Evolve Fundamentals HESI
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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.: 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.
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
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.: The most
, Evolve Fundamentals HESI
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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
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.: 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.: 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
, Evolve Fundamentals HESI
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6. A client is in the radiology department at 0900 when the prescription lev-
ofloxacin (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
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.
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
, Evolve Fundamentals HESI
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8. 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
9. 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
10. 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
Study online at https://quizlet.com/_bfgkpr
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.: 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.
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
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.: The most
, Evolve Fundamentals HESI
Study online at https://quizlet.com/_bfgkpr
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
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.: 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.: 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
, Evolve Fundamentals HESI
Study online at https://quizlet.com/_bfgkpr
6. A client is in the radiology department at 0900 when the prescription lev-
ofloxacin (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
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.
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
, Evolve Fundamentals HESI
Study online at https://quizlet.com/_bfgkpr
8. 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
9. 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
10. 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
