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Evolve Fundamentals HESI Questions with correct answers.
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Evolve Fundamentals HESI Questions with correct answers.
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Evolve Fundamentals HESI Questions with correctanswers
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
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. 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
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
,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
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
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
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