EVOLVE HESI FUNDAMENTALS EXAM|| HESI FUNDA m m m m m
MENTALS EXIT EVOLVE ACTUAL EXAM ALL 220 QU m m m m m m m
ESTIONS AND 100% CORRECT ANSWERS WELL EXP m m m m m m
LAINED ALREADY GRADED A+|| LATEST AND COMP m m m m m m
LETE UPDATE 2024- m m
2025 WITH VERIFIED SOLUTIONS|| ASSURED PASS!!!
m m m m m
Urinary catheterization is prescribed for a postoperative female client who has be
m m m m m m m m m m m
en unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen i
m m m m m m m m m m m m m m m m m
n the tubing. Which action will the nurse take next?
m m m m m m m m m
A. Clamp the catheter and recheck it in 60 minutes.
m m m m m m m m
B. Pull the catheter back 3 inches and redirect upward.
m m m m m m m m
C. Leave the catheter in place and reattempt with another catheter.
m m m m m m m m m
D. Notify the health care provider of a possible obstruction. - ANSWER: C
m m m m m m m m m m m
It is likely that the first catheter is in the vagina, rather than the bladder. Leavin
m m m m m m m m m m m m m m m
g the first catheter in place will help locate the meatus when attempting the seco
m m m m m m m m m m m m m m
nd catheterization
m
(C). The client should have at least 240 mL of urine after 8 hours.
m m m m m m m m m m m m m
(A) does not resolve the problem.
m m m m m
(B) will not change the location of the catheter unless it is completely removed, in wh
m m m m m m m m m m m m m m m
ich case a new catheter must be used.
m m m m m m m
There is no evidence of a urinary tract obstruction if the catheter could be easily insert
m m m m m m m m m m m m m m m
ed (D). m
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, abou
m m m m m m m m m m m
t reducing the risk of a heart attack or stroke. Which health promotion brochure is
m m m m m m m m m m m m m m
mmost important for the nurse to provide to this client?
m m m m m m m m m
A. "Monitoring Your Blood Pressure at Home" m m m m m
,2m|mPm am gm e
B. "Smoking Cessation as a Lifelong Commitment"
m m m m m
C. "Decreasing Cholesterol Levels Through Diet" m m m m
D. "Stress Management for a Healthier You" - ANSWER: C
m m m m m m m m
A health promotion brochure about decreasing cholesterol (C) is most important t
m m m m m m m m m m m
o provide this client, because the most significant risk factor contributing to devel
m m m m m m m m m m m m
opment of arteriosclerosis is excess dietary fat, particularly saturated fat and chol
m m m m m m m m m m m
esterol. (A) does not address the underlying causes of arteriosclerosis. (B and D)
m m m m m m m m m m m m m
are also important factors for reversing arteriosclerosis but are not as important as
m m m m m m m m m m m m
mlowering cholesterol (C). m m
Ten minutes after signing an operative permit for a fractured hip, an older client s
m m m m m m m m m m m m m m
tates, "The aliens will be coming to get me soon!" and falls asleep. Which action s
m m m m m m m m m m m m m m m
hould the nurse implement next?
m m m m
A. Make the client comfortable and allow the client to sleep.
m m m m m m m m m
B. Assess the client's neurologic status.
m m m m
C. Notify the surgeon about the comment.
m m m m m
D. Ask the client's family to co-sign the operative permit. -
m m m m m m m m m
m ANSWER: B This statement may indicate that the client is confused. Informed
m m m m m m m m m m m m
consent must be m m
provided by a mentally competent individual, so the nurse should further assess th
m m m m m m m m m m m m
e client's neurologic status (B) to be sure that the client understands and can legall
m m m m m m m m m m m m m m
y provide consent for surgery. (A) does not provide sufficient follow-
m m m m m m m m m m
up. If the nurse determines that the client is confused, the surgeon must be notifie
m m m m m m m m m m m m m m
d (C) and permission obtained from the next of kin (D).
m m m m m m m m m m
The nurse- m
manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to pr
m m m m m m m m m m m m m m
event complications of immobility. Which intervention should be included in this
m m m m m m m m m m m
instruction?
A. Perform range-of-motion exercises to prevent contractures.
m m m m m
,3m|mPm am gm e
B. Decrease the client's fluid intake to prevent diarrhea.
m m m m m m m
C. Massage the client's legs to reduce embolism occurrence.
m m m m m m m
D. Turn the client from side to back every shift. - ANSWER: A
m m m m m m m m m m m
Performing range-of- m
motion exercises (A) is beneficial in reducing contractures around joints. (B, C, a
m m m m m m m m m m m m
nd D) are all potentially harmful practices that place the immobile client at risk of
m m m m m m m m m m m m m m
complications.
m
The nurse is assisting a client to the bathroom. When the client is 5 feet from the
m m m m m m m m m m m m m m m m m
bathroom door, he states, "I feel faint." Before the nurse can get the client to a ch
m m m m m m m m m m m m m m m m
air, the client starts to fall. Which is the priority action for the nurse to take?
m m m m m m m m m m m m m m m
A. Check the client's carotid pulse.
m m m m
B. Encourage the client to get to the toilet.
m m m m m m m
C. In a loud voice, call for help.
m m m m m m
D. Gently lower the client to the floor. - ANSWER: D
m m m m m m m m m
(D) is the most prudent intervention and is the priority nursing action to prevent i
m m m m m m m m m m m m m m
njury to the client and the nurse. Lowering the client to the floor should be done
m m m m m m m m m m m m m m m m
when the client cannot support his own weight. The client should be placed in a b
m m m m m m m m m m m m m m m
ed or chair only when sufficient help is available to prevent injury. (A) is importa
m m m m m m m m m m m m m m
nt but should be done after the client is in a safe position. Because the client is no
m m m m m m m m m m m m m m m m m
t supporting himself, (B) is impractical. (C) is likely to cause chaos on the unit an
m m m m m m m m m m m m m m m
d might alarm the other clients.
m m m m m
A female nurse is assigned to care for a close friend, who says, "I am worried that fri
m m m m m m m m m m m m m m m m m
ends will find out about my diagnosis." The nurse tells her friend that legally she must
m m m m m m m m m m m m m m m
mprotect a client's confidentiality. Which resource describes the nurse's legal responsib
m m m m m m m m m m
ilities?
A. Code of Ethics for Nurses
m m m m
B. State Nurse Practice Act
m m m
C. Patient's Bill of Rights m m m
D. ANA Standards of Practice - ANSWER: B
m m m m m m
, 4m|mPm am gm e
The State Nurse Practice Act (B) contains legal requirements for the protection of
m m m m m m m m m m m m
mclient confidentiality and the consequences for breaches in confidentiality. (A) o
m m m m m m m m m m
utlines ethical standards for nursing care but does not include legal guidelines. (C
m m m m m m m m m m m m m
and D) describe expectations for nursing practice but do not address legal implica
m m m m m m m m m m m m
tions.
The nurse is teaching a client how to perform progressive muscle relaxation techn
m m m m m m m m m m m m
iques to relieve insomnia. A week later the client reports that he is still unable to sl
m m m m m m m m m m m m m m m m
eep, despite following the same routine every night. Which action should the nurs
m m m m m m m m m m m m
e take first?
m m
A. Instruct the client to add regular exercise as a daily routine.
m m m m m m m m m m
B. Determine if the client has been keeping a sleep diary.
m m m m m m m m m
C. Encourage the client to continue the routine until sleep is achieved.
m m m m m m m m m m
D. Ask the client to describe the route - ANSWER: D
m m m m m m m m m
The nurse should first evaluate whether the client has been adhering to the origina
m m m m m m m m m m m m m
l instructions (D). A verbal report of the client's routine will provide more specifi
m m m m m m m m m m m m m
c information than the client's written diary (B). The nurse can then determine whi
m m m m m m m m m m m m m
ch changes need to be made (A). The routine practiced by the client is clearly uns
m m m m m m m m m m m m m m m
uccessful, so encouragement alone is insufficient (C).
m m m m m m
A 65-year-old client who attends an adult daycare program and is wheelchair-
m m m m m m m m m m m
mmobile has redness in the sacral area. Which instruction is most important for the
m m m m m m m m m m m m m m
nurse to provide? m m
A. Take a vitamin supplement tablet once a day.
m m m m m m m
B. Change positions in the chair at least every hour.
m m m m m m m m
C. Increase daily intake of water or other oral fluids.
m m m m m m m m
D. Purchase a newer model wheelchair. - ANSWER: B
m m m m m m m
The most important teaching is to change positions frequently (B) because pressur
m m m m m m m m m m m
e is the most significant factor related to the development of pressure ulcers.
m m m m m m m m m m m m
Increased vitamin and fluid intake (A and C) may also be beneficial promote
m m m m m m m m m m m m