EVOLVE HESI FUNDAMENTALS
VERSION 1, 2 & 3 ACTUAL EXAM
QUESTIONS AND CORRECT
DETAILED CORRECT ANSWER S
AND RATIONALES 2025.
,1. Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8
hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next?
A. Clamp the catheter and recheck it in 60 minutes.
B. Pull the catheter back 3 inches and redirect upward.
C. Leave the catheter in place and reattempt with another catheter.
D. Notify the health care provider of a possible obstruction.: Correct Answer : C
It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help
locate the meatus when attempting the second catheterization (C). The client should have at least 240 mL of urine after 8
hours. (A) does not resolve the problem. (B) will not change the location of the catheter unless it is completely removed, in
which case a new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter could be easily
inserted (D).
2. The nurse is teaching an obese client, newly diagnosed with arteriosclero- sis, about reducing the risk of a heart
attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client?
A. "Monitoring Your Blood Pressure at Home"
B. "Smoking Cessation as a Lifelong Commitment"
C. "Decreasing Cholesterol Levels Through Diet"
D. "Stress Management for a Healthier You": Correct Answer : C
A health promotion brochure about decreasing cholesterol (C) is most important to provide this client, because the most
significant risk factor contributing to de- velopment of arteriosclerosis is excess dietary fat, particularly saturated fat and
cholesterol. (A) does not address the underlying causes of arteriosclerosis. (B and D) are also important factors for
reversing arteriosclerosis but are not as important as lowering cholesterol (C).
3. Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be
coming to get me soon!" and falls asleep. Which action should the nurse implement next?
A. Make the client comfortable and allow the client to sleep.
B. Assess the client's neurologic status.
C. Notify the surgeon about the comment.
,D. Ask the client's family to co-sign the operative permit.: Correct Answer : B
This statement may indicate that the client is confused. Informed consent must be provided by a mentally competent
individual, so the nurse should further assess the client's neurologic status (B) to be sure that the client understands and
can legally provide consent for surgery. (A) does not provide sufficient follow-up. If the nurse determines that the client
is confused, the surgeon must be notified (C) and permission obtained from the next of kin (D). The nurse-manager of a
skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which
intervention should be included in this instruction?
E. Perform range-of-motion exercises to prevent contractures.
F. Decrease the client's fluid intake to prevent diarrhea.
G. Massage the client's legs to reduce embolism occurrence.
H. Turn the client from side to back every shift.: Correct Answer : A
Performing range-of-motion exercises (A) is beneficial in reducing contractures around joints. (B, C, and D) are all
potentially harmful practices that place the immobile client at risk of complications.
4. The nurse is assisting a client to the bathroom.When the client is 5 feet from the bathroom door, he states, "I feel
faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the
nurse to take?
A. Check the client's carotid pulse.
B. Encourage the client to get to the toilet.
C. In a loud voice, call for help.
D. Gently lower the client to the floor.: Correct Answer : D
(D) is the most prudent intervention and is the priority nursing action to prevent injury to the client and the nurse. Lowering
the client to the floor should be done when the client cannot support his own weight. The client should be placed in a bed
or chair only when sufficient help is available to prevent injury. (A) is important but should be done after the client is in a
safe position. Because the client is not supporting himself, (B) is impractical. (C) is likely to cause chaos on the unit and
might alarm the other clients.
5. A female nurse is assigned to care for a close friend, who says, "I am worried that friends will find out about my
, diagnosis." The nurse tells her friend that legally she must protect a client's confidentiality. Which resource
describes the nurse's legal responsibilities?
A. Code of Ethics for Nurses
B. State Nurse Practice Act
C. Patient's Bill of Rights
D. ANA Standards of Practice: Correct Answer : B
The State Nurse Practice Act (B) contains legal requirements for the protection of client confidentiality and the
consequences for breaches in confidentiality. (A) outlines ethical standards for nursing care but does not include legal
guidelines. (C and D) describe expectations for nursing practice but do not address legal implications.
VERSION 1, 2 & 3 ACTUAL EXAM
QUESTIONS AND CORRECT
DETAILED CORRECT ANSWER S
AND RATIONALES 2025.
,1. Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8
hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next?
A. Clamp the catheter and recheck it in 60 minutes.
B. Pull the catheter back 3 inches and redirect upward.
C. Leave the catheter in place and reattempt with another catheter.
D. Notify the health care provider of a possible obstruction.: Correct Answer : C
It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help
locate the meatus when attempting the second catheterization (C). The client should have at least 240 mL of urine after 8
hours. (A) does not resolve the problem. (B) will not change the location of the catheter unless it is completely removed, in
which case a new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter could be easily
inserted (D).
2. The nurse is teaching an obese client, newly diagnosed with arteriosclero- sis, about reducing the risk of a heart
attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client?
A. "Monitoring Your Blood Pressure at Home"
B. "Smoking Cessation as a Lifelong Commitment"
C. "Decreasing Cholesterol Levels Through Diet"
D. "Stress Management for a Healthier You": Correct Answer : C
A health promotion brochure about decreasing cholesterol (C) is most important to provide this client, because the most
significant risk factor contributing to de- velopment of arteriosclerosis is excess dietary fat, particularly saturated fat and
cholesterol. (A) does not address the underlying causes of arteriosclerosis. (B and D) are also important factors for
reversing arteriosclerosis but are not as important as lowering cholesterol (C).
3. Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be
coming to get me soon!" and falls asleep. Which action should the nurse implement next?
A. Make the client comfortable and allow the client to sleep.
B. Assess the client's neurologic status.
C. Notify the surgeon about the comment.
,D. Ask the client's family to co-sign the operative permit.: Correct Answer : B
This statement may indicate that the client is confused. Informed consent must be provided by a mentally competent
individual, so the nurse should further assess the client's neurologic status (B) to be sure that the client understands and
can legally provide consent for surgery. (A) does not provide sufficient follow-up. If the nurse determines that the client
is confused, the surgeon must be notified (C) and permission obtained from the next of kin (D). The nurse-manager of a
skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which
intervention should be included in this instruction?
E. Perform range-of-motion exercises to prevent contractures.
F. Decrease the client's fluid intake to prevent diarrhea.
G. Massage the client's legs to reduce embolism occurrence.
H. Turn the client from side to back every shift.: Correct Answer : A
Performing range-of-motion exercises (A) is beneficial in reducing contractures around joints. (B, C, and D) are all
potentially harmful practices that place the immobile client at risk of complications.
4. The nurse is assisting a client to the bathroom.When the client is 5 feet from the bathroom door, he states, "I feel
faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the
nurse to take?
A. Check the client's carotid pulse.
B. Encourage the client to get to the toilet.
C. In a loud voice, call for help.
D. Gently lower the client to the floor.: Correct Answer : D
(D) is the most prudent intervention and is the priority nursing action to prevent injury to the client and the nurse. Lowering
the client to the floor should be done when the client cannot support his own weight. The client should be placed in a bed
or chair only when sufficient help is available to prevent injury. (A) is important but should be done after the client is in a
safe position. Because the client is not supporting himself, (B) is impractical. (C) is likely to cause chaos on the unit and
might alarm the other clients.
5. A female nurse is assigned to care for a close friend, who says, "I am worried that friends will find out about my
, diagnosis." The nurse tells her friend that legally she must protect a client's confidentiality. Which resource
describes the nurse's legal responsibilities?
A. Code of Ethics for Nurses
B. State Nurse Practice Act
C. Patient's Bill of Rights
D. ANA Standards of Practice: Correct Answer : B
The State Nurse Practice Act (B) contains legal requirements for the protection of client confidentiality and the
consequences for breaches in confidentiality. (A) outlines ethical standards for nursing care but does not include legal
guidelines. (C and D) describe expectations for nursing practice but do not address legal implications.
