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EVOLVE HESI PRACTICE EXAM
QUESTIONS AND ANSWERS
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Morphine comes in 8 mg per ml
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5 ml
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The tubing has been changed to a 20
gtt/ml administration set
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During the initial morning assessment, a male client denies dysuria but
reports that his urine appears dark amber
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When initially assessing the
client, the nurse notes that the TPN solution has run out and the next TPN
solution is not available
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(TPN is discontinued gradually to allow patient to adjust to decreased levels
of glucose
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)

A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over
4 hours
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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
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On admission, a client presents a signed living will that includes a Do Not
Resuscitate (DNR) prescription
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What legal issues could be brought against the nurse? - CorreCt
Answers -) 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)
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(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
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At the beginning of the shift, the nurse assesses a client who is admitted
from the post-anesthesia care unit (PACU)
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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
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Traditional Muslim women live in a patriarchal family where decisions are
made by men
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Which placement of the stethoscope should the
nurse use to hear the client's heart sounds? - CorreCt Answers -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
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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 Answers -Closed-ended
questions

Lay descriptors of health problems can be vague and nonspecific
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Which finding should the nurse identify as a client
risk factor for pressure ulcers? - CorreCt Answers -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
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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
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Which action is most important for the
nurse to implement? - CorreCt Answers -Document in the medical record
that these normal findings are expected outcomes

The results are all within normal range
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What action should the nurse implement when accessing an implanted
infusion port for a client who receives long term IV medications? - CorreCt
Answers -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
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What
action should the nurse take? - CorreCt Answers -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
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(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
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What information should the
genogram provide? - CorreCt Answers -Genetic and familial health
disorders

A genogram that is used during the health assessment process identifies
genetic and familial health disorders (A)
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Each family member speaks fluent
English
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What is the best plan to
obtain consent for surgery for this client? - CorreCt Answers -Tell the
surgeon that the brother-in-law will decide after explanation of the
proposed surgery is provided to him and the widow
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The tubing has been
changed to a 20 gtt/ml administration set
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(This is THE BEST indicator that the tubing is properly placed
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)

During a shift change report, the nurse receives report that a client has
abnormal heart sounds
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(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
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The scored tablets are labeled 0
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How many tablets should the nurse administer? - CorreCt
Answers -1
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He reports that he had a bad
bout of severe coughing a few minutes ago, but feels fine now
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(Coughing, vomiting, and suctioning can precipitate displacement of the
small bore upward into the esophagus
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)

A client is in the radiology department at 0900 when the prescription
levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered
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What is the best intervention for the
nurse to implement? - CorreCt Answers -Give the missed dose at 1300 and
change the schedule to administer daily at 1300
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The healthcare provider prescribes an analgesic every four hours as needed
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After completing an assessment and determining that a client has a
problem, which action should the nurse perform next? - CorreCt Answers 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
Answers -A decreased flow rate could result in the formation of a
thrombosis
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What action should the nurse
take? - CorreCt Answers -Continue asking the mother questions about the
child
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A client who is a Jehovah's Witness is admitted to the nursing unit
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While instructing a male client's wife in the performance of passive rangeof-motion exercises to his contracted shoulder, the nurse observes that she
is holding his arm above and below the elbow
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An elderly male client who is unresponsive following a cerebral vascular
accident (CVA) is receiving bolus enteral feedings though a gastrostomy
tube
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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
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A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB
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9% NaCl
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For how many
ml/hr should the infusion pump be set to deliver the secondary infusion? CorreCt Answers -150

The nurse is completing a mental assessment for a client who is
demonstrating slow thought processes, personality changes, and emotional

lability
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The nurse observes erythema, swelling,
and a red streak along the vessel above the IV access site
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A female client asks the nurse to find someone who can translate into her
native language her concerns about a treatment
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A 73-year-old female client had a hemiarthroplasty of the left hip yesterday
due to a fracture resulting from a fall
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An elderly resident of a long-term care facility is no longer able to perform
self-care and is becoming progressively weaker
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What action should the nurse implement first? CorreCt Answers -Notify the healthcare provider of the family's request
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What information should the nurse obtain first? CorreCt Answers -Nutritional history
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The infusion set delivers 10 drops per milliliter
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He becomes quite upset and tells the nurse that it is much bigger
than he expected
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(Postoperative swelling causes enlargement of the stoma
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This will help reduce the anxiety and promote colostomy
acceptance
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On
hand is Lasix 20 mg/2 ml
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5ml

Which assessment data would provide the most accurate determination of
proper placement of a nasogastric tube? - CorreCt Answers -Examining a
chest x-ray obtained after the tubing was inserted
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Using a drip factor of 60 gtt/ml, how many drops per minute
should the client receive? - CorreCt Answers -124 gtt/min
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The nurse tells the client that the incision is healing
well, but the client refuses to talk about it
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I will be available when you are ready
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5
cm in diameter
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5 cm in
diameter
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Which instruction should be included in this teaching plan? CorreCt Answers -Avoid any types of sprays, powders, and perfumes
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Based on these findings, which intervention should
the nurse implement first? - CorreCt Answers -Assist the ambulating client
back to the bed
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When should the
client administer the inhaler-delivered medication to demonstrate correct
use of the inhaler? - CorreCt Answers -During the inhalation

The nurse is instructing a client with high cholesterol about diet and life
style modification
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When assessing a client with wrist restraints, the nurse observes that the
fingers on the right hand are blue
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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
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m
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m
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(Theophylline should be administered on a regular around-the-clock
schedule
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)

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
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Which nurse is at greatest risk for a malpractice judgment? - CorreCt
Answers -The nurse who transferred the client to the chair when the fall
occurred
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Which statement best explains this nursing responsibility? CorreCt Answers -The client voluntarily signed the form
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After ensuring correct tube placement, what
action should the nurse take next? - CorreCt Answers -Flush the tube with
water
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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
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(The most important teaching is that the client will not begin a dangerous
level of exercise when he is not sufficiently fit
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)

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 Answers -upper torso

(Stooped posture results in the upper torso becoming center of gravity
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Which finding should the nurse expect to
measure? - CorreCt Answers -Degree of flexion and extension of the client's
knee joint
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What question is most important for the nurse to include during
the preoperative assessment? - CorreCt Answers -What vitamin and
mineral supplements do you take?

(Vitamin and mineral supplements may impact medications used during
the procedure
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Which nursing
measure is essential to the client's nursing care? - CorreCt Answers -Gently
lift the client when moving into a desired position
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Which action is
best for the nurse to take? - CorreCt Answers -Acknowledge the client's
distress and tell her it is all right to cry
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The nurse is evaluating client learning about a low-sodium diet
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(considered low sodium foods
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Which instruction
should the nurse provide the UAP? - CorreCt Answers -Reposition in a
Sim's position with the client's weight on the anterior ilium
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" Based on this statement, which
focused assessment should the nurse conduct? - CorreCt Answers -Inquire
about the source and type of pain

A postoperative client will need to perform daily dressing changes after
discharge
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The nurse assigns a UAP to obtain vital signs from a very anxious client
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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
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The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7
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Zaroxolyn is available in 5 mg tablets
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Which intervention is most
important for the nurse to implement? - CorreCt Answers -Ensure the
accuracy of the blood type match
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Other liquids, including gelatin, popsicles, and juices, remain untouched
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A client's infusion of normal saline infiltrated earlier today, and
approximately 500 ml of saline infused into the subcutaneous tissue
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" What initial action is most important for the
nurse to take? - CorreCt Answers -Measure the

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