Evolve HESI Practice Questions And Answers Verified
100% Correct
The nurse is assigning care for a 4-year-old child with otitis media and is concerned
about the child's increasing temperature over the past 24 hours. When planning care for
this child, it is important for the nurse to consider that
A. Only an RN should be assigned to monitor this child's temperature. Incorrect B.
A tympanic measurement of temperature will provide the most accurate reading.
C. The licensed practical nurse should be instructed to obtain rectal temperatures
on this child.
D. The healthcare provider should be asked to prescribe the method for
measurement of the child's temperatures. - ANSWER B. A tympanic measurement of
temperature will provide the most accurate reading.
(B) A tympanic membrane sensor is an excellent site because both the eardrum and
hypothalamus (temperature-regulating center) are perfused by the same circulation.
The sensor is unaffected by cerumen and the presence of suppurative or unsuppurative
otitis media does not effect measurement. RULE OF THUMB: for management--sterile
procedures should be assigned to licensed personnel. Management skills will be tested
on the NCLEX! An RN is not required (A). Rectal temperature measurement (C) is less
accurate because of the possibility of stool in the rectum. (D) is unnecessary.
A 3-year-old boy is brought to the emergency room because he swallowed an entire
bottle of children's vitamin pills. Which intervention should the nurse implement first?
Insert N/G tube for gastric lavage.
Determine the child's pulse and respirations.
Assess the child's level of consciousness.
Administer an IV D5/0.25 NS as prescribed. - ANSWER Determine the child's pulse
and respirations.
The most important principle in dealing with a poisoning is to treat the child first, not the
poison. Initiate immediate life support measures with assessment of vital signs (B), in
particular, respirations. Inserting an airway or initiating mechanical ventilation may be
necessary. Assessment and identification of the poison should occur prior to (A). (C and
D) should occur after assessing the airway.
To take the vital signs of a 4-month-old child, which order provides the most accurate
results?
Respiratory rate, heart rate, then rectal temperature.
Heart rate, rectal temperature, then respiratory rate.
Rectal temperature, heart rate, then respiratory rate.
, Rectal temperature, respiratory rate, then heart rate. - ANSWER Respiratory rate, heart
rate, then rectal temperature.
The respiratory rate should be taken first (A) in infants, since touching them or
performing unpleasant procedures usually makes them cry, elevating the heart rate and
making respirations difficult to count (B). Rectal temperature is the most invasive
procedure, and is most likely to precipitate crying, so should be done last (C and D).
The parents of a 3-week-old infant report that the child eats well but vomits after each
feeding. What information is most important for the nurse to obtain?
Description of vomiting episodes in past 24 hours.
Number of wet diapers in last 24 hours.
Feeding and sleep schedule.
Amount of formula consumed during the past 24 hours. - ANSWER Description of
vomiting episodes in past 24 hours.
A description of the vomiting episodes (A) will assist the nurse in determining the reason
for the symptoms, which may be helpful in developing a plan of care for this infant. (B
and C) provide related information but are not as helpful as (A). (D) may be related to
the vomiting, but the nurse should first obtain a better description of the vomiting
episodes.
A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician
prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCl/100 ml to be infused
at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment
finding?
Frequency of emesis in the last 8 hours.
Serum BUN and creatinine levels.
Current blood sugar level.
Appearance of the stool. - ANSWER Serum BUN and creatinine levels.
Regardless of a client's age, adequate renal function must be present before adding
potassium to IV fluids (B). (A) is important in determining the need for fluid replacement.
(C) is not indicated. (D) is useful information, but will not impact administration of the
prescribed IV solution.
Which finding in a 19-year-old female client should trigger further assessment by the
nurse?
Menstruation has not occurred.
Reports no tetanus immunization since childhood.
Denies having any wisdom teeth.
History of painful, inward growth on bottom of foot. - ANSWER Menstruation has not
occurred.
, Menstruation is an expected secondary sex characteristic that occurs with pubescence
and typically occurs by age 18, so (A) should prompt further investigation to determine
the cause of this primary amenorrhea. Children receive tetanus as part of the DPT
childhood immunization series, and a booster is not typically given until age 16 (B).
Wisdom teeth are the third molar teeth of the permanent dentition and are the last to
erupt, so (C) is a normal finding. (D) describes a plantar surface wart, harmless but
painful because of the pressure with walking or standing.
The nurse is giving a liquid iron preparation to a 3-year-old child. Which technique
should the nurse implement to engage the child's cooperation?
Use a colorful straw.
Mix the medication in water.
Administer the medication using an oral syringe.
Ask the pharmacy to provide an enteric tablet. - ANSWER Use a colorful straw.
A liquid iron preparation administered through a straw may help the child to accept the
medication since young children consider drinking from a colorful straw fun (A). (B) may
cause staining of the child's teeth. (C) is often used if the child is uncooperative. (D) is
ineffective and should be requested from the healthcare provider.
When evaluating the effectiveness of interventions to improve the nutritional status of an
infant with gastro-esophageal reflux, which intervention is most important for the nurse
to implement?
Record weight daily.
Assess for signs of anemia.
Document sleeping patterns.
Teach parenting skills. - ANSWER Record weight daily.
The most definitive measure of improved nutrition in an infant is obtaining the child's
daily weight (A). (B, C, and D) may also be useful, but they are not as definitive as a
daily weight measurement.
A three-month old boy weighing 10 lbs 15 oz has an axillary temperature of 98.9° F. The
nurse determines the daily caloric need for this child is approximately
400 calories per day.
500 calories per day.
600 calories per day.
700 calories per day. - ANSWER 600 calories per day.
10 lbs 15 oz = 10.9 lbs. Convert lbs to kg by dividing pounds by 2.2; 10.9/2.2 = 4.954
kg, rounded to 5 kg. An infant requires 108 calories/kg/day (108 × 5 = 540 calories/day).
However, this infant requires 10% more calories because he has one degree
temperature elevation. 10% of 540 is 54 and 540 + 54 = 594. This infant will require
approximately 600 calories/day. Tough question! You know that 400 calories are too
100% Correct
The nurse is assigning care for a 4-year-old child with otitis media and is concerned
about the child's increasing temperature over the past 24 hours. When planning care for
this child, it is important for the nurse to consider that
A. Only an RN should be assigned to monitor this child's temperature. Incorrect B.
A tympanic measurement of temperature will provide the most accurate reading.
C. The licensed practical nurse should be instructed to obtain rectal temperatures
on this child.
D. The healthcare provider should be asked to prescribe the method for
measurement of the child's temperatures. - ANSWER B. A tympanic measurement of
temperature will provide the most accurate reading.
(B) A tympanic membrane sensor is an excellent site because both the eardrum and
hypothalamus (temperature-regulating center) are perfused by the same circulation.
The sensor is unaffected by cerumen and the presence of suppurative or unsuppurative
otitis media does not effect measurement. RULE OF THUMB: for management--sterile
procedures should be assigned to licensed personnel. Management skills will be tested
on the NCLEX! An RN is not required (A). Rectal temperature measurement (C) is less
accurate because of the possibility of stool in the rectum. (D) is unnecessary.
A 3-year-old boy is brought to the emergency room because he swallowed an entire
bottle of children's vitamin pills. Which intervention should the nurse implement first?
Insert N/G tube for gastric lavage.
Determine the child's pulse and respirations.
Assess the child's level of consciousness.
Administer an IV D5/0.25 NS as prescribed. - ANSWER Determine the child's pulse
and respirations.
The most important principle in dealing with a poisoning is to treat the child first, not the
poison. Initiate immediate life support measures with assessment of vital signs (B), in
particular, respirations. Inserting an airway or initiating mechanical ventilation may be
necessary. Assessment and identification of the poison should occur prior to (A). (C and
D) should occur after assessing the airway.
To take the vital signs of a 4-month-old child, which order provides the most accurate
results?
Respiratory rate, heart rate, then rectal temperature.
Heart rate, rectal temperature, then respiratory rate.
Rectal temperature, heart rate, then respiratory rate.
, Rectal temperature, respiratory rate, then heart rate. - ANSWER Respiratory rate, heart
rate, then rectal temperature.
The respiratory rate should be taken first (A) in infants, since touching them or
performing unpleasant procedures usually makes them cry, elevating the heart rate and
making respirations difficult to count (B). Rectal temperature is the most invasive
procedure, and is most likely to precipitate crying, so should be done last (C and D).
The parents of a 3-week-old infant report that the child eats well but vomits after each
feeding. What information is most important for the nurse to obtain?
Description of vomiting episodes in past 24 hours.
Number of wet diapers in last 24 hours.
Feeding and sleep schedule.
Amount of formula consumed during the past 24 hours. - ANSWER Description of
vomiting episodes in past 24 hours.
A description of the vomiting episodes (A) will assist the nurse in determining the reason
for the symptoms, which may be helpful in developing a plan of care for this infant. (B
and C) provide related information but are not as helpful as (A). (D) may be related to
the vomiting, but the nurse should first obtain a better description of the vomiting
episodes.
A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician
prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCl/100 ml to be infused
at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment
finding?
Frequency of emesis in the last 8 hours.
Serum BUN and creatinine levels.
Current blood sugar level.
Appearance of the stool. - ANSWER Serum BUN and creatinine levels.
Regardless of a client's age, adequate renal function must be present before adding
potassium to IV fluids (B). (A) is important in determining the need for fluid replacement.
(C) is not indicated. (D) is useful information, but will not impact administration of the
prescribed IV solution.
Which finding in a 19-year-old female client should trigger further assessment by the
nurse?
Menstruation has not occurred.
Reports no tetanus immunization since childhood.
Denies having any wisdom teeth.
History of painful, inward growth on bottom of foot. - ANSWER Menstruation has not
occurred.
, Menstruation is an expected secondary sex characteristic that occurs with pubescence
and typically occurs by age 18, so (A) should prompt further investigation to determine
the cause of this primary amenorrhea. Children receive tetanus as part of the DPT
childhood immunization series, and a booster is not typically given until age 16 (B).
Wisdom teeth are the third molar teeth of the permanent dentition and are the last to
erupt, so (C) is a normal finding. (D) describes a plantar surface wart, harmless but
painful because of the pressure with walking or standing.
The nurse is giving a liquid iron preparation to a 3-year-old child. Which technique
should the nurse implement to engage the child's cooperation?
Use a colorful straw.
Mix the medication in water.
Administer the medication using an oral syringe.
Ask the pharmacy to provide an enteric tablet. - ANSWER Use a colorful straw.
A liquid iron preparation administered through a straw may help the child to accept the
medication since young children consider drinking from a colorful straw fun (A). (B) may
cause staining of the child's teeth. (C) is often used if the child is uncooperative. (D) is
ineffective and should be requested from the healthcare provider.
When evaluating the effectiveness of interventions to improve the nutritional status of an
infant with gastro-esophageal reflux, which intervention is most important for the nurse
to implement?
Record weight daily.
Assess for signs of anemia.
Document sleeping patterns.
Teach parenting skills. - ANSWER Record weight daily.
The most definitive measure of improved nutrition in an infant is obtaining the child's
daily weight (A). (B, C, and D) may also be useful, but they are not as definitive as a
daily weight measurement.
A three-month old boy weighing 10 lbs 15 oz has an axillary temperature of 98.9° F. The
nurse determines the daily caloric need for this child is approximately
400 calories per day.
500 calories per day.
600 calories per day.
700 calories per day. - ANSWER 600 calories per day.
10 lbs 15 oz = 10.9 lbs. Convert lbs to kg by dividing pounds by 2.2; 10.9/2.2 = 4.954
kg, rounded to 5 kg. An infant requires 108 calories/kg/day (108 × 5 = 540 calories/day).
However, this infant requires 10% more calories because he has one degree
temperature elevation. 10% of 540 is 54 and 540 + 54 = 594. This infant will require
approximately 600 calories/day. Tough question! You know that 400 calories are too
