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EVOLVE HESI FUNDAMENTALS EXAM|| HESI FUNDA P P P P P
MENTALS EXIT EVOLVE ACTUAL EXAM ALL220 QUE P P P P P P P
STIONS AND 100% CORRECT ANSWERS WELL EXPLA P P P P P P
INED ALREADY GRADED A+|| LATEST AND COMPLET
P P P P P P
E UPDATE 2024-
P P
2025 WITH VERIFIED SOLUTIONS|| ASSURED PASS!!!
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Urinary catheterization is prescribed for a postoperative female client who has been
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unable to void for 8 hours. The nurse inserts the catheter, but no urine is seenin the tu
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bing. Which action will the nurse take next?
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A. Clamp the catheter and recheck it in 60 minutes.
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B. Pull the catheter back 3 inches and redirect upward.
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C. Leave the catheter in place and reattempt with another catheter.
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D. Notify the health care provider of a possible obstruction. - ANSWER: C
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It is likely that the first catheter is in the vagina, rather than the bladder. Leavingth
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e first catheter in place will help locate the meatus when attempting the secondcat
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heterization
(C). The client should have at least 240 mL of urine after 8 hours.
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(A) does not resolve the problem. P P P P
(B) will not change the location of the catheter unless it is completely removed, inw
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hich case a new catheter must be used.
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There is no evidence of a urinary tract obstruction if the catheter could be easilyinser
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ted (D). P
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, aboutre
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ducing the risk of a heart attack or stroke. Which health promotion brochure is most
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important for the nurse to provide to this client?
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A. "Monitoring Your Blood Pressure at Home" P P P P P
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B. "Smoking Cessation as a Lifelong Commitment" P P P P P
C. "Decreasing Cholesterol Levels Through Diet" P P P P
D. "Stress Management for a Healthier You" - ANSWER: C
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A health promotion brochure about decreasing cholesterol (C) is most important top
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rovide this client, because the most significant risk factor contributing to developme
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nt of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. (
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A) does not address the underlying causes of arteriosclerosis. (B and D) are also im
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portant factors for reversing arteriosclerosis but are not as importantas lowering cho
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lesterol (C). P
Ten minutes after signing an operative permit for a fractured hip, an older client stat
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es, "The aliens will be coming to get me soon!" and falls asleep. Which actionshould
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the nurse implement next?
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A. Make the client comfortable and allow the client to sleep.
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B. Assess the client's neurologic status. P P P P
C. Notify the surgeon about the comment.
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D. Ask the client's family to co-sign the operative permit. -
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P ANSWER: B This statement may indicate that the client is confused. Informed co
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nsent must be P P
provided by a mentally competent individual, so the nurse should further assess thecl
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ient's neurologic status (B) to be sure that the client understands and can legally prov
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ide consent for surgery. (A) does not provide sufficient follow-
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up. If the nursedetermines that the client is confused, the surgeon must be notified (C
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) and permission obtained from the next of kin (D).
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The nurse- P
manager of a skilled nursing (chronic care) unit is instructing UAPs onways to preve
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nt complications of immobility. Which intervention should be included in this instru
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ction?
A. Perform range-of-motion exercises to prevent contractures.
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B. Decrease the client's fluid intake to prevent diarrhea.
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C. Massage the client's legs to reduce embolism occurrence.
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D. Turn the client from side to back every shift. - ANSWER: A
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Performing range-of- P
motion exercises (A) is beneficial in reducing contracturesaround joints. (B, C, and
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D) are all potentially harmful practices that place the immobile client at risk of com
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plications.
The nurse is assisting a client to the bathroom. When the client is 5 feet from thebath
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room door, he states, "I feel faint." Before the nurse can get the client to a chair, the
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client starts to fall. Which is the priority action for the nurse to take?
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A. Check the client's carotid pulse. P P P P
B. Encourage the client to get to the toilet. P P P P P P P
C. In a loud voice, call for help.
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D. Gently lower the client to the floor. - ANSWER: D
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(D) is the most prudent intervention and is the priority nursing action to prevent inju
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ry to the client and the nurse. Lowering the client to the floor should be donewhen th
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e client cannot support his own weight. The client should be placed in a bed or chair
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only when sufficient help is available to prevent injury. (A) is important but should
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be done after the client is in a safe position. Because the client is not supporting him
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self, (B) is impractical. (C) is likely to cause chaos onthe unit and might alarm the ot
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her clients. P
A female nurse is assigned to care for a close friend, who says, "I am worried that fri
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ends will find out about my diagnosis." The nurse tells her friend that legally shemus
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t protect a client's confidentiality. Which resource describes the nurse's legal respon
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sibilities?
A. Code of Ethics for Nurses P P P P
B. State Nurse Practice Act P P P
C. Patient's Bill of Rights P P P
D. ANA Standards of Practice - ANSWER: B
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The State Nurse Practice Act (B) contains legal requirements for the protection of cl
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ient confidentiality and the consequences for breaches in confidentiality. (A) outlin
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es ethical standards for nursing care but does not include legal guidelines. (Cand D)
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describe expectations for nursing practice but do not address legal implications.
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The nurse is teaching a client how to perform progressive muscle relaxation techniq
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ues to relieve insomnia. A week later the client reports that he is still unableto sleep,
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despite following the same routine every night. Which action should the nurse take fi
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rst?
A. Instruct the client to add regular exercise as a daily routine.
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B. Determine if the client has been keeping a sleep diary.
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C. Encourage the client to continue the routine until sleep is achieved.
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D. Ask the client to describe the route - ANSWER: D
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The nurse should first evaluate whether the client has been adhering to the originalin
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structions (D). A verbal report of the client's routine will provide more specific infor
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mation than the client's written diary (B). The nurse can then determine whichchang
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es need to be made (A). The routine practiced by the client is clearly unsuccessful, s
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o encouragement alone is insufficient (C).
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A 65-year-old client who attends an adult daycare program and is wheelchair-
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Pmobile has redness in the sacral area. Which instruction is most important for thenur
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se to provide?
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A. Take a vitamin supplement tablet once a day.
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B. Change positions in the chair at least every hour.
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C. Increase daily intake of water or other oral fluids.
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D. Purchase a newer model wheelchair. - ANSWER: B
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The most important teaching is to change positions frequently (B) because pressureis
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Pthe most significant factor related to the development of pressure ulcers.
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Increased vitamin and fluid intake (A and C) may also be beneficial promote
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EVOLVE HESI FUNDAMENTALS EXAM|| HESI FUNDA P P P P P
MENTALS EXIT EVOLVE ACTUAL EXAM ALL220 QUE P P P P P P P
STIONS AND 100% CORRECT ANSWERS WELL EXPLA P P P P P P
INED ALREADY GRADED A+|| LATEST AND COMPLET
P P P P P P
E UPDATE 2024-
P P
2025 WITH VERIFIED SOLUTIONS|| ASSURED PASS!!!
P P P P P
Urinary catheterization is prescribed for a postoperative female client who has been
P P P P P P P P P P P P
unable to void for 8 hours. The nurse inserts the catheter, but no urine is seenin the tu
P P P P P P P P P P P P P P P P P P
bing. Which action will the nurse take next?
P P P P P P P
A. Clamp the catheter and recheck it in 60 minutes.
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B. Pull the catheter back 3 inches and redirect upward.
P P P P P P P P
C. Leave the catheter in place and reattempt with another catheter.
P P P P P P P P P
D. Notify the health care provider of a possible obstruction. - ANSWER: C
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It is likely that the first catheter is in the vagina, rather than the bladder. Leavingth
P P P P P P P P P P P P P P P P
e first catheter in place will help locate the meatus when attempting the secondcat
P P P P P P P P P P P P P P
heterization
(C). The client should have at least 240 mL of urine after 8 hours.
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(A) does not resolve the problem. P P P P
(B) will not change the location of the catheter unless it is completely removed, inw
P P P P P P P P P P P P P P
hich case a new catheter must be used.
P P P P P P P
There is no evidence of a urinary tract obstruction if the catheter could be easilyinser
P P P P P P P P P P P P P P P
ted (D). P
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, aboutre
P P P P P P P P P P P P
ducing the risk of a heart attack or stroke. Which health promotion brochure is most
P P P P P P P P P P P P P P P
important for the nurse to provide to this client?
P P P P P P P P
A. "Monitoring Your Blood Pressure at Home" P P P P P
,2 |PPP aP gP e
B. "Smoking Cessation as a Lifelong Commitment" P P P P P
C. "Decreasing Cholesterol Levels Through Diet" P P P P
D. "Stress Management for a Healthier You" - ANSWER: C
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A health promotion brochure about decreasing cholesterol (C) is most important top
P P P P P P P P P P P P
rovide this client, because the most significant risk factor contributing to developme
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nt of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. (
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A) does not address the underlying causes of arteriosclerosis. (B and D) are also im
P P P P P P P P P P P P P P
portant factors for reversing arteriosclerosis but are not as importantas lowering cho
P P P P P P P P P P P P
lesterol (C). P
Ten minutes after signing an operative permit for a fractured hip, an older client stat
P P P P P P P P P P P P P P
es, "The aliens will be coming to get me soon!" and falls asleep. Which actionshould
P P P P P P P P P P P P P P P
the nurse implement next?
P P P P
A. Make the client comfortable and allow the client to sleep.
P P P P P P P P P
B. Assess the client's neurologic status. P P P P
C. Notify the surgeon about the comment.
P P P P P
D. Ask the client's family to co-sign the operative permit. -
P P P P P P P P P
P ANSWER: B This statement may indicate that the client is confused. Informed co
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nsent must be P P
provided by a mentally competent individual, so the nurse should further assess thecl
P P P P P P P P P P P P P
ient's neurologic status (B) to be sure that the client understands and can legally prov
P P P P P P P P P P P P P P
ide consent for surgery. (A) does not provide sufficient follow-
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up. If the nursedetermines that the client is confused, the surgeon must be notified (C
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) and permission obtained from the next of kin (D).
P P P P P P P P P
The nurse- P
manager of a skilled nursing (chronic care) unit is instructing UAPs onways to preve
P P P P P P P P P P P P P P
nt complications of immobility. Which intervention should be included in this instru
P P P P P P P P P P P
ction?
A. Perform range-of-motion exercises to prevent contractures.
P P P P P
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B. Decrease the client's fluid intake to prevent diarrhea.
P P P P P P P
C. Massage the client's legs to reduce embolism occurrence.
P P P P P P P
D. Turn the client from side to back every shift. - ANSWER: A
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Performing range-of- P
motion exercises (A) is beneficial in reducing contracturesaround joints. (B, C, and
P P P P P P P P P P P P P
D) are all potentially harmful practices that place the immobile client at risk of com
P P P P P P P P P P P P P P
plications.
The nurse is assisting a client to the bathroom. When the client is 5 feet from thebath
P P P P P P P P P P P P P P P P P
room door, he states, "I feel faint." Before the nurse can get the client to a chair, the
P P P P P P P P P P P P P P P P P P
client starts to fall. Which is the priority action for the nurse to take?
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A. Check the client's carotid pulse. P P P P
B. Encourage the client to get to the toilet. P P P P P P P
C. In a loud voice, call for help.
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D. Gently lower the client to the floor. - ANSWER: D
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(D) is the most prudent intervention and is the priority nursing action to prevent inju
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ry to the client and the nurse. Lowering the client to the floor should be donewhen th
P P P P P P P P P P P P P P P P P
e client cannot support his own weight. The client should be placed in a bed or chair
P P P P P P P P P P P P P P P P P
only when sufficient help is available to prevent injury. (A) is important but should
P P P P P P P P P P P P P P
be done after the client is in a safe position. Because the client is not supporting him
P P P P P P P P P P P P P P P P
self, (B) is impractical. (C) is likely to cause chaos onthe unit and might alarm the ot
P P P P P P P P P P P P P P P P P
her clients. P
A female nurse is assigned to care for a close friend, who says, "I am worried that fri
P P P P P P P P P P P P P P P P P
ends will find out about my diagnosis." The nurse tells her friend that legally shemus
P P P P P P P P P P P P P P P
t protect a client's confidentiality. Which resource describes the nurse's legal respon
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sibilities?
A. Code of Ethics for Nurses P P P P
B. State Nurse Practice Act P P P
C. Patient's Bill of Rights P P P
D. ANA Standards of Practice - ANSWER: B
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The State Nurse Practice Act (B) contains legal requirements for the protection of cl
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ient confidentiality and the consequences for breaches in confidentiality. (A) outlin
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es ethical standards for nursing care but does not include legal guidelines. (Cand D)
P P P P P P P P P P P P P P P
describe expectations for nursing practice but do not address legal implications.
P P P P P P P P P P
The nurse is teaching a client how to perform progressive muscle relaxation techniq
P P P P P P P P P P P P
ues to relieve insomnia. A week later the client reports that he is still unableto sleep,
P P P P P P P P P P P P P P P P P
despite following the same routine every night. Which action should the nurse take fi
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rst?
A. Instruct the client to add regular exercise as a daily routine.
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B. Determine if the client has been keeping a sleep diary.
P P P P P P P P P
C. Encourage the client to continue the routine until sleep is achieved.
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D. Ask the client to describe the route - ANSWER: D
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The nurse should first evaluate whether the client has been adhering to the originalin
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structions (D). A verbal report of the client's routine will provide more specific infor
P P P P P P P P P P P P P
mation than the client's written diary (B). The nurse can then determine whichchang
P P P P P P P P P P P P P
es need to be made (A). The routine practiced by the client is clearly unsuccessful, s
P P P P P P P P P P P P P P P
o encouragement alone is insufficient (C).
P P P P P
A 65-year-old client who attends an adult daycare program and is wheelchair-
P P P P P P P P P P P
Pmobile has redness in the sacral area. Which instruction is most important for thenur
P P P P P P P P P P P P P P
se to provide?
P P
A. Take a vitamin supplement tablet once a day.
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B. Change positions in the chair at least every hour.
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C. Increase daily intake of water or other oral fluids.
P P P P P P P P
D. Purchase a newer model wheelchair. - ANSWER: B
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The most important teaching is to change positions frequently (B) because pressureis
P P P P P P P P P P P P
Pthe most significant factor related to the development of pressure ulcers.
P P P P P P P P P P
Increased vitamin and fluid intake (A and C) may also be beneficial promote
P P P P P P P P P P P P
