Evolve HESI practice Exam 92 Questions with Verified Answers,100% CORRECT

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Evolve HESI practice Exam 92 Questions with Verified Answers The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer?... - CORRECT ANSWER 0.5 ml. A hospitalized male client is receiving nasogastric 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? - CORRECT ANSWER After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 1.5ml Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER The client voluntarily signed the form. 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? - CORRECT ANSWER Flush the tube with water. An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? - CORRECT ANSWER Be sure to have a complete physical examination before beginning your planned exercise program. (The most important teaching is that the client will not begin a dangerous level of exercise when he is not sufficiently fit. This might result in chest pain, an MI, or stroke.) When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the - CORRECT ANSWER upper torso (Stooped posture results in the upper torso becoming center of gravity.) Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? - CORRECT ANSWER upper arm circumference During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? - CORRECT ANSWER Degree of flexion and extension of the client's knee joint. A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? - CORRECT ANSWER What vitamin and mineral supplements do you take? (Vitamin and mineral supplements may impact medications used during the procedure.) An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? - CORRECT ANSWER Gently lift the client when moving into a desired position. During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? - CORRECT ANSWER Acknowledge the client's distress and tell her it is all right to cry. Which action is most important for the nurse to implement when donning sterile gloves? - CORRECT ANSWER Keep gloved hands above the elbows. The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? - CORRECT ANSWER Skim milk, turkey salad, roll, and vanilla ice cream. (considered low sodium foods.) An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? - CORRECT ANSWER Reposition in a Sim's position with the client's weight on the anterior ilium. An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? - CORRECT ANSWER Inquire about the source and type of pain A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client - CORRECT ANSWER demonstrates the wound care procedure correctly. The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? - CORRECT ANSWER Report the results of the vital signs to the nurse. 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? - CORRECT ANSWER Reassess the client's blood pressure using a larger cuff. The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to - CORRECT ANSWER 1½ tablets A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? - CORRECT ANSWER Ensure the accuracy of the blood type match. The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? - CORRECT ANSWER Hot remedies restore balance after surgery, which is considered a "cold" condition. A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take? - CORRECT ANSWER Measure the pulse volume and capillary refill distal to the infiltration. (Pain and diminished pulse volume are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity.) A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? - CORRECT ANSWER Reposition the client on her side (The immediate priority is to determine if the tube is functioning correctly, which would then relieve the nausea. Repositioning is the least invasive.) The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? - CORRECT ANSWER A lactating woman nursing her 3-day-old infant. In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly - CORRECT ANSWER often follows relocation to new surroundings. The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? - CORRECT ANSWER Observe the appearance of the skin under the ice pack. (The first action taken by the nurse should be to assess the skin for any possible thermal injury) A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? - CORRECT ANSWER Commend the client for selecting a high biologic value protein. (Foods such as eggs and milk are high in biologic proteins which are allowed because they are complete proteins and supply the essential amino acids necessary growth and cellular repair.) When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? - CORRECT ANSWER Many complimentary healing practices can be used in conjunction with conventional practices. An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is - CORRECT ANSWER Fowler's. Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? - CORRECT ANSWER 11,000 units Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? - CORRECT ANSWER Chocolate pudding. (A patient with MG is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia. Snacks that are semisolid are easy to swallow and require minimal chewing and provide calories and protein.) The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? - CORRECT ANSWER Re-oxygenate the client before attempting to suction again. (Suctioning should not be done for longer than 10 to 15 sec., since patient's oxygenation is compromised during this time.) When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? - CORRECT ANSWER Note which actions were not implemented. (First the nurse should review which actions in the original plan were not implemented in order to determine why the original plan did not produce the desired outcome.) 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? - CORRECT ANSWER The body's receptors adapt over time as they are exposed to heat. (describes thermal adaptation) A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? - CORRECT ANSWER is disoriented to place and time. Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? - CORRECT ANSWER 1 tab The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? - CORRECT ANSWER 83 gtt/min. During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? - CORRECT ANSWER Encourage additional oral intake of juices and water The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? - CORRECT ANSWER Infuse 10 percent dextrose and water at 54 ml/hr. (TPN is discontinued gradually to allow patient to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate, it will keep the patient from experiencing hypoglycemia until the next TPN is available.) A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? - CORRECT ANSWER 63 ml/hour. The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? - CORRECT ANSWER Move the chair parallel to the right side of the bed, and stand the client on the right foot. On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? - CORRECT ANSWER ) Battery Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching). Performing any procedure against the client's wishes can potentially poise a legal issue, such as battery (B), even if the procedure is of questionable benefit to the client. (A, C, and D) are not examples against the client's request A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? - CORRECT ANSWER Healthcare provider notified of client's refusal to have blood specimens collected for testing. At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? - CORRECT ANSWER Immediately after the assessments are completed. An Arab-American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client? - CORRECT ANSWER D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided. Traditional Muslim women live in a patriarchal family where decisions are made by men. Most likely, the son will make the decision for his mother, so Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met? - CORRECT ANSWER Accepts that punishment from God is not related to illness Acceptance that she is not being punished by God indicates a desired outcome During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds? - CORRECT ANSWER Use the stethoscope bell over the valvular areas of the anterior chest Abnormal heart sounds are best heard with the bell of the stethoscope, which picks up lower-pitched sounds, that is placed at points on the anterior chest A nurse is preparing to give medications through a nasogastric feeding tube. Which nursing action should prevent complications during administration? - CORRECT ANSWER A) Mix each medication individually Medications should be mixed separately (A) to prevent clumping. During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? - CORRECT ANSWER Closed-ended questions Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use closed-ended questions (C) that focus on common signs and symptoms about a client's health problem An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? - CORRECT ANSWER Rashes in the axillary, groin, and skin fold regions Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? - CORRECT ANSWER Document in the medical record that these normal findings are expected outcomes The results are all within normal range.(C) No changes are needed. What action should the nurse implement when accessing an implanted infusion port for a client who receives long term IV medications? - CORRECT ANSWER Insert a Huber-point needle into the port An implanted infusion port needs to be accessed using a Huber-point needle (B) (non-coring) to be prevent damage to the self-sealing septum of the port. During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? - CORRECT ANSWER Listen and show interest as the client expresses these feelings When a client begins to cry and express feelings, a therapeutic nursing intervention is to listen and show interest as the client expresses feelings The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? - CORRECT ANSWER Client A primary source of information for a health assessment is the client (A). (B, C, and D) are considered secondary sources about the client's health history, but other details, such as subjective data, can only be provided directly from the client. The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? - CORRECT ANSWER Genetic and familial health disorders A genogram that is used during the health assessment process identifies genetic and familial health disorders (A). It may not identify the client's chronic health problems A Sub-Saharan African widowed immigrant woman lives with her deceased husband's brother and his family, which includes the brother-in-law's children and the widow's adult children. Each family member speaks fluent English. Surgery was recommended for the client. What is the best plan to obtain consent for surgery for this client? - CORRECT ANSWER Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow. The healthcare provider prescribes an IV infusion of 1,000 ml of Ringer's lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 lb infant by cesarian section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? - CORRECT ANSWER 83 gtt/min gtt/min = 20 gtt/ml x 1000ml/4hrs x 1hr/60 min = 83gtt/min Which assessment data provides the most accurate determination of proper placement of a nasogastric tube? - CORRECT ANSWER Examining a chest x-ray obtained after the tubing was inserted. (This is THE BEST indicator that the tubing is properly placed. aspirating gastric contents and hearing air pass in the stomach after injecting air into tubing are both ways to check but not the best.) During a shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the patient's heart sound? - CORRECT ANSWER Use the stethoscope bell over the valvular areas of the anterior chest. (Abnormal heart sounds are best heard with the bell of the stethoscope, which picks up lower-pitched sounds, that is placed at points on the anterior chest.) Secobarbital 150 mg is prescribed at bedtime for a male client who is schedule for surgery in the morning. The scored tablets are labeled 0.1 gram/tablet. How many tablets should the nurse administer? - CORRECT ANSWER 1.5 [Show More]

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