EVOLVE HESI FUNDAMENTALS
PRACTICE QUESTIONS AND
CORRECT ANSWERS
After completing an assessment and determining that a client has a problem, which action
should the nurse perform next? - ANSWER --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? - ANSWER --A decreased flow rate could
result in the formation of a thrombosis.
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? - ANSWER --After
clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
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? - ANSWER --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?
- ANSWER --Give an around-the-clock schedule for administration of analgesics.
,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? - ANSWER --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? - ANSWER --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? - ANSWER --Blood
transfusions are forbidden.
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? - ANSWER --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? - ANSWER --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? - ANSWER --Nutritional history.
The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The
infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer
approximately how many drops per minute? - ANSWER --21
,Three days following surgery, a male client observes his colostomy for the first time. He
becomes quite upset and tells the nurse that it is much bigger than he expected. What is the
best response by the nurse? - ANSWER --Instruct the client that the stoma will become
smaller when the initial swelling diminishes.
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2
ml. How many milliliters should the nurse administer? - ANSWER --1.5ml
Which assessment data would provide the most accurate determination of proper placement of
a nasogastric tube? - ANSWER --Examining a chest x-ray obtained after the tubing was
inserted.
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a
rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how
many drops per minute should the client receive? - ANSWER --124 gtt/min.
At the time of the first dressing change, the client refuses to look at her mastectomy incision.
The nurse tells the client that the incision is healing well, but the client refuses to talk about it.
What would be an appropriate response to this client's silence? - ANSWER --It is OK if you
don't want to talk about your surgery. I will be available when you are ready.
Examination of a client complaining of itching on his right arm reveals a rash made up of
multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the
nurse record this finding? - ANSWER --Localized red rash comprised of flat areas, pinpoint
to 0.5 cm in diameter.
The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction
should be included in this teaching plan? - ANSWER --Avoid any types of sprays, powders,
and perfumes.
, 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? -
ANSWER --Assist the ambulating client back to the bed.
The nurse is teaching a client proper use of an inhaler. When should the client administer the
inhaler-delivered medication to demonstrate correct use of the inhaler? - ANSWER --
During the inhalation
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? - ANSWER --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? - ANSWER --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? - ANSWER --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? - ANSWER --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? - ANSWER --Frontal lobe
PRACTICE QUESTIONS AND
CORRECT ANSWERS
After completing an assessment and determining that a client has a problem, which action
should the nurse perform next? - ANSWER --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? - ANSWER --A decreased flow rate could
result in the formation of a thrombosis.
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? - ANSWER --After
clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
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? - ANSWER --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?
- ANSWER --Give an around-the-clock schedule for administration of analgesics.
,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? - ANSWER --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? - ANSWER --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? - ANSWER --Blood
transfusions are forbidden.
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? - ANSWER --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? - ANSWER --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? - ANSWER --Nutritional history.
The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The
infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer
approximately how many drops per minute? - ANSWER --21
,Three days following surgery, a male client observes his colostomy for the first time. He
becomes quite upset and tells the nurse that it is much bigger than he expected. What is the
best response by the nurse? - ANSWER --Instruct the client that the stoma will become
smaller when the initial swelling diminishes.
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2
ml. How many milliliters should the nurse administer? - ANSWER --1.5ml
Which assessment data would provide the most accurate determination of proper placement of
a nasogastric tube? - ANSWER --Examining a chest x-ray obtained after the tubing was
inserted.
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a
rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how
many drops per minute should the client receive? - ANSWER --124 gtt/min.
At the time of the first dressing change, the client refuses to look at her mastectomy incision.
The nurse tells the client that the incision is healing well, but the client refuses to talk about it.
What would be an appropriate response to this client's silence? - ANSWER --It is OK if you
don't want to talk about your surgery. I will be available when you are ready.
Examination of a client complaining of itching on his right arm reveals a rash made up of
multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the
nurse record this finding? - ANSWER --Localized red rash comprised of flat areas, pinpoint
to 0.5 cm in diameter.
The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction
should be included in this teaching plan? - ANSWER --Avoid any types of sprays, powders,
and perfumes.
, 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? -
ANSWER --Assist the ambulating client back to the bed.
The nurse is teaching a client proper use of an inhaler. When should the client administer the
inhaler-delivered medication to demonstrate correct use of the inhaler? - ANSWER --
During the inhalation
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? - ANSWER --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? - ANSWER --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? - ANSWER --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? - ANSWER --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? - ANSWER --Frontal lobe
