to test the water temperature."
B) "Examine your feet daily using a mirror."
C) "Wear white socks instead of colored socks."
D) "Rotate your insulin injection sites." Answer: A
Clients with diminished sensory perception can easily experience a burn injury when
bath water is too hot. Instead of checking the temperature of the water by feeling it, they
should use a thermometer. Examining the feet daily does not prevent injury, although
daily foot examinations are important to find problems so they can be addressed.
Rotating insulin and wearing white socks also will not prevent injury.
▶ Which client does the nurse assess to be at greatest risk for pressure ulcer
development?
A) Client who requires assistance with ambulation
B) Incontinent client with limited mobility
C) Client with hypertension on multiple medications
D) Client who has pneumonia Answer: B
Being immobile and being incontinent are two significant risk factors for the
development of pressure ulcers. Clients with pneumonia and hypertension do not have
specific risk factors. The client who needs assistance with ambulation might be at
moderate risk if he or she does not move about much, but having two risk factors makes
the last option the person at highest risk.
▶ The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail
older patient; the nursing assistant understands the instruction when she agrees to:
A) bathe and dry the skin vigorously to stimulate circulation.
B) limit intake of fluid and offer frequent snacks.
C) turn the patient at least every 2 hours.
D) keep the head of the bed elevated 30 degrees. Answer: C
The patient should be turned at least every 2 hours as permanent damage can occur in
2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning
schedule, the patient must be turned more frequently. Limiting fluids will prevent
