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Evolve HESI practice Exam Questions and Accurate answers. 100% proven pass rate

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The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer? - 0.5 ml. A hospitalized male client is receiving nasogastri... c tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? - After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. (Coughing, vomiting, and suctioning can precipitate displacement of the small bore upward into the esophagus. This will help check tube placement.) 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? - Give the missed dose at 1300 and change the schedule to administer daily at 1300. 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? - Give an around-the-clock schedule for administration of analgesics. After completing an assessment and determining that a client has a problem, which action should the nurse perform next? - determine the etiology of the problem What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? - A decreased flow rate could result in the formation of a thrombosis. The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? - Continue asking the mother questions about the child. Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? - Assess for bladder distention. A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? - Blood transfusions are forbidden. 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? - Acknowledge that she is supporting the arm correctly. An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? - Fowler's. An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? - It is important that you continue your medication while learning to meditate. A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion? - 150 The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? - Frontal lobe A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? - Initiate an alternate site for the IV infusion of the medication. A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? - Request and document the name of the certified translator. A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? - Place a pillow between your knees while lying in bed to prevent hip dislocation. An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? - Notify the healthcare provider of the family's request. A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? - Nutritional history. The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? - 21 Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? - Instruct the client that the stoma will become smaller when the initial swelling diminishes. (Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished. This will help reduce the anxiety and promote colostomy acceptance.) The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? - 1.5ml Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? - Examining a chest x-ray obtained after the tubing was inserted. The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? - 124 gtt/min. At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? - It is OK if you don't want to talk about your surgery. I will be available when you are ready. (It displays sensitivity and understanding without judging the patient) Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? - Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? - Avoid any types of sprays, powders, and perfumes. A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? - Assist the ambulating client back to the bed. The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? - During the inhalation The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? - I will limit my intake of beef to 4 ounces per week. 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? - Loosen the right wrist restraint. A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? - 8 a.m., 4 p.m., and midnight. (Theophylline should be administered on a regular around-the-clock schedule. 8,4 and midnight provide the best bronchodilating effect and reduce the potential for adverse effects.) An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? - 180 180ml/hr = 500 ml/5mg x 1mg/1000mcg x 30 mcg/min x 60min/hr An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? - The nurse who transferred the client to the chair when the fall occurred. The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? - The client voluntarily signed the form [Show More]

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