HESI EVOLVE FUNDAMENTALS 2024 UPDATE
COMPREHENSIVE QUESTIONS AND ANSWERS GRADE A+
The nurse is assessing the nutritional status of several clients. Which client has
the greatest nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer.
A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D)
are all conditions that require protein, but do not have the increased metabolic protein
demands of lactation.
Correct Answer: B
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?
A. Contact the healthcare provider and complete a medication variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
C. Notify the charge nurse and complete an incident report to explain the missed
dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at
1300.
To ensure that a therapeutic level of medication is maintained, the nurse should
administer the missed dose as soon as possible, and revise the administration schedule
accordingly to prevent dangerously increasing the level of the medication in the
bloodstream (D). The nurse should document the reason for the late dose, but (A and
C) are not warranted. (B) could result in increased blood levels of the drug.
Correct Answer: D
The nurse is administering medications through a nasogastric tube (NGT) which
is connected to suction. After ensuring correct tube placement, what action
should the nurse take next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water.
The NGT should be flushed before, after and in between each medication administered
(B). Once all medications are administered, the NGT should be clamped for 20 minutes
(A). (C and D) may be implemented only after the tubing has been flushed.
,Correct Answer: B
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?
A. Give an around-the-clock schedule for administration of analgesics.
B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities.
The most effective management of pain is achieved using an around-the-clock schedule
that provides analgesic medications on a regular basis (A) and in a timely manner.
Analgesics are less effective if pain persists until it is severe, so an analgesic
medication should be administered before the client's pain peaks (B). Providing comfort
is a priority for the client who is dying, but sedation that impairs the client's ability to
interact and experience the time before life ends should be minimized (C). Offering a
medication-free period allows the serum drug level to fall, which is not an effective
method to manage chronic pain (D).
Correct Answer: A
When assessing a client with wrist restraints, the nurse observes that the fingers
on the right hand are blue. What action should the nurse implement first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse.
The priority nursing action is to restore circulation by loosening the restraint (A),
because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also
important nursing interventions, but do not have the priority of (A). Pulse oximetry (B)
measures the saturation of hemoglobin with oxygen and is not indicated in situations
where the cyanosis is related to mechanical compression (the restraints).
Correct Answer: A
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?
A. Acknowledge that she is supporting the arm correctly.
B. Encourage her to keep the joint covered to maintain warmth.
C. Reinforce the need to grip directly under the joint for better support.
D. Instruct her to grip directly over the joint for better motion.
The wife is performing the passive ROM correctly, therefore the nurse should
acknowledge this fact (A). The joint that is being exercised should be uncovered (B)
while the rest of the body should remain covered for warmth and privacy. (C and D) do
,not provide adequate support to the joint while still allowing for joint movement.
Correct Answer: A
What is the most important reason for starting intravenous infusions in the upper
extremities rather than the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result in the formation of a thrombosis.
C. A cannulated extremity is more difficult to move when the leg or foot is used.
D. Veins are located deep in the feet and ankles, resulting in a more painful
procedure.
Venous return is usually better in the upper extremities. Cannulation of the veins in the
lower extremities increases the risk of thrombus formation (B) which, if dislodged, could
be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs.
Handling a leg or foot with an IV (C) is probably not any more difficult than handling an
arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult,
this is not the most important reason for using the upper extremities. Pain (D) is not a
consideration.
Correct Answer: B
The nurse observes an unlicensed assistive personnel (UAP) taking a client's
blood pressure with a cuff that is too small, but the blood pressure reading
obtained is within the client's usual range. What action is most important for the
nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure.
The most important action is to ensure that an accurate BP reading is obtained. The
nurse should reassess the BP with the correct size cuff (B). Reassessment should not
be postponed (A). Though (C and D) are likely indicated, these actions do not have the
priority of (B).
Correct Answer: B
Twenty minutes after beginning a heat application, the client states that the
heating pad no longer feels warm enough. What is the best response by the
nurse?
A. "That means you have derived the maximum benefit, and the heat can be
removed."
B. "Your blood vessels are becoming dilated and removing the heat from the
site."
C. "We will increase the temperature 5 degrees when the pad no longer feels
warm."
D. "The body's receptors adapt over time as they are exposed to heat."
, (D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application.
(A and B) provide false information. (C) is not based on a knowledge of physiology and
is an unsafe action that may harm the client.
Correct Answer: D
The nurse is instructing a client with high cholesterol about diet and life style
modification. What comment from the client indicates that the teaching has been
effective?
A. "If I exercise at least two times weekly for one hour, I will lower my
cholesterol."
B. "I need to avoid eating proteins, including red meat."
C. "I will limit my intake of beef to 4 ounces per week."
D. "My blood level of low density lipoproteins needs to increase."
Limiting saturated fat from animal food sources to no more than 4 ounces per week (C)
is an important diet modification for lowering cholesterol. To be effective in reducing
cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per
week (A). Red meat and all proteins do not need to be eliminated (B) to lower
cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-
ounce servings). The low density lipoproteins (D) need to decrease rather than
increase.
Correct Answer: C
The UAPs working on a chronic neuro unit ask the nurse to help them determine
the safest way to transfer an elderly client with left-sided weakness from the bed
to the chair. What method describes the correct transfer procedure for this
client?
A. Place the chair at a right angle to the bed on the client's left side before
moving.
B. Assist the client to a standing position, then place the right hand on the
armrest.
C. Have the client place the left foot next to the chair and pivot to the left before
sitting.
D. Move the chair parallel to the right side of the bed, and stand the client on the
right foot.
(D) uses the client's stronger side, the right side, for weight-bearing during the transfer,
and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and
include the use of poor body mechanics by the caregiver.
Correct Answer: D
An unlicensed assistive personnel (UAP) places a client in a left lateral position
prior to administering a soap suds enema. Which instruction should the nurse
provide the UAP?
A. Position the client on the right side of the bed in reverse Trendelenburg.
COMPREHENSIVE QUESTIONS AND ANSWERS GRADE A+
The nurse is assessing the nutritional status of several clients. Which client has
the greatest nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer.
A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D)
are all conditions that require protein, but do not have the increased metabolic protein
demands of lactation.
Correct Answer: B
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?
A. Contact the healthcare provider and complete a medication variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
C. Notify the charge nurse and complete an incident report to explain the missed
dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at
1300.
To ensure that a therapeutic level of medication is maintained, the nurse should
administer the missed dose as soon as possible, and revise the administration schedule
accordingly to prevent dangerously increasing the level of the medication in the
bloodstream (D). The nurse should document the reason for the late dose, but (A and
C) are not warranted. (B) could result in increased blood levels of the drug.
Correct Answer: D
The nurse is administering medications through a nasogastric tube (NGT) which
is connected to suction. After ensuring correct tube placement, what action
should the nurse take next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water.
The NGT should be flushed before, after and in between each medication administered
(B). Once all medications are administered, the NGT should be clamped for 20 minutes
(A). (C and D) may be implemented only after the tubing has been flushed.
,Correct Answer: B
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?
A. Give an around-the-clock schedule for administration of analgesics.
B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities.
The most effective management of pain is achieved using an around-the-clock schedule
that provides analgesic medications on a regular basis (A) and in a timely manner.
Analgesics are less effective if pain persists until it is severe, so an analgesic
medication should be administered before the client's pain peaks (B). Providing comfort
is a priority for the client who is dying, but sedation that impairs the client's ability to
interact and experience the time before life ends should be minimized (C). Offering a
medication-free period allows the serum drug level to fall, which is not an effective
method to manage chronic pain (D).
Correct Answer: A
When assessing a client with wrist restraints, the nurse observes that the fingers
on the right hand are blue. What action should the nurse implement first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse.
The priority nursing action is to restore circulation by loosening the restraint (A),
because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also
important nursing interventions, but do not have the priority of (A). Pulse oximetry (B)
measures the saturation of hemoglobin with oxygen and is not indicated in situations
where the cyanosis is related to mechanical compression (the restraints).
Correct Answer: A
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?
A. Acknowledge that she is supporting the arm correctly.
B. Encourage her to keep the joint covered to maintain warmth.
C. Reinforce the need to grip directly under the joint for better support.
D. Instruct her to grip directly over the joint for better motion.
The wife is performing the passive ROM correctly, therefore the nurse should
acknowledge this fact (A). The joint that is being exercised should be uncovered (B)
while the rest of the body should remain covered for warmth and privacy. (C and D) do
,not provide adequate support to the joint while still allowing for joint movement.
Correct Answer: A
What is the most important reason for starting intravenous infusions in the upper
extremities rather than the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result in the formation of a thrombosis.
C. A cannulated extremity is more difficult to move when the leg or foot is used.
D. Veins are located deep in the feet and ankles, resulting in a more painful
procedure.
Venous return is usually better in the upper extremities. Cannulation of the veins in the
lower extremities increases the risk of thrombus formation (B) which, if dislodged, could
be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs.
Handling a leg or foot with an IV (C) is probably not any more difficult than handling an
arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult,
this is not the most important reason for using the upper extremities. Pain (D) is not a
consideration.
Correct Answer: B
The nurse observes an unlicensed assistive personnel (UAP) taking a client's
blood pressure with a cuff that is too small, but the blood pressure reading
obtained is within the client's usual range. What action is most important for the
nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure.
The most important action is to ensure that an accurate BP reading is obtained. The
nurse should reassess the BP with the correct size cuff (B). Reassessment should not
be postponed (A). Though (C and D) are likely indicated, these actions do not have the
priority of (B).
Correct Answer: B
Twenty minutes after beginning a heat application, the client states that the
heating pad no longer feels warm enough. What is the best response by the
nurse?
A. "That means you have derived the maximum benefit, and the heat can be
removed."
B. "Your blood vessels are becoming dilated and removing the heat from the
site."
C. "We will increase the temperature 5 degrees when the pad no longer feels
warm."
D. "The body's receptors adapt over time as they are exposed to heat."
, (D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application.
(A and B) provide false information. (C) is not based on a knowledge of physiology and
is an unsafe action that may harm the client.
Correct Answer: D
The nurse is instructing a client with high cholesterol about diet and life style
modification. What comment from the client indicates that the teaching has been
effective?
A. "If I exercise at least two times weekly for one hour, I will lower my
cholesterol."
B. "I need to avoid eating proteins, including red meat."
C. "I will limit my intake of beef to 4 ounces per week."
D. "My blood level of low density lipoproteins needs to increase."
Limiting saturated fat from animal food sources to no more than 4 ounces per week (C)
is an important diet modification for lowering cholesterol. To be effective in reducing
cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per
week (A). Red meat and all proteins do not need to be eliminated (B) to lower
cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-
ounce servings). The low density lipoproteins (D) need to decrease rather than
increase.
Correct Answer: C
The UAPs working on a chronic neuro unit ask the nurse to help them determine
the safest way to transfer an elderly client with left-sided weakness from the bed
to the chair. What method describes the correct transfer procedure for this
client?
A. Place the chair at a right angle to the bed on the client's left side before
moving.
B. Assist the client to a standing position, then place the right hand on the
armrest.
C. Have the client place the left foot next to the chair and pivot to the left before
sitting.
D. Move the chair parallel to the right side of the bed, and stand the client on the
right foot.
(D) uses the client's stronger side, the right side, for weight-bearing during the transfer,
and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and
include the use of poor body mechanics by the caregiver.
Correct Answer: D
An unlicensed assistive personnel (UAP) places a client in a left lateral position
prior to administering a soap suds enema. Which instruction should the nurse
provide the UAP?
A. Position the client on the right side of the bed in reverse Trendelenburg.
