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RN HESI EVOLVE
FUNDAMENTALS | EVOLVE HESI FUNDAMENTALS
WITH RATIONALES AND EXAM QUESTIONS WITH
ANSWERS
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?
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. -- ANSWER--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.
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. -- ANSWER--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
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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.
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 -- ANSWER--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.
The nurse is teaching a client how to perform progressive muscle relaxation techniques to
relieve insomnia. A week later the client reports that he is still unable to sleep, despite
following the same routine every night. Which action should the nurse take first? A. Instruct
the client to add regular 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. --
ANSWER--
Answer: D
The nurse should first evaluate whether the client has been adhering to the original
instructions (D). A verbal report of the client's routine will provide more specific information
than the client's written diary (B). The nurse can then determine which changes need to be
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made (A). The routine practiced by the client is clearly unsuccessful, so encouragement alone
is insufficient (C).
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has
redness in the sacral area. Which instruction is most important for the nurse to provide? A.
Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D. Purchase a newer model wheelchair. -- ANSWER--Answer: B
The most important teaching is to change positions frequently (B) because pressure is the
most significant factor related to the development of pressure ulcers. Increased vitamin and
fluid intake (A and C) may also be beneficial promote healing and reduce further risk. (D) is
an intervention of last resort because this will be very expensive for the client.
A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her
friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is
best for the nurse provide?
A. Orange juice has vitamin C that deters bacterial growth.
B. Apple juice is the most useful in acidifying the urine.
C. Cranberry juice stops pathogens' adherence to the bladder.
D. Grapefruit juice increases absorption of most antibiotics. -- ANSWER--Answer: C
Cranberry juice (C) maintains urinary tract health by reducing the adherence of Escherichia
coli bacteria to cells within the bladder. (A, B, and D) have not been shown to be as effective
as cranberry juice (C) in preventing UTIs.
The nurse is aware that malnutrition is a common problem among clients served by a
community health clinic for the homeless. Which laboratory value is the most reliable
indicator of chronic protein malnutrition?
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A. Low serum albumin level
B. Low serum transferrin level
C. High hemoglobin level
D. High cholesterol level -- ANSWER--Answer: A
Long-term protein deficiency is required to cause significantly lowered serum albumin levels
(A). Albumin is made by the liver only when adequate amounts of amino acids (from protein
breakdown) are available. Albumin has a long half-life, so acute protein loss does not
significantly alter serum levels. (B) is a serum protein with a half-life of only 8 to 10 days, so
it will drop with an acute protein deficiency. Neither (C or D) are clinical measures of protein
malnutrition.
The nurse identifies a potential for infection in a patient with partial-thickness (seconddegree)
and full-thickness (third-degree) burns. What intervention has the highest priority in
decreasing the client's risk of infection? A. Administration of plasma expanders
B. Use of careful hand washing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns -- ANSWER--Answer: B
Careful hand washing technique (B) is the single most effective intervention for the
prevention of contamination to all clients. (A) reverses the hypovolemia that initially
accompanies burn trauma but is not related to decreasing the proliferation of infective
organisms. (C and D) are recommended by various burn centers as possible ways to reduce
the chance of infection. (B) is a proven technique to prevent infection.
Which serum laboratory value should the nurse monitor carefully for a client who has a
nasogastric (NG) tube to suction for the past week?
A. White blood cell count
B. Albumin
RN HESI EVOLVE
FUNDAMENTALS | EVOLVE HESI FUNDAMENTALS
WITH RATIONALES AND EXAM QUESTIONS WITH
ANSWERS
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?
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. -- ANSWER--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.
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. -- ANSWER--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
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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.
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 -- ANSWER--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.
The nurse is teaching a client how to perform progressive muscle relaxation techniques to
relieve insomnia. A week later the client reports that he is still unable to sleep, despite
following the same routine every night. Which action should the nurse take first? A. Instruct
the client to add regular 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. --
ANSWER--
Answer: D
The nurse should first evaluate whether the client has been adhering to the original
instructions (D). A verbal report of the client's routine will provide more specific information
than the client's written diary (B). The nurse can then determine which changes need to be
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made (A). The routine practiced by the client is clearly unsuccessful, so encouragement alone
is insufficient (C).
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has
redness in the sacral area. Which instruction is most important for the nurse to provide? A.
Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D. Purchase a newer model wheelchair. -- ANSWER--Answer: B
The most important teaching is to change positions frequently (B) because pressure is the
most significant factor related to the development of pressure ulcers. Increased vitamin and
fluid intake (A and C) may also be beneficial promote healing and reduce further risk. (D) is
an intervention of last resort because this will be very expensive for the client.
A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her
friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is
best for the nurse provide?
A. Orange juice has vitamin C that deters bacterial growth.
B. Apple juice is the most useful in acidifying the urine.
C. Cranberry juice stops pathogens' adherence to the bladder.
D. Grapefruit juice increases absorption of most antibiotics. -- ANSWER--Answer: C
Cranberry juice (C) maintains urinary tract health by reducing the adherence of Escherichia
coli bacteria to cells within the bladder. (A, B, and D) have not been shown to be as effective
as cranberry juice (C) in preventing UTIs.
The nurse is aware that malnutrition is a common problem among clients served by a
community health clinic for the homeless. Which laboratory value is the most reliable
indicator of chronic protein malnutrition?
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A. Low serum albumin level
B. Low serum transferrin level
C. High hemoglobin level
D. High cholesterol level -- ANSWER--Answer: A
Long-term protein deficiency is required to cause significantly lowered serum albumin levels
(A). Albumin is made by the liver only when adequate amounts of amino acids (from protein
breakdown) are available. Albumin has a long half-life, so acute protein loss does not
significantly alter serum levels. (B) is a serum protein with a half-life of only 8 to 10 days, so
it will drop with an acute protein deficiency. Neither (C or D) are clinical measures of protein
malnutrition.
The nurse identifies a potential for infection in a patient with partial-thickness (seconddegree)
and full-thickness (third-degree) burns. What intervention has the highest priority in
decreasing the client's risk of infection? A. Administration of plasma expanders
B. Use of careful hand washing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns -- ANSWER--Answer: B
Careful hand washing technique (B) is the single most effective intervention for the
prevention of contamination to all clients. (A) reverses the hypovolemia that initially
accompanies burn trauma but is not related to decreasing the proliferation of infective
organisms. (C and D) are recommended by various burn centers as possible ways to reduce
the chance of infection. (B) is a proven technique to prevent infection.
Which serum laboratory value should the nurse monitor carefully for a client who has a
nasogastric (NG) tube to suction for the past week?
A. White blood cell count
B. Albumin
