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EVOLVE HESI FUNDAMENTALS EXAM|| HESI FUNDA z z z z z
MENTALS EXIT EVOLVE ACTUAL EXAM ALL 220 QUE z z z z z z z
STIONS AND 100% CORRECT ANSWERS WELL EXPLA z z z z z z
INED ALREADY GRADED A+|| LATEST AND COMPLET
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E UPDATE 2024-
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2025 WITH VERIFIED SOLUTIONS|| ASSURED PASS!!!
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Urinary catheterization is prescribed for a postoperative female client who has been u
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nable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubi
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ng. 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. Leaving the
z z z z z z z z z z z z z z z z z
first catheter in place will help locate the meatus when attempting the second cathet
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erization
(C). The client should have at least 240 mL of urine after 8 hours.
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(A) does not resolve the problem.
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(B) will not change the location of the catheter unless it is completely removed, in which c
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ase a new catheter must be used.
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There is no evidence of a urinary tract obstruction if the catheter could be easily inserted (
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D).
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about re
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ducing the risk of a heart attack or stroke. Which health promotion brochure is most i
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mportant for the nurse to provide to this client?
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A. "Monitoring Your Blood Pressure at Home" z z z z z
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B. "Smoking Cessation as a Lifelong Commitment" z z z z z
C. "Decreasing Cholesterol Levels Through Diet" z z z z
D. "Stress Management for a Healthier You" - ANSWER: C
z z z z z z z z
A health promotion brochure about decreasing cholesterol (C) is most important to pr
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ovide this client, because the most significant risk factor contributing to development
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of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. (A)
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does not address the underlying causes of arteriosclerosis. (B and D) are also importa
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nt factors for reversing arteriosclerosis but are not as important as lowering cholester
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ol (C). z
Ten minutes after signing an operative permit for a fractured hip, an older client states
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, "The aliens will be coming to get me soon!" and falls asleep. Which action should the
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znurse implement next? z z
A. Make the client comfortable and allow the client to sleep.
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B. Assess the client's neurologic status.
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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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z ANSWER: B This statement may indicate that the client is confused. Informed con
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sent must be z z
provided by a mentally competent individual, so the nurse should further assess the cli
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ent's neurologic status (B) to be sure that the client understands and can legally provid
z z z z z z z z z z z z z z
e consent for surgery. (A) does not provide sufficient follow-
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up. If the nurse determines 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- z
manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to preve
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nt complications of immobility. Which intervention should be included in this instruc
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tion?
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- z
motion exercises (A) is beneficial in reducing contractures around joints. (B, C, and
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D) are all potentially harmful practices that place the immobile client at risk of compl
z z z z z z z z z z z z z z
ications.
The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathr
z z z z z z z z z z z z z z z z z
oom door, he states, "I feel faint." Before the nurse can get the client to a chair, the cli
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ent starts to fall. Which is the priority action for the nurse to take?
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A. Check the client's carotid pulse.
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B. Encourage the client to get to the toilet. z z z z z z z
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 injur
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y to the client and the nurse. Lowering the client to the floor should be done when the
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client cannot support his own weight. The client should be placed in a bed or chair onl
z z z z z z z z z z z z z z z z
y when sufficient help is available to prevent injury. (A) is important but should be do
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ne after the client is in a safe position. Because the client is not supporting himself, (B
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) is impractical. (C) is likely to cause chaos on the unit and might alarm the other clien
z z z z z z z z z z z z z z z z z
ts.
A female nurse is assigned to care for a close friend, who says, "I am worried that friends
z z z z z z z z z z z z z z z z z z
will find out about my diagnosis." The nurse tells her friend that legally she must protect a
z z z z z z z z z z z z z z z z z
client's confidentiality. Which resource describes the nurse's legal responsibilities?
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A. Code of Ethics for Nurses z z z z
B. State Nurse Practice Actz z z
C. Patient's Bill of Rights z z z
D. ANA Standards of Practice - ANSWER: B
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The State Nurse Practice Act (B) contains legal requirements for the protection of cli
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ent confidentiality and the consequences for breaches in confidentiality. (A) outlines
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ethical standards for nursing care but does not include legal guidelines. (C and D) des
z z z z z z z z z z z z z z
cribe expectations for nursing practice but do not address legal implications.
z z z z z z z z z z
The nurse is teaching a client how to perform progressive muscle relaxation techniqu
z z z z z z z z z z z z
es to relieve insomnia. A week later the client reports that he is still unable to sleep, des
z z z z z z z z z z z z z z z z z
pite following the same routine every night. Which action should the nurse take first?
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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. z z z z z z z z z
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 original ins
z z z z z z z z z z z z z z
tructions (D). A verbal report of the client's routine will provide more specific inform
z z z z z z z z z z z z z
ation than the client's written diary (B). The nurse can then determine which changes
z z z z z z z z z z z z z z
need to be made (A). The routine practiced by the client is clearly unsuccessful, so en
z z z z z z z z z z z z z z z
couragement alone is insufficient (C). z z z z
A 65-year-old client who attends an adult daycare program and is wheelchair-
z z z z z z z z z z z
mobile has redness in the sacral area. Which instruction is most important for the nurs
z z z z z z z z z z z z z z z
e to provide?
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A. Take a vitamin supplement tablet once a day.
z z z z z z z
B. Change positions in the chair at least every hour.
z z z z z z z z
C. Increase daily intake of water or other oral fluids.
z z z z z z z z
D. Purchase a newer model wheelchair. - ANSWER: B z z z z z z z
The most important teaching is to change positions frequently (B) because pressure is
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the most significant factor related to the development of pressure ulcers.
z z z z z z z z z z
Increased vitamin and fluid intake (A and C) may also be beneficial promote
z z z z z z z z z z z z
EVOLVE HESI FUNDAMENTALS EXAM|| HESI FUNDA z z z z z
MENTALS EXIT EVOLVE ACTUAL EXAM ALL 220 QUE z z z z z z z
STIONS AND 100% CORRECT ANSWERS WELL EXPLA z z z z z z
INED ALREADY GRADED A+|| LATEST AND COMPLET
z z z z z z
E UPDATE 2024-
z z
2025 WITH VERIFIED SOLUTIONS|| ASSURED PASS!!!
z z z z z
Urinary catheterization is prescribed for a postoperative female client who has been u
z z z z z z z z z z z z
nable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubi
z z z z z z z z z z z z z z z z z z
ng. Which action will the nurse take next?
z z z z z z z
A. Clamp the catheter and recheck it in 60 minutes.
z z z z z z z z
B. Pull the catheter back 3 inches and redirect upward.
z z z z z z z z
C. Leave the catheter in place and reattempt with another catheter.
z z z z z z z z z
D. Notify the health care provider of a possible obstruction. - ANSWER: C
z z z z z z z z z z z
It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the
z z z z z z z z z z z z z z z z z
first catheter in place will help locate the meatus when attempting the second cathet
z z z z z z z z z z z z z
erization
(C). The client should have at least 240 mL of urine after 8 hours.
z z z z z z z z z z z z z
(A) does not resolve the problem.
z z z z z
(B) will not change the location of the catheter unless it is completely removed, in which c
z z z z z z z z z z z z z z z z
ase a new catheter must be used.
z z z z z z
There is no evidence of a urinary tract obstruction if the catheter could be easily inserted (
z z z z z z z z z z z z z z z z
D).
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about re
z z z z z z z z z z z z
ducing the risk of a heart attack or stroke. Which health promotion brochure is most i
z z z z z z z z z z z z z z z
mportant for the nurse to provide to this client?
z z z z z z z z
A. "Monitoring Your Blood Pressure at Home" z z z z z
,2z|zPz az gz e
B. "Smoking Cessation as a Lifelong Commitment" z z z z z
C. "Decreasing Cholesterol Levels Through Diet" z z z z
D. "Stress Management for a Healthier You" - ANSWER: C
z z z z z z z z
A health promotion brochure about decreasing cholesterol (C) is most important to pr
z z z z z z z z z z z z
ovide this client, because the most significant risk factor contributing to development
z z z z z z z z z z z
of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. (A)
z z z z z z z z z z z z z
does not address the underlying causes of arteriosclerosis. (B and D) are also importa
z z z z z z z z z z z z z
nt factors for reversing arteriosclerosis but are not as important as lowering cholester
z z z z z z z z z z z z
ol (C). z
Ten minutes after signing an operative permit for a fractured hip, an older client states
z z z z z z z z z z z z z z
, "The aliens will be coming to get me soon!" and falls asleep. Which action should the
z z z z z z z z z z z z z z z z
znurse implement next? z z
A. Make the client comfortable and allow the client to sleep.
z z z z z z z z z
B. Assess the client's neurologic status.
z z z z
C. Notify the surgeon about the comment.
z z z z z
D. Ask the client's family to co-sign the operative permit. -
z z z z z z z z z
z ANSWER: B This statement may indicate that the client is confused. Informed con
z z z z z z z z z z z z
sent must be z z
provided by a mentally competent individual, so the nurse should further assess the cli
z z z z z z z z z z z z z
ent's neurologic status (B) to be sure that the client understands and can legally provid
z z z z z z z z z z z z z z
e consent for surgery. (A) does not provide sufficient follow-
z z z z z z z z z
up. If the nurse determines that the client is confused, the surgeon must be notified (C)
z z z z z z z z z z z z z z z
and permission obtained from the next of kin (D).
z z z z z z z z z
The nurse- z
manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to preve
z z z z z z z z z z z z z z
nt complications of immobility. Which intervention should be included in this instruc
z z z z z z z z z z z
tion?
A. Perform range-of-motion exercises to prevent contractures.
z z z z z
,3z|zPz az gz e
B. Decrease the client's fluid intake to prevent diarrhea.
z z z z z z z
C. Massage the client's legs to reduce embolism occurrence.
z z z z z z z
D. Turn the client from side to back every shift. - ANSWER: A
z z z z z z z z z z z
Performing range-of- z
motion exercises (A) is beneficial in reducing contractures around joints. (B, C, and
z z z z z z z z z z z z z
D) are all potentially harmful practices that place the immobile client at risk of compl
z z z z z z z z z z z z z z
ications.
The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathr
z z z z z z z z z z z z z z z z z
oom door, he states, "I feel faint." Before the nurse can get the client to a chair, the cli
z z z z z z z z z z z z z z z z z z
ent starts to fall. Which is the priority action for the nurse to take?
z z z z z z z z z z z z z
A. Check the client's carotid pulse.
z z z z
B. Encourage the client to get to the toilet. z z z z z z z
C. In a loud voice, call for help.
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D. Gently lower the client to the floor. - ANSWER: D
z z z z z z z z z
(D) is the most prudent intervention and is the priority nursing action to prevent injur
z z z z z z z z z z z z z z
y to the client and the nurse. Lowering the client to the floor should be done when the
z z z z z z z z z z z z z z z z z z
client cannot support his own weight. The client should be placed in a bed or chair onl
z z z z z z z z z z z z z z z z
y when sufficient help is available to prevent injury. (A) is important but should be do
z z z z z z z z z z z z z z z
ne after the client is in a safe position. Because the client is not supporting himself, (B
z z z z z z z z z z z z z z z z
) is impractical. (C) is likely to cause chaos on the unit and might alarm the other clien
z z z z z z z z z z z z z z z z z
ts.
A female nurse is assigned to care for a close friend, who says, "I am worried that friends
z z z z z z z z z z z z z z z z z z
will find out about my diagnosis." The nurse tells her friend that legally she must protect a
z z z z z z z z z z z z z z z z z
client's confidentiality. Which resource describes the nurse's legal responsibilities?
z z z z z z z z
A. Code of Ethics for Nurses z z z z
B. State Nurse Practice Actz z z
C. Patient's Bill of Rights z z z
D. ANA Standards of Practice - ANSWER: B
z z z z z z
, 4z|zPz az gz e
The State Nurse Practice Act (B) contains legal requirements for the protection of cli
z z z z z z z z z z z z z
ent confidentiality and the consequences for breaches in confidentiality. (A) outlines
z z z z z z z z z z z
ethical standards for nursing care but does not include legal guidelines. (C and D) des
z z z z z z z z z z z z z z
cribe expectations for nursing practice but do not address legal implications.
z z z z z z z z z z
The nurse is teaching a client how to perform progressive muscle relaxation techniqu
z z z z z z z z z z z z
es to relieve insomnia. A week later the client reports that he is still unable to sleep, des
z z z z z z z z z z z z z z z z z
pite following the same routine every night. Which action should the nurse take first?
z z z z z z z z z z z z z
A. Instruct the client to add regular exercise as a daily routine.
z z z z z z z z z z
B. Determine if the client has been keeping a sleep diary. z z z z z z z z z
C. Encourage the client to continue the routine until sleep is achieved.
z z z z z z z z z z
D. Ask the client to describe the route - ANSWER: D
z z z z z z z z z
The nurse should first evaluate whether the client has been adhering to the original ins
z z z z z z z z z z z z z z
tructions (D). A verbal report of the client's routine will provide more specific inform
z z z z z z z z z z z z z
ation than the client's written diary (B). The nurse can then determine which changes
z z z z z z z z z z z z z z
need to be made (A). The routine practiced by the client is clearly unsuccessful, so en
z z z z z z z z z z z z z z z
couragement alone is insufficient (C). z z z z
A 65-year-old client who attends an adult daycare program and is wheelchair-
z z z z z z z z z z z
mobile has redness in the sacral area. Which instruction is most important for the nurs
z z z z z z z z z z z z z z z
e to provide?
z z
A. Take a vitamin supplement tablet once a day.
z z z z z z z
B. Change positions in the chair at least every hour.
z z z z z z z z
C. Increase daily intake of water or other oral fluids.
z z z z z z z z
D. Purchase a newer model wheelchair. - ANSWER: B z z z z z z z
The most important teaching is to change positions frequently (B) because pressure is
z z z z z z z z z z z z z
the most significant factor related to the development of pressure ulcers.
z z z z z z z z z z
Increased vitamin and fluid intake (A and C) may also be beneficial promote
z z z z z z z z z z z z
