Evolve Hesi 1 Comprehensive EXAM NEWEST 2026 COMPLETE
QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+||BRAND NEW!!
Following major abdominal surgery, a male client's arterial blood gas analysis
reveals Pa02 95 mmHg and PaC02 50 mmHg. He is receiving
oxygen by nasal cannula at 4 liters/minute and is reluctant to move in bed or
deep breathe. Based on this information, what action should the nurse
implement at this time?
Encourage the use of an incentive spirometer.
The blood gas reveals adequate oxygenation (Pa02 95) and hypoventilation
(PaC02 > 45). The client needs to be encouraged in activities that increase the
depth of breathing (e. g., use of the incentive spirometer) (B). (A) will
only increase an already adequate Pa02. These are not crisis blood gas findings
(C). (D) will only worsen the hypoventilation.
A dyspneic male client refuses to wear an oxygen face mask because he
states it is "smothering" him. What oxygen delivery system is best for this
client?
Nasal cannula.
(C) will provide oxygen without covering the client's face. (A and B) are also
masks and will not alleviate the problem of feeling "smothered." (D) is used for
medication administration rather than oxygen.
,After receiving report, the nurse prioritizes the client care assignment. Which
client should the nurse assess first?
The client who has a new onset of difficult breathing.
Based on Maslow's hierarchy of needs and the need to address airway,
breathing, and circulation (ABCs), the client with a new onset of difficulty
breathing (A) should be assessed first. (B, C and D) do not have the priority of
(A).
When engaging in planned change on the unit, what should the nurse- manager
establish first?
Staff members are aware of the need for change
The first step in planned change involves establishing a relationship with those
involved in the change process and instilling knowledge and
awareness of the need for change (D). The nurse-manager should next
implement (C), and then (A and B).
,A female client makes routine visits to a neighborhood community health center.
The nurse notes that this client often presents with facial bruising, particularly
around the eyes. The nurse discusses prevention of domestic violence with the
client even though the client does not admit to being battered. What level of
prevention has the nurse applied in this situation?
Secondary prevention
Secondary prevention (B) attempts to halt the progression of the disease
process, in this case, an escalation in the battering, by educating the client about
prevention strategies. The nurse has identified client injuries that
create a suspicion of battering and domestic violence. (A) would be activities
that occur before the disease process begins, such as providing community
seminars on the risks, and signs and symptoms of domestic
violence. (C) occurs after the disease process has started, and includes
referring the client to a battered women's shelter for treatment following
unabated, chronic abuse. Health promotion can be incorporated in all levels
of prevention (D).
, The nurse is monitoring neurological vital signs for a male client who lost
consciousness after falling and hitting his head. Which assessment finding is the
earliest and most sensitive indication of altered cerebral function?
Change in level of consciousness
Neurological vital signs include serial assessments of TPR, blood pressure,
and components of the Glasgow coma scale (GCS), which includes verbal,
musculoskeletal, and pupillary responses. A change in the client's level of
consciousness (D), as indicated by responses to commands during the GCS, is
the first and the most sensitive sign of change in cerebral function. (A, B, and C)
are late signs of altered cerebral function.
The nurse is assessing a client and identifies the presence of petechiae. Which
documentation best describes this finding?
Purplish-red pinpoint lesions of the skin
Petechiae are described as purplish to red, non-blanchable, pinpoint lesions
(A) that are tiny hemorrhages within the dermal or submucosal layers. (B)
describes ecchymosis caused by trauma to the underlying blood vessels.
(C) describes pustules. (D) is nonspecific and incomplete.
QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+||BRAND NEW!!
Following major abdominal surgery, a male client's arterial blood gas analysis
reveals Pa02 95 mmHg and PaC02 50 mmHg. He is receiving
oxygen by nasal cannula at 4 liters/minute and is reluctant to move in bed or
deep breathe. Based on this information, what action should the nurse
implement at this time?
Encourage the use of an incentive spirometer.
The blood gas reveals adequate oxygenation (Pa02 95) and hypoventilation
(PaC02 > 45). The client needs to be encouraged in activities that increase the
depth of breathing (e. g., use of the incentive spirometer) (B). (A) will
only increase an already adequate Pa02. These are not crisis blood gas findings
(C). (D) will only worsen the hypoventilation.
A dyspneic male client refuses to wear an oxygen face mask because he
states it is "smothering" him. What oxygen delivery system is best for this
client?
Nasal cannula.
(C) will provide oxygen without covering the client's face. (A and B) are also
masks and will not alleviate the problem of feeling "smothered." (D) is used for
medication administration rather than oxygen.
,After receiving report, the nurse prioritizes the client care assignment. Which
client should the nurse assess first?
The client who has a new onset of difficult breathing.
Based on Maslow's hierarchy of needs and the need to address airway,
breathing, and circulation (ABCs), the client with a new onset of difficulty
breathing (A) should be assessed first. (B, C and D) do not have the priority of
(A).
When engaging in planned change on the unit, what should the nurse- manager
establish first?
Staff members are aware of the need for change
The first step in planned change involves establishing a relationship with those
involved in the change process and instilling knowledge and
awareness of the need for change (D). The nurse-manager should next
implement (C), and then (A and B).
,A female client makes routine visits to a neighborhood community health center.
The nurse notes that this client often presents with facial bruising, particularly
around the eyes. The nurse discusses prevention of domestic violence with the
client even though the client does not admit to being battered. What level of
prevention has the nurse applied in this situation?
Secondary prevention
Secondary prevention (B) attempts to halt the progression of the disease
process, in this case, an escalation in the battering, by educating the client about
prevention strategies. The nurse has identified client injuries that
create a suspicion of battering and domestic violence. (A) would be activities
that occur before the disease process begins, such as providing community
seminars on the risks, and signs and symptoms of domestic
violence. (C) occurs after the disease process has started, and includes
referring the client to a battered women's shelter for treatment following
unabated, chronic abuse. Health promotion can be incorporated in all levels
of prevention (D).
, The nurse is monitoring neurological vital signs for a male client who lost
consciousness after falling and hitting his head. Which assessment finding is the
earliest and most sensitive indication of altered cerebral function?
Change in level of consciousness
Neurological vital signs include serial assessments of TPR, blood pressure,
and components of the Glasgow coma scale (GCS), which includes verbal,
musculoskeletal, and pupillary responses. A change in the client's level of
consciousness (D), as indicated by responses to commands during the GCS, is
the first and the most sensitive sign of change in cerebral function. (A, B, and C)
are late signs of altered cerebral function.
The nurse is assessing a client and identifies the presence of petechiae. Which
documentation best describes this finding?
Purplish-red pinpoint lesions of the skin
Petechiae are described as purplish to red, non-blanchable, pinpoint lesions
(A) that are tiny hemorrhages within the dermal or submucosal layers. (B)
describes ecchymosis caused by trauma to the underlying blood vessels.
(C) describes pustules. (D) is nonspecific and incomplete.
