NUR 111 EVOLVE HESI QUESTIONS WITH ACCURATE
ANSWERS
A 17-year-old male student reports to the school clinic one morning for a
scheduled health exam. He tells the nurse that he just finished football practice
and is on his way to class. The nurse assesses his vital signs: temperature 100 F,
pulse 80, respirations 20, and blood pressure 122/82. What is the best action for
the nurse to take?
a. Tell the student to proceed directly to his regularly scheduled class.
b. Call the parent and suggest re-taking the student's temperature at home.
c. Give the student a glass of cool fluids, then retake his temperature.
d. Send the student to class, but re-verify his temperature after lunch. correct
answer Tell the student to proceed directly to his regularly scheduled class
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks
gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine)
0.25 mg subcutaneous. Which assessment is the highest priority for the nurse to
monitor during the administration of this drug?
a. Maternal blood pressure and respirations.
b. Maternal and fetal heart rates.
c. Hourly urinary output.
d. Deep tendon reflexes. correct answer Maternal and fetal heart rates
A 73-year-old Hispanic client is seen at the community health clinic with a history
of protein malnutrition. What information should the nurse obtain first?
a. Amount of liquid protein supplements consumed daily.
b. Foods and liquids consumed during the past 24 hours.
c. Usual weekly intake of milk products and red meats.
,d. Grains and legume combinations used by the client. correct answer Amount of
liquid protein supplements consumed daily
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment
finding is most indicative of an impending convulsion?
a. 3+ deep tendon reflexes and hyperclonus.
b. Periorbital edema, flashing lights, and aura.
c. Epigastric pain in the third trimester.
d. Recent decreased urinary output. correct answer 3+ deep tendon reflexes and
hyperclonus
A client in hospice care develops audible gurgling sounds on inspiration. Which
nursing action has the highest priority?
a. Ensure cultural customs are observed.
b. Increase oxygen flow to 4L/minute.
c. Auscultate bilateral lung fields.
d. Inform the family that death is imminent. correct answer Inform the family that
death is imminent
A client is admitted to the hospital with intractable pain. What instruction should
the nurse provide the unlicensed assistive personnel (UAP) who is preparing to
assist this client with a bed bath?
a. Take measures to promote as much comfort as possible.
b. Report any signs of drug addiction to the nurse immediately.
c. Wait until the client's pain is gone before assisting with personal care.
d. This client's pain will be difficult to manage, since the cause is unknown. correct
answer Take measures to promote as much comfort as possible
, A client is taking sulfisoxazole (Gantrisin) for a urinary tract infection (UTI) and
complains of nausea and gastric upset since starting the medication. Which
additional adverse reaction should the nurse instruct the client to report?
a. Rash.
b. Diarrhea.
c. Hematuria.
d. Muscle cramping. correct answer Rash
A client receives a prescription for sulfamethoxazole-trimethoprim (Septra) for a
urinary tract infection (UTI). What instruction should the nurse provide the client?
a. Ingest food prior to taking the antibiotic.
b. Drink at least 8 glasses of water a day.
c. Take the medication with grapefruit juice.
d. Avoid prolonged exposure to sunlight. correct answer Drink at least 8 glasses of
water a day
A client with pneumonia has a decrease in oxygen saturation from 94% to 88%
while ambulating. Based on these findings, which intervention should the nurse
implement first?
a. Assist the ambulating client back to the bed.
b. Encourage the client to ambulate to resolve pneumonia.
c. Obtain a prescription for portable oxygen while ambulating.
d. Move the oximetry probe from the finger to the earlobe. correct answer Assist
the ambulating client back to the bed
ANSWERS
A 17-year-old male student reports to the school clinic one morning for a
scheduled health exam. He tells the nurse that he just finished football practice
and is on his way to class. The nurse assesses his vital signs: temperature 100 F,
pulse 80, respirations 20, and blood pressure 122/82. What is the best action for
the nurse to take?
a. Tell the student to proceed directly to his regularly scheduled class.
b. Call the parent and suggest re-taking the student's temperature at home.
c. Give the student a glass of cool fluids, then retake his temperature.
d. Send the student to class, but re-verify his temperature after lunch. correct
answer Tell the student to proceed directly to his regularly scheduled class
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks
gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine)
0.25 mg subcutaneous. Which assessment is the highest priority for the nurse to
monitor during the administration of this drug?
a. Maternal blood pressure and respirations.
b. Maternal and fetal heart rates.
c. Hourly urinary output.
d. Deep tendon reflexes. correct answer Maternal and fetal heart rates
A 73-year-old Hispanic client is seen at the community health clinic with a history
of protein malnutrition. What information should the nurse obtain first?
a. Amount of liquid protein supplements consumed daily.
b. Foods and liquids consumed during the past 24 hours.
c. Usual weekly intake of milk products and red meats.
,d. Grains and legume combinations used by the client. correct answer Amount of
liquid protein supplements consumed daily
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment
finding is most indicative of an impending convulsion?
a. 3+ deep tendon reflexes and hyperclonus.
b. Periorbital edema, flashing lights, and aura.
c. Epigastric pain in the third trimester.
d. Recent decreased urinary output. correct answer 3+ deep tendon reflexes and
hyperclonus
A client in hospice care develops audible gurgling sounds on inspiration. Which
nursing action has the highest priority?
a. Ensure cultural customs are observed.
b. Increase oxygen flow to 4L/minute.
c. Auscultate bilateral lung fields.
d. Inform the family that death is imminent. correct answer Inform the family that
death is imminent
A client is admitted to the hospital with intractable pain. What instruction should
the nurse provide the unlicensed assistive personnel (UAP) who is preparing to
assist this client with a bed bath?
a. Take measures to promote as much comfort as possible.
b. Report any signs of drug addiction to the nurse immediately.
c. Wait until the client's pain is gone before assisting with personal care.
d. This client's pain will be difficult to manage, since the cause is unknown. correct
answer Take measures to promote as much comfort as possible
, A client is taking sulfisoxazole (Gantrisin) for a urinary tract infection (UTI) and
complains of nausea and gastric upset since starting the medication. Which
additional adverse reaction should the nurse instruct the client to report?
a. Rash.
b. Diarrhea.
c. Hematuria.
d. Muscle cramping. correct answer Rash
A client receives a prescription for sulfamethoxazole-trimethoprim (Septra) for a
urinary tract infection (UTI). What instruction should the nurse provide the client?
a. Ingest food prior to taking the antibiotic.
b. Drink at least 8 glasses of water a day.
c. Take the medication with grapefruit juice.
d. Avoid prolonged exposure to sunlight. correct answer Drink at least 8 glasses of
water a day
A client with pneumonia has a decrease in oxygen saturation from 94% to 88%
while ambulating. Based on these findings, which intervention should the nurse
implement first?
a. Assist the ambulating client back to the bed.
b. Encourage the client to ambulate to resolve pneumonia.
c. Obtain a prescription for portable oxygen while ambulating.
d. Move the oximetry probe from the finger to the earlobe. correct answer Assist
the ambulating client back to the bed
