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2025 HESI Fundamentals Real Exam | Evolve V1, 2 & 3 | 100%
Verified Questions with Correct Answers & Rationales |
Guaranteed Pass
1. 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. - correct answer -
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 on the
affected leg. The position described in (C) is contraindicated for a client with
a fractured left hip.
Correct Answer: D
2. 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.
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Page |2
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water. - correct answer - 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
3. 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.
- correct answer - 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
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4. 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. - correct answer - 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
5. 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. - correct answer - 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
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Page |4
6. 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. - correct answer - 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
7. 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.
2025 HESI Fundamentals Real Exam | Evolve V1, 2 & 3 | 100%
Verified Questions with Correct Answers & Rationales |
Guaranteed Pass
1. 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. - correct answer -
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 on the
affected leg. The position described in (C) is contraindicated for a client with
a fractured left hip.
Correct Answer: D
2. 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.
, 2
Page |2
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water. - correct answer - 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
3. 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.
- correct answer - 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
, 3
Page |3
4. 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. - correct answer - 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
5. 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. - correct answer - 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
, 4
Page |4
6. 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. - correct answer - 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
7. 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.
