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EVOLVE FUNDAMENTALS HESI
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. - 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. - 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. - 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
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. - 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. - 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 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? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support.
important reason for using the upper extremities. Pain (D) is not a consideration. Correct ANSWER : B 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? A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure. - ANSWER - The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the BP with the correct size cuff (B). Reassessment should not be postponed (A). Though (C and D) are likely indicated, these actions do not have the priority of (B). Correct ANSWER : B 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?
A. "That means you have derived the maximum benefit, and the heat can be removed." B. "Your blood vessels are becoming dilated and removing the heat from the site." C. "We will increase the temperature 5 degrees when the pad no longer feels warm." D. "The body's receptors adapt over time as they are exposed to heat." - ANSWER - (D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B) provide false information. (C) is not based on a knowledge of physiology and is an unsafe action that may harm the client. Correct ANSWER : D 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? A. "If I exercise at least two times weekly for one hour, I will lower my cholesterol." B. "I need to avoid eating proteins, including red meat." C. "I will limit my intake of beef to 4 ounces per week."
the right side, for weight-bearing during the transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver. Correct ANSWER : D 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? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level. - ANSWER - The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the client is positioned.
Correct ANSWER : C 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? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed. - ANSWER - Blood transfusions are forbidden (B) in the Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of these sects are vegetarian (D), but the direct impact on nursing care is (B). Correct ANSWER : B 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? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice.
Correct ANSWER : D 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? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. - ANSWER - Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action (C). (A and B) are not indicated. The auscultating method (D) has been found to be unreliable for small-bore feeding tubes. Correct ANSWER : C
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? A. 9 a.m., 1 p.m., and 5 p.m. B. 8 a.m., 4 p.m., and midnight. C. Before breakfast, before lunch and before dinner. D. With breakfast, with lunch, and with dinner. - ANSWER - Theophylline should be administered on a regular around-the-clock schedule (B) to provide the best bronchodilating effect and reduce the potential for adverse effects. (A, C, and D) do not provide around-the-clock dosing. Food may alter absorption of the medication (D). Correct ANSWER : B 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?
(B). After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for distribution of the medication. The client should not deliver the dose as stated in (A or D), and should deliver no more than two inhalations at a time (C). Correct ANSWER : B 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 administer? A. ½ tablet. B. 1 tablet. C. 1½ tablets. D. 2 tablets. - ANSWER - (C) is the correct calculation: D/H × Q = 7.5/5 × 1 tablet = 1½ tablets. Correct ANSWER : C 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?
A. 1 ml. B. 1.5 ml. C. 1.75 ml. D. 2 ml. - ANSWER - (B) is the correct calculation: Dosage on hand/amount on hand = Dosage desired/x amount. 20 mg : 2 ml = 15 mg : x. 20x = 30. x = 30/20; = 1½ or 1.5 ml. Correct ANSWER : B 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? A. 11,000 units. B. 13,000 units. C. 15,000 units. D. 17,000 units. - ANSWER - (A) is the correct calculation: 20, units/500 ml = 40 units (the amount of units in one ml of fluid). 40 units/ml x 50 ml/hr = 2,000 units/hour (1,000 units in 1/2 hour). 5.5 x 2,000 = 11,000 (A). OR, multiply 5 x 2,000 and add the 1/2 hour amount of 1,000 to reach the same conclusion = 11,000 units. Correct ANSWER : A
D. Put the glove on the dominant hand first. - ANSWER - Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D). Correct ANSWER : C 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? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area. - ANSWER
- Pain and diminished pulse volume (B) are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast), or internal pressure (usually from subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity. (A) should not be pursued until physical causes of the pain are ruled out. (C) is of less
priority than determining the effects of the edema on circulation and nerve function. Further assessment of the client's ecchymosis can be delayed until the signs of edema and compression that suggest compartment syndrome have been examined (D). Correct ANSWER : B 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? A. Prone. B. Fowler's. C. Sims'. D. Supine. - ANSWER - The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long- term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration.
