EVOLVE COMPREHENSIVE EXAM (HESI) 1
QUESTIONS AND ANSWERS LATEST VERSION
2024 VERIFIED RATIONALE GRADED A+
A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured
bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action
should be implemented to obtain a valid informed consent? - ansObtain the permission of the custodial
parent for the surgery.
The client is a minor and cannot legally sign his own consent unless he is an emancipated minor, so the
consent should be obtained from the guardian for this client, which is the custodial parent (B). (A) is not
a legal option. A stepparent is not a legal guardian for a minor unless the child has been adopted by the
stepparent (C). The non-custodial parent does not need to co-sign this form (D).
A 56 year old female client is receiving intracavitary radiation via a radium implant. Which nurse should
be assigned to care for this client? - ansA nurse with marfran's syndrome who is postmenopausal.
A client receiving intracavity radiation poses a radiation hazard as long as the intracavity radiation source
is in place. A nurse's ability to care of this client is not affected by Marfan's syndrome (B), which is a
hereditary disorder of connective tissues, bones, muscles, ligaments and skeletal structures. The goal is
to limit any one staff member's exposure to the calculated time span based on the half-life of radium,
such as the number of minutes at the bedside per day, so (A) should not be assigned. (C) should not be
exposed to the radiation due to the possible effect on the fetus. A radiation exposure decreases the
immune response in the client who should not be exposed to the potential inadvertent transmission of
an infectious organism (D).
A 6 year old child is alert but quiet when brought to the emergency center with periobital ecchymosis
and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the
child for additional manifestations of a basilar skull fracture. What assessment finding would be
consistent with the basilar skull fracture? - ansRhinorrhoea or otorrhoea with halo sign
Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear over the mastoid
process) are both signs of a basilar skull fracture, so the nurse should assess for possible meningeal tears
that manifest as a Halo sign with CSF leakage from the ears or nose (D). (A) is consistent with orbital
fractures. (B) occurs with wrenching traumas of the shoulder or arm fractures. (C) occurs with blunt
abdominal injuries.
, EVOLVE COMPREHENSIVE EXAM (HESI) 1
QUESTIONS AND ANSWERS LATEST VERSION
2024 VERIFIED RATIONALE GRADED A+
A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her
daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set
the table for her deceased husband. What nursing problem best describes this problem? - ansDenial
related to the loss of a loved one.
Based on the data provided, (C) is the best nursing diagnosis. This client is exhibiting symptoms of
anxiety and the pain is too great for her to acknowledge, so she is denying the situation. Although she
may seem confused (A), she is actually trying to deal with the pain through the defense mechanism of
denial. (B) occurs after one year or longer following the loss. The client's husband died one month ago.
(D) and depression are often related, and depression is sometimes described as unexpressed anger.
However, this client has not acknowledged her loss (denial) and the anger is not yet realized.
A 9 year old is hospitalized for the neutropenia and is placed in reverse isolation. The child asks the nurse
" why do you have to wear a gown and mask when you are in my room?" How should the nurse
respond? - ans" To protect you because you can get an infection very easily
Reverse isolation precaution implement measures to protect the client from exposure to microorganisms
from others (B). Although microbes are prevalent in all environments, (A) does not adequately answer
the child's question. Reverse isolation should be implemented until the client's white blood cell increases
(C). Neutropenia in this child does not place others (D) at risk for infection.
A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg of body
weight, plus 50 mL/kg per day for each kilogram between 10 and 20. How many milliliters per hour
should the nurse program the infusion pump for a child who weighs 19.5 kg? (Enter numeric value only.
If rounding is required, round to the nearest whole number.) - ans61
The formula for calculating daily fluid requirements is: 0 to 10 kg, 100 mL/kg per day; or 10 to 20 kg,
1000 mL for the first 10 kg of body weight plus 50 mL/kg per day for each kilogram between 10 and 20.
To determine an hourly rate, divide the total milliliters per day by 24. 19.5 kg x 50 mL/kg = 475 mL + 1000
mL = 1475 mL / 24 hours = 61 mL/hour
, EVOLVE COMPREHENSIVE EXAM (HESI) 1
QUESTIONS AND ANSWERS LATEST VERSION
2024 VERIFIED RATIONALE GRADED A+
A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which
information is most important for the nurse to include in the teaching plan? - ansAvoid sharing towels
and washcloths with siblings
All of the information is important to include in the teaching plan, but it is most important to avoid
spreading the bacterial infection. The child should avoid sharing towels and washcloths (D) and should
stay home from school for the first 24 hours after antibiotics are started, to prevent contamination of
others. (A, B, and C) are important measures to reduce the child's discomfort, but inhibiting the spread
of the infection is the priority intervention.
A child with tetrology of ballot suffers a hyper cyanotic episode. Which immediate action by the nurse
can lessen the symptoms of this " TET" spell? - ansPlace child in knee-chest positionThis pressure
reduces the rush of blood flow through the septal hole and improves blood circulation.
The child should be placed on his or her back in the knee-to-chest position (B) to increase blood vessel
resistance. The increased pressure reduces the rush of blood through the septal hole and improves
blood circulation. (A) has nominal effects in hypercyanosis. (C) is self-regulating. (D) is not indicated for
immediate relief of tet spells. It is used to improve cardiac output.
A client assigned to a female practical nurse (PN) needs total morning care and sterile wound packing
with a wet to dry dressing. The PN tells the nurse that she has never performed a wound packing. Which
intervention should the charge nurse implement? - ansDemonstrate the wound care procedure to the
PN while the PN assists
It is within the PN's scope of practice to perform sterile wound care. The best learning of skills is through
demonstration and return demonstration, therefore (D) promotes safe practice while allowing the PN
the best opportunity to learn. (A) does not allow the PN to gain the experience needed to perform her
role. (B) does not provide the best learning opportunity for the PN, or ensure safe practice. While (C)
would provide a safe method for learning the wet-to-dry procedure, it doesn't address the problem
immediately and is a more costly way for the PN to learn.
A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention
during the first 48 hours following admission? - ansMonitor for increased blood pressure and pulse
, EVOLVE COMPREHENSIVE EXAM (HESI) 1
QUESTIONS AND ANSWERS LATEST VERSION
2024 VERIFIED RATIONALE GRADED A+
Clients with alcohol dependency experience withdrawal symptoms, which include elevated blood
pressure, pulse, and temperature, so (B) has the highest priority. (A) will prevent Korsakoff's syndrome
(secondary dementia caused by thiamine deficiency, associated with malnutrition secondary to excessive
alcohol intake), but this intervention does not have the priority of (B). (C and D) are important for alcohol
detoxification, but do not have the priority of (B).
A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza. Which
categories of illness should the nurse develop goals for the client's plan of care? - ansOne chronic and
one acute illness
The plan of care should include goals that are specific for chronic and acute illnesses. Adult-onset
diabetes is a life-long chronic disease, whereas influenza is an acute illness with a short term duration
(C). (A, B, and D) do not include the correct duration categories for this situation.
A client is admitted with a medical diagnosis of addisonian crisis. When completing the admission
assessment, the nurse expects this client to exhibit which clinical manifestations? - ansHypotension,
rapid weak pulse, and rapid respiratory rate
The clinical manifestations of Addisonian crisis are often the manifestations of shock (C); the client is at
risk for circulatory collapse and shock. (A) indicates clinical manifestations of Cushing's syndrome, (B) of
pheochromocytoma (tumor of adrenal medulla), and (D) of thyroid storm (thyrotoxic crisis).
A client is being admitted to the medical unit form the emergency department after having a chest tube
inserted. What equipment should be brought to this client's room? - ansRubber-tipped clamps
Rubber-tipped clamps (C) should be kept at the client's bedside for assessment of possible chest tube air
leaks, with the prescription of the healthcare provider. (A), used during a respiratory or cardiac arrest,
does not need to be brought to the client's room as a routine precaution. (B) is used to intubate a client
and is not indicated for routine care of the client with a chest tube. (D) is indicated by the client's oxygen
saturation or arterial blood gases, and is not routinely placed in the room of a client with a chest tube.
