2024 EVOLVE HESI FUNDAMENTALS VERSION 1,2& 3 ACTUAL EXAM
EACH VERSION CONTAINS 265 QUESTIONS AND CORRECT DETAILED
ANSWERS
Study online at https://quizlet.com/_flq04r
To avoid shearing forces when reposi-
An elderly client with a fractured left hip is
tioning, the client should be lifted gen-
on strict bedrest. Which nursing measure
tly across a surface (D). Reddened ar-
is essential to the client's nursing care?
eas should not be massaged (A) since
this may increase the damage to al-
A. Massage any reddened areas for at
ready traumatized skin. To control pain
least five minutes.
and muscle spasms, active range of mo-
B. Encourage active range of motion ex-
tion (B) may be limited on the affected
ercises on extremities.
leg. The position described in (C) is con-
C. Position the client laterally, prone, and
traindicated for a client with a fractured
dorsally in sequence.
left hip.
D. Gently lift the client when moving into
a desired position.
Correct Answer: D
The nurse is administering medications
through a nasogastric tube (NGT) which
The NGT should be flushed before, after
is connected to suction. After ensur-
and in between each medication admin-
ing correct tube placement, what action
istered (B). Once all medications are ad-
should the nurse take next?
ministered, the NGT should be clamped
for 20 minutes (A). (C and D) may be
A. Clamp the tube for 20 minutes.
implemented only after the tubing has
B. Flush the tube with water.
been flushed.
C. Administer the medications as pre-
scribed.
Correct Answer: B
D. Crush the tablets and dissolve in ster-
ile water.
The most effective management of pain
A client who is in hospice care com- is achieved using an around-the-clock
plains of increasing amounts of pain. The schedule that provides analgesic med-
healthcare provider prescribes an anal- ications on a regular basis (A) and in
gesic every four hours as needed. Which a timely manner. Analgesics are less
action should the nurse implement? effective if pain persists until it is se-
vere, so an analgesic medication should
A. Give an around-the-clock schedule for be administered before the client's pain
administration of analgesics. peaks (B). Providing comfort is a priority
B. Administer analgesic medication as for the client who is dying, but sedation
needed when the pain is severe. that impairs the client's ability to inter-
act and experience the time before life
, 2024 EVOLVE HESI FUNDAMENTALS VERSION 1,2& 3 ACTUAL EXAM
EACH VERSION CONTAINS 265 QUESTIONS AND CORRECT DETAILED
ANSWERS
Study online at https://quizlet.com/_flq04r
ends should be minimized (C). Offering a
C. Provide medication to keep the client medication-free period allows the serum
sedated and unaware of stimuli. drug level to fall, which is not an effective
D. Offer a medication-free period so that method to manage chronic pain (D).
the client can do daily activities.
Correct Answer: A
The priority nursing action is to restore
circulation by loosening the restraint (A),
When assessing a client with wrist re-
because blue fingers (cyanosis) indi-
straints, the nurse observes that the fin-
cates decreased circulation. (C and D)
gers on the right hand are blue. What
are also important nursing interventions,
action should the nurse implement first?
but do not have the priority of (A). Pulse
oximetry (B) measures the saturation of
A. Loosen the right wrist restraint.
hemoglobin with oxygen and is not indi-
B. Apply a pulse oximeter to the right
cated in situations where the cyanosis is
hand.
related to mechanical compression (the
C. Compare hand color bilaterally.
restraints).
D. Palpate the right radial pulse.
Correct Answer: A
The nurse is assessing the nutritional
status of several clients. Which client has
the greatest nutritional need for addition-
al intake of protein? A lactating woman (B) has the greatest
need for additional protein intake. (A, C,
A. A college-age track runner with a and D) are all conditions that require
sprained ankle. protein, but do not have the increased
B. A lactating woman nursing her metabolic protein demands of lactation.
3-day-old infant.
C. A school-aged child with Type 2 dia- Correct Answer: B
betes.
D. An elderly man being treated for a
peptic ulcer.
A client is in the radiology department at
0900 when the prescription levofloxacin
To ensure that a therapeutic level of med-
(Levaquin) 500 mg IV q24h is scheduled
ication is maintained, the nurse should
to be administered. The client returns to
the unit at 1300. What is the best inter-
, 2024 EVOLVE HESI FUNDAMENTALS VERSION 1,2& 3 ACTUAL EXAM
EACH VERSION CONTAINS 265 QUESTIONS AND CORRECT DETAILED
ANSWERS
Study online at https://quizlet.com/_flq04r
vention for the nurse to implement?
administer the missed dose as soon as
A. Contact the healthcare provider and possible, and revise the administration
complete a medication variance form. schedule accordingly to prevent danger-
B. Administer the Levaquin at 1300 and ously increasing the level of the medica-
resume the 0900 schedule in the morn- tion in the bloodstream (D). The nurse
ing. should document the reason for the late
C. Notify the charge nurse and complete dose, but (A and C) are not warranted.
an incident report to explain the missed (B) could result in increased blood levels
dose. of the drug.
D. Give the missed dose at 1300 and
change the schedule to administer daily Correct Answer: D
at 1300.
While instructing a male client's wife in
the performance of passive range-of-mo-
tion exercises to his contracted shoul-
The wife is performing the passive ROM
der, the nurse observes that she is hold-
correctly, therefore the nurse should ac-
ing his arm above and below the elbow.
knowledge this fact (A). The joint that is
What nursing action should the nurse
being exercised should be uncovered (B)
implement?
while the rest of the body should remain
covered for warmth and privacy. (C and
A. Acknowledge that she is supporting
D) do not provide adequate support to
the arm correctly.
the joint while still allowing for joint move-
B. Encourage her to keep the joint cov-
ment.
ered to maintain warmth.
C. Reinforce the need to grip directly un-
Correct Answer: A
der the joint for better support.
D. Instruct her to grip directly over the
joint for better motion.
Venous return is usually better in the up-
What is the most important reason for
per extremities. Cannulation of the veins
starting intravenous infusions in the up-
in the lower extremities increases the risk
per extremities rather than the lower ex-
of thrombus formation (B) which, if dis-
tremities of adults?
lodged, could be life-threatening. Super-
ficial veins are often very easy (A) to find
A. It is more difficult to find a superficial
in the feet and legs. Handling a leg or foot
vein in the feet and ankles.
with an IV (C) is probably not any more
, 2024 EVOLVE HESI FUNDAMENTALS VERSION 1,2& 3 ACTUAL EXAM
EACH VERSION CONTAINS 265 QUESTIONS AND CORRECT DETAILED
ANSWERS
Study online at https://quizlet.com/_flq04r
difficult than handling an arm or hand.
B. A decreased flow rate could result in
Even if the nurse did believe moving a
the formation of a thrombosis.
cannulated leg was more difficult, this is
C. A cannulated extremity is more diffi-
not the most important reason for using
cult to move when the leg or foot is used.
the upper extremities. Pain (D) is not a
D. Veins are located deep in the feet and
consideration.
ankles, resulting in a more painful proce-
dure.
Correct Answer: B
The nurse observes an unlicensed as-
sistive personnel (UAP) taking a client's
blood pressure with a cuff that is too
small, but the blood pressure reading ob-
The most important action is to ensure
tained is within the client's usual range.
that an accurate BP reading is obtained.
What action is most important for the
The nurse should reassess the BP with
nurse to implement?
the correct size cuff (B). Reassessment
should not be postponed (A). Though (C
A. Tell the UAP to use a larger cuff at the
and D) are likely indicated, these actions
next scheduled assessment.
do not have the priority of (B).
B. Reassess the client's blood pressure
using a larger cuff.
Correct Answer: B
C. Have the unit educator review this pro-
cedure with the UAPs.
D. Teach the UAP the correct technique
for assessing blood pressure.
Twenty minutes after beginning a heat
application, the client states that the
heating pad no longer feels warm
(D) describes thermal adaptation, which
enough. What is the best response by
occurs 20 to 30 minutes after heat appli-
the nurse?
cation. (A and B) provide false informa-
tion. (C) is not based on a knowledge of
A. "That means you have derived the
physiology and is an unsafe action that
maximum benefit, and the heat can be
may harm the client.
removed."
B. "Your blood vessels are becoming di-
Correct Answer: D
lated and removing the heat from the
site."
C. "We will increase the temperature 5
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