Evolve HESI Fundamentals Practice Qs EXAM
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Urinary catheterization is prescribed Answer: C
for a postoperative female client It is likely that the first catheter is in the vagina,
who has been unable to void for 8 rather than the bladder. Leaving the first catheter in
hours. The nurse inserts the catheter, place will help locate the meatus when attempting
but no urine is seen in the tubing. the second catheterization (C). The client should
Which action will the nurse take have at least 240 mL of urine after 8 hours. (A) does
next? not resolve the problem. (B) will not change the
A. Clamp the catheter and recheck it location of the catheter unless it is completely
in 60 minutes. removed, in which case a new catheter must be
B. Pull the catheter back 3 inches and used. There is no evidence of a urinary tract
redirect upward. obstruction if the catheter could be easily inserted
C. Leave the catheter in place and (D).
reattempt with another catheter.
D. Notify the health care provider of
a possible obstruction.
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The nurse is teaching an obese Answer: C
client, newly diagnosed with A health promotion brochure about decreasing
arteriosclerosis, about reducing the cholesterol (C) is most important to provide this
risk of a heart attack or stroke. Which client, because the most significant risk factor
health promotion brochure is most contributing to development of arteriosclerosis is
important for the nurse to provide to excess dietary fat, particularly saturated fat and
this client? cholesterol. (A) does not address the underlying
A. "Monitoring Your Blood Pressure causes of arteriosclerosis. (B and D) are also
at Home" important factors for reversing arteriosclerosis but
B. "Smoking Cessation as a Lifelong are not as important as lowering cholesterol (C).
Commitment"
C. "Decreasing Cholesterol Levels
Through Diet"
D. "Stress Management for a
Healthier You"
Ten minutes after signing an Answer: B
operative permit for a fractured hip, This statement may indicate that the client is
an older client states, "The aliens will confused. Informed consent must be provided by a
be coming to get me soon!" and falls mentally competent individual, so the nurse should
asleep. Which action should the further assess the client's neurologic status (B) to
nurse implement next? be sure that the client understands and can legally
A. Make the client comfortable and provide consent for surgery. (A) does not provide
allow the client to sleep. sufficient follow-up. If the nurse determines that
B. Assess the client's neurologic the client is confused, the surgeon must be notified
status. (C) and permission obtained from the next of kin
C. Notify the surgeon about the (D).
comment.
D. Ask the client's family to co-sign
the operative permit.
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The nurse-manager of a skilled Answer: A
nursing (chronic care) unit is Performing range-of-motion exercises (A) is
instructing UAPs on ways to prevent beneficial in reducing contractures around joints.
complications of immobility. Which (B, C, and D) are all potentially harmful practices
intervention should be included in that place the immobile client at risk of
this instruction? complications.
A. Perform range-of-motion
exercises to prevent contractures.
B. Decrease the client's fluid intake to
prevent diarrhea.
C. Massage the client's legs to
reduce embolism occurrence.
D. Turn the client from side to back
every shift.
The nurse is assisting a client to the Answer: D
bathroom. When the client is 5 feet (D) is the most prudent intervention and is the
from the bathroom door, he states, "I priority nursing action to prevent injury to the client
feel faint." Before the nurse can get and the nurse. Lowering the client to the floor
the client to a chair, the client starts should be done when the client cannot support his
to fall. Which is the priority action for own weight. The client should be placed in a bed
the nurse to take? or chair only when sufficient help is available to
A. Check the client's carotid pulse. prevent injury. (A) is important but should be done
B. Encourage the client to get to the after the client is in a safe position. Because the
toilet. client is not supporting himself, (B) is impractical.
C. In a loud voice, call for help. (C) is likely to cause chaos on the unit and might
D. Gently lower the client to the alarm the other clients.
floor.
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A female nurse is assigned to care Answer: B
for a close friend, who says, "I am The State Nurse Practice Act (B) contains legal
worried that friends will find out requirements for the protection of client
about my diagnosis." The nurse tells confidentiality and the consequences for breaches
her friend that legally she must in confidentiality. (A) outlines ethical standards for
protect a client's confidentiality. nursing care but does not include legal guidelines.
Which resource describes the nurse's (C and D) describe expectations for nursing
legal responsibilities? practice but do not address legal implications.
A. Code of Ethics for Nurses
B. State Nurse Practice Act
C. Patient's Bill of Rights
D. ANA Standards of Practice
The nurse is teaching a client how to Answer: D
perform progressive muscle The nurse should first evaluate whether the client
relaxation techniques to relieve has been adhering to the original instructions (D). A
insomnia. A week later the client verbal report of the client's routine will provide
reports that he is still unable to more specific information than the client's written
sleep, despite following the same diary (B). The nurse can then determine which
routine every night. Which action changes need to be made (A). The routine
should the nurse take first? practiced by the client is clearly unsuccessful, so
A. Instruct the client to add regular encouragement alone is insufficient (C).
exercise as a daily routine.
B. Determine if the client has been
keeping a sleep diary.
C. Encourage the client to continue
the routine until sleep is achieved.
D. Ask the client to describe the
routine that the client is currently
following.
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