Evolve HESI Practice Questions And
Answers/100% correct/ Best Scores
A 6-month-old infant with congestive heart failure (CHF) is receiving
digoxin elixir. Which observation by the nurse warrants immediate
intervention?
Apical heart rate of 60.
Sweating across the
forehead. Doesn't suck
well.
Respiratory rate of 30 breaths per minute. Correct ans - Apical
heart rate of 60.
A heart rate of 60 (A) is much lower than normal for a 6-month-old
and warrants immediate intervention. The normal heart rate for a 6-
month-old is 80 to 150 BPM when awake, and a rate of 70 while
sleeping is considered within normal limits. (B and C) are expected
symptoms of heart failure in an infant. (D) is within normal limits for
an infant.
The nurse is teaching the parents of a 5-year-old with cystic fibrosis
about respiratory treatments. Which statement indicates to the nurse
that the parents understand?
Perform postural drainage before starting aerosol
therapy. Give respiratory treatments when the child is
coughing a lot.
Administer aerosol therapy followed by postural drainage before
meals. Ensure respiratory therapy is done daily during any
respiratory infection. Correct ans - Administer aerosol therapy
followed by postural drainage before meals.
Postural drainage for a child with cystic fibrosis is most effective
when performed after nebulization and before meals (C) or at least 1
hour after eating to prevent nausea and vomiting. Postural drainage
uses gravity to promote mucous removal after nebulization (A)
treatments which open the airways. Pulmonary toileting or
respiratory treatments should be given 3 to 4 times daily, not
episodically (B and D).
A female teenager is taking oral tetracycline HCL (Achromycin V)
for acne vulgaris. What is the most important instruction for the
nurse to include in this client's teaching plan?
Use sunscreen when lying by the pool.
Cleanse the skin at least 4 times a
day. Take the medication with a glass
of milk.
Menstrual periods may become irregular. Correct ans - Use
sunscreen when lying by the pool.
Photosensitivity is a common side effect of tetracycline HCL
,(Achromycin V) therapy. Severe sunburn can occur with minimal sun
exposure and clients
,should be instructed to avoid sunlight and to use sunscreen (A). (B
and D) are not related to tetracycline HCL (Achromycin V) therapy.
(C) should be avoided because dairy products interfere with the
absorption of tetracyclines.
What preoperative nursing intervention should be included in the
plan of care for an infant with pyloric stenosis?
Monitor for signs of metabolic
acidosis. Estimate the quantity of
diarrhea stools. Place in a supine
position after feeding.
Observe for projectile vomiting. Correct ans - Observe for
projectile vomiting.
Projectile vomiting (D), which contributes to metabolic alkalosis (A), is
the classic sign of pyloric stenosis. (B) is not indicated. (C) is
dangerous, due to the potential for aspiration with frequent vomiting.
An infant is born with a ventricular septal defect (VSD) and surgery
is planned to correct the defect. The nurse recognizes that surgical
correction is designed to achieve which outcome?
Stop the flow of unoxygenated blood into systemic
circulation. Increase the flow of unoxygenated blood to the
lungs.
Prevent the return of oxygenated blood to the lungs.
Reduce peripheral tissue hypoxia and nailbed clubbing
Correct ans
- Prevent
the return of oxygenated blood to the lungs.
Closure of VSDs stops oxygenated blood from being shunted from
the left ventricle to the right ventricle (C). VSDs are acyanotic
defects, which means that no unoxygenated blood enters the
systemic circulation (A and B). (D) is common with Tetrology of
Fallot, which is a cyanotic defect.
A 3-week-old newborn is brought to the clinic for follow-up after a
home birth. The mother reports that her child bottle feeds for 5
minutes only and then falls asleep. The nurse auscultates a loud
murmur characteristic of a ventricular septal defect (VSD), and finds
the newborn is acyanotic with a respiratory rate of 64 breaths per
minute. What instruction should the nurse provide the mother to
ensure the infant is receiving adequate intake? (Select all that
apply.)
A. Monitor the the infant's weight and number of wet diapers per day.
B. Increase the infant's intake per feeding by 1 to 2 ounces per
week.
C. Mix the dose of prophylactic antibiotic in a full bottle of formula.
D. Allow the infant to rest and refeed on demand or every 2 hours.
E. Use a softer nipple or increase the size of the nipple opening.
, Correct ans - A.
Monitor the the infant's weight and number of wet diapers per day.
B. Increase the infant's intake per feeding by 1 to 2 ounces per
week.
D. Allow the infant to rest and refeed on demand or every 2 hours.
Answers/100% correct/ Best Scores
A 6-month-old infant with congestive heart failure (CHF) is receiving
digoxin elixir. Which observation by the nurse warrants immediate
intervention?
Apical heart rate of 60.
Sweating across the
forehead. Doesn't suck
well.
Respiratory rate of 30 breaths per minute. Correct ans - Apical
heart rate of 60.
A heart rate of 60 (A) is much lower than normal for a 6-month-old
and warrants immediate intervention. The normal heart rate for a 6-
month-old is 80 to 150 BPM when awake, and a rate of 70 while
sleeping is considered within normal limits. (B and C) are expected
symptoms of heart failure in an infant. (D) is within normal limits for
an infant.
The nurse is teaching the parents of a 5-year-old with cystic fibrosis
about respiratory treatments. Which statement indicates to the nurse
that the parents understand?
Perform postural drainage before starting aerosol
therapy. Give respiratory treatments when the child is
coughing a lot.
Administer aerosol therapy followed by postural drainage before
meals. Ensure respiratory therapy is done daily during any
respiratory infection. Correct ans - Administer aerosol therapy
followed by postural drainage before meals.
Postural drainage for a child with cystic fibrosis is most effective
when performed after nebulization and before meals (C) or at least 1
hour after eating to prevent nausea and vomiting. Postural drainage
uses gravity to promote mucous removal after nebulization (A)
treatments which open the airways. Pulmonary toileting or
respiratory treatments should be given 3 to 4 times daily, not
episodically (B and D).
A female teenager is taking oral tetracycline HCL (Achromycin V)
for acne vulgaris. What is the most important instruction for the
nurse to include in this client's teaching plan?
Use sunscreen when lying by the pool.
Cleanse the skin at least 4 times a
day. Take the medication with a glass
of milk.
Menstrual periods may become irregular. Correct ans - Use
sunscreen when lying by the pool.
Photosensitivity is a common side effect of tetracycline HCL
,(Achromycin V) therapy. Severe sunburn can occur with minimal sun
exposure and clients
,should be instructed to avoid sunlight and to use sunscreen (A). (B
and D) are not related to tetracycline HCL (Achromycin V) therapy.
(C) should be avoided because dairy products interfere with the
absorption of tetracyclines.
What preoperative nursing intervention should be included in the
plan of care for an infant with pyloric stenosis?
Monitor for signs of metabolic
acidosis. Estimate the quantity of
diarrhea stools. Place in a supine
position after feeding.
Observe for projectile vomiting. Correct ans - Observe for
projectile vomiting.
Projectile vomiting (D), which contributes to metabolic alkalosis (A), is
the classic sign of pyloric stenosis. (B) is not indicated. (C) is
dangerous, due to the potential for aspiration with frequent vomiting.
An infant is born with a ventricular septal defect (VSD) and surgery
is planned to correct the defect. The nurse recognizes that surgical
correction is designed to achieve which outcome?
Stop the flow of unoxygenated blood into systemic
circulation. Increase the flow of unoxygenated blood to the
lungs.
Prevent the return of oxygenated blood to the lungs.
Reduce peripheral tissue hypoxia and nailbed clubbing
Correct ans
- Prevent
the return of oxygenated blood to the lungs.
Closure of VSDs stops oxygenated blood from being shunted from
the left ventricle to the right ventricle (C). VSDs are acyanotic
defects, which means that no unoxygenated blood enters the
systemic circulation (A and B). (D) is common with Tetrology of
Fallot, which is a cyanotic defect.
A 3-week-old newborn is brought to the clinic for follow-up after a
home birth. The mother reports that her child bottle feeds for 5
minutes only and then falls asleep. The nurse auscultates a loud
murmur characteristic of a ventricular septal defect (VSD), and finds
the newborn is acyanotic with a respiratory rate of 64 breaths per
minute. What instruction should the nurse provide the mother to
ensure the infant is receiving adequate intake? (Select all that
apply.)
A. Monitor the the infant's weight and number of wet diapers per day.
B. Increase the infant's intake per feeding by 1 to 2 ounces per
week.
C. Mix the dose of prophylactic antibiotic in a full bottle of formula.
D. Allow the infant to rest and refeed on demand or every 2 hours.
E. Use a softer nipple or increase the size of the nipple opening.
, Correct ans - A.
Monitor the the infant's weight and number of wet diapers per day.
B. Increase the infant's intake per feeding by 1 to 2 ounces per
week.
D. Allow the infant to rest and refeed on demand or every 2 hours.
