EVOLVE HESI PRACTICE EXAM

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EVOLVE HESI PRACTICE EXAM

Actual Qs and Ans Expert-Verified Explanation

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-Guarantee passing score -92 Questions and Answers -format set of multiple-choice -Expert-Verified Explanation Question 1: 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?

Answer:

Inquire about the source and type of pain Question 2: Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?

Answer:

Assess for bladder distention.Question 3: 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?

Answer:

Continue asking the mother questions about the child.Question 4: 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?

Answer:

Ensure the accuracy of the blood type match.

Question 5: 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?

Answer:

Notify the healthcare provider of the family's request.Question 6: 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?

Answer:

I will limit my intake of beef to 4 ounces per week.Question 7: 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?

Answer:

Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow.Question 8: 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?

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 Question 9: 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?

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)

Question 10: 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?

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.) Question 11: 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?

Answer:

During the inhalation Question 12: 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?

Answer:

83 gtt/min gtt/min = 20 gtt/ml x 1000ml/4hrs x 1hr/60 min = 83gtt/min Question 13: 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?

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.) Question 14: 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?

Answer:

1.5

Question 15: 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?

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.) Question 16: 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?

Answer:

Initiate an alternate site for the IV infusion of the medication.Question 17: 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?

Answer:

Fowler's.Question 18: 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?

Answer:

Many complimentary healing practices can be used in conjunction with conventional practices.Question 19: An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment?

Answer:

The nurse who transferred the client to the chair when the fall occurred.Question 20: 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?

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.)