Evolve Fundamentals HESI
EVOLVE HESI FUNDAMENTALS 270 QUESTIONS WITH 100% CORRECT
ANSWERS
The nurse observes that a male client has removed the covering from an ice pack applied to his
knee. What action should the nurse take first?
A) Observe the appearance of the skin under the ice pack
B) Instruct the client regarding the need for the covering.
C) Reapply the covering after filling with fresh ice.
D) Ask the client how long the ice was applied to the skin.
A) Observe the appearance of the skin under the ice pack.
Which assessment data provides the most accurate determination of proper placement of a
nasogastric tube?
A) Aspirating gastric contents to assure a pH value of 4 or less.
B) Hearing air pass in the stomach after injecting air into the tubing.
C) Examining a chest x-ray obtained after the tubing was inserted.
D) Checking the remaining length of tubing to ensure that the correct length was inserted.
C) Examining a chest x-ray obtained after the tubing was inserted.
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?
A) Reassure the client that he will become accustomed to the stoma appearance in time.
B) Instruct the client that the stoma will become smaller when the initial swelling diminishes.
C) Offer to contact a member of the local ostomy support group to help him with his concerns.
,D) Encourage the client to handle the stoma equipment to gain confidence with the procedure.
B) Instruct the client that the stoma will become smaller when the initial swelling diminishes.
A female client with a nasogastric tube attached to low suction states that she is nauseated. The
nurse assesses that there has been no drainage through the nasogastric tube in the last two
hours. What action should the nurse take first?
A) Irrigate the nasogastric tube with sterile normal saline.
B) Reposition the client on her side.
C) Advance the nasogastric tube an additional five centimeters.
D) Administer an intravenous antiemetic prescribed for PRN use.
B) Reposition the client on her side.
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a
continuous pump infusions. 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?
A) Record the coughing incident. No further action is required at this time.
B) Stop the feeding, explain to the family why it is being stopped and notify the healthcare
provider.
C) After clearing the tube with 30 mL of air, check the pH of fluid withdrawn from the tube.
D) Inject 30 mL of air into the tube while auscultating the epigastrium for gurgling.
C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
A male client tells the nurse that he does not know where he is or what year it is. What data
should the nurse document that is most accurate?
A) demonstrate loss of remote memory.
,B) exhibits expressive dysphasia
C) has a diminished attention span
D) is disoriented to place and time
D) is disoriented to place and time
A client with chronic kidney disease selects scrambled egg for his breakfast. What action should
the nurse take?
A) Commend the client for selecting a high biologic value protein.
B) Remind the client that protein in the diet should be avoided.
C) Suggest that the client also select orange juice, to promote absorption.
D) Encourage the client to attend classes on dietary management of CKD.
A) Commend the client for selecting a high biologic value protein.
In developing a plan of care for a client with dementia, the nurse should remember that
confusion in the elderly
A) is to be expected, and progresses with age
B) often follows relocation to new surroundings
C) is a result of irreversible brain pathology
D) can be prevented with adequate sleep
B) often follows relocation to new surroundings
A postoperative client will need to perform daily dressing changes after discharge. Which
outcome statement best demonstrates the client's readiness to manage his wound care after
discharge? The client
, A) asks relevant questions regarding the dressing change
B) states he will be able to complete the wound care regimen
C) demonstrates the wound care procedure correctly
D) has all the necessary supplies for wound care.
C) demonstrates the wound care procedure correctly
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells)
as rapidly as possible. Which intervention is most important for the nurse to implement?
A) Obtain the pre-transfusion hemoglobin level
B) Prime the tubing and prepare a blood pump set-up
C) Monitor vital signs q15 mintues for the first hour
D) Ensure the accuracy of the blood type match
D) Ensure the accuracy of the blood type match
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential
to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position.
To avoid shearing forces when repositioning, the client should be lifted gently across a surface
(D). Reddened areas should not be massaged (A) since this may increase the damage to already
traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited
EVOLVE HESI FUNDAMENTALS 270 QUESTIONS WITH 100% CORRECT
ANSWERS
The nurse observes that a male client has removed the covering from an ice pack applied to his
knee. What action should the nurse take first?
A) Observe the appearance of the skin under the ice pack
B) Instruct the client regarding the need for the covering.
C) Reapply the covering after filling with fresh ice.
D) Ask the client how long the ice was applied to the skin.
A) Observe the appearance of the skin under the ice pack.
Which assessment data provides the most accurate determination of proper placement of a
nasogastric tube?
A) Aspirating gastric contents to assure a pH value of 4 or less.
B) Hearing air pass in the stomach after injecting air into the tubing.
C) Examining a chest x-ray obtained after the tubing was inserted.
D) Checking the remaining length of tubing to ensure that the correct length was inserted.
C) Examining a chest x-ray obtained after the tubing was inserted.
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?
A) Reassure the client that he will become accustomed to the stoma appearance in time.
B) Instruct the client that the stoma will become smaller when the initial swelling diminishes.
C) Offer to contact a member of the local ostomy support group to help him with his concerns.
,D) Encourage the client to handle the stoma equipment to gain confidence with the procedure.
B) Instruct the client that the stoma will become smaller when the initial swelling diminishes.
A female client with a nasogastric tube attached to low suction states that she is nauseated. The
nurse assesses that there has been no drainage through the nasogastric tube in the last two
hours. What action should the nurse take first?
A) Irrigate the nasogastric tube with sterile normal saline.
B) Reposition the client on her side.
C) Advance the nasogastric tube an additional five centimeters.
D) Administer an intravenous antiemetic prescribed for PRN use.
B) Reposition the client on her side.
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a
continuous pump infusions. 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?
A) Record the coughing incident. No further action is required at this time.
B) Stop the feeding, explain to the family why it is being stopped and notify the healthcare
provider.
C) After clearing the tube with 30 mL of air, check the pH of fluid withdrawn from the tube.
D) Inject 30 mL of air into the tube while auscultating the epigastrium for gurgling.
C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
A male client tells the nurse that he does not know where he is or what year it is. What data
should the nurse document that is most accurate?
A) demonstrate loss of remote memory.
,B) exhibits expressive dysphasia
C) has a diminished attention span
D) is disoriented to place and time
D) is disoriented to place and time
A client with chronic kidney disease selects scrambled egg for his breakfast. What action should
the nurse take?
A) Commend the client for selecting a high biologic value protein.
B) Remind the client that protein in the diet should be avoided.
C) Suggest that the client also select orange juice, to promote absorption.
D) Encourage the client to attend classes on dietary management of CKD.
A) Commend the client for selecting a high biologic value protein.
In developing a plan of care for a client with dementia, the nurse should remember that
confusion in the elderly
A) is to be expected, and progresses with age
B) often follows relocation to new surroundings
C) is a result of irreversible brain pathology
D) can be prevented with adequate sleep
B) often follows relocation to new surroundings
A postoperative client will need to perform daily dressing changes after discharge. Which
outcome statement best demonstrates the client's readiness to manage his wound care after
discharge? The client
, A) asks relevant questions regarding the dressing change
B) states he will be able to complete the wound care regimen
C) demonstrates the wound care procedure correctly
D) has all the necessary supplies for wound care.
C) demonstrates the wound care procedure correctly
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells)
as rapidly as possible. Which intervention is most important for the nurse to implement?
A) Obtain the pre-transfusion hemoglobin level
B) Prime the tubing and prepare a blood pump set-up
C) Monitor vital signs q15 mintues for the first hour
D) Ensure the accuracy of the blood type match
D) Ensure the accuracy of the blood type match
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential
to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position.
To avoid shearing forces when repositioning, the client should be lifted gently across a surface
(D). Reddened areas should not be massaged (A) since this may increase the damage to already
traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited
