2025 EVOLVE HESI FUNDAMENTALS VERSION BRAND NEW ACTUAL
EXAM WITH 100% VERIFIED QUESTIONS AND CORRECT SOLUTIONS|
GUARANTEED VALUE PACK| ACE YOUR GRADES
Which intervention is most important for the nurse to implement for a male client who is experiencing
urinary retention?
A. Apply a condom catheter.
B. Apply a skin protectant.
C. Encourage increased fluid intake.
D. Assess for bladder distention. - CORRECT ANSWERS-Urinary retention is the inability to
void all urine collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B) are
useful actions to protect the skin of a client with urinary incontinence. (C) may worsen the bladder
distention.
Correct Answer: D
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate
to the nurse that this client understands the dietary restrictions?
A. Tossed salad, low-sodium dressing, bacon and tomato sandwich.
B. New England clam chowder, no-salt crackers, fresh fruit salad.
C. Skim milk, turkey salad, roll, and vanilla ice cream.
D. Macaroni and cheese, diet Coke, a slice of cherry pie. - CORRECT ANSWERS-Skim milk,
turkey, bread, and ice cream (C), while containing some sodium, are considered low-sodium foods.
Bacon (A), canned soups (B), especially those with seafood, hard cheeses, macaroni, and most diet drinks
(D) are very high in sodium.
Correct Answer: C
,Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an
adolescent?
A. Height in inches or centimeters.
B. Weight in kilograms or pounds.
C. Triceps skin fold thickness.
D. Upper arm circumference. - CORRECT ANSWERS-Upper arm circumference (D) is an
indirect measure of muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C)
is a measure of body fat.
Correct Answer: D
An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming
progressively weaker. The resident previously requested that no resuscitative efforts be performed, and
the family requests hospice care. What action should the nurse implement first?
A. Reaffirm the client's desire for no resuscitative efforts.
B. Transfer the client to a hospice inpatient facility.
C. Prepare the family for the client's impending death.
D. Notify the healthcare provider of the family's request. - CORRECT ANSWERS-The nurse
should first communicate with the healthcare provider (D). Hospice care is provided for clients with a
limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this
time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with
the hospice staff and healthcare provider to determine when (B and C) should be implemented.
Correct Answer: D
After completing an assessment and determining that a client has a problem, which action should the
nurse perform next?
A. Determine the etiology of the problem.
B. Prioritize nursing care interventions.
,C. Plan appropriate interventions.
D. Collaborate with the client to set goals. - CORRECT ANSWERS-Before planning care, the
nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C,
and D).
Correct Answer: A
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest
risk for a malpractice judgment?
A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
B. The nurse assigned to care for the client who was at lunch at the time of the fall.
C. The nurse who transferred the client to the chair when the fall occurred.
D. The charge nurse who completed rounds 30 minutes before the fall occurred. - CORRECT
ANSWERS-The four elements of malpractice are: breach of duty owed, failure to adhere to the
recognized standard of care, direct causation of injury, and evidence of actual injury. The hip fracture is
the actual injury and the standard of care was "frequent monitoring." (C) implies that duty was owed
and the injury occurred while the nurse was in charge of the client's care. There is no evidence of
negligence in (A, B, and D).
Correct Answer: C
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff
that is too small, but the blood pressure reading obtained is within the client's usual range. What action
is most important for the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure. - CORRECT ANSWERS-
The most important action is to ensure that an accurate BP reading is obtained. The nurse should
reassess the BP with the correct size cuff (B). Reassessment should not be postponed (A). Though (C and
D) are likely indicated, these actions do not have the priority of (B).
, Correct Answer: B
Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels
warm enough. What is the best response by the nurse?
A. "That means you have derived the maximum benefit, and the heat can be removed."
B. "Your blood vessels are becoming dilated and removing the heat from the site."
C. "We will increase the temperature 5 degrees when the pad no longer feels warm."
D. "The body's receptors adapt over time as they are exposed to heat." - CORRECT ANSWERS-
(D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B)
provide false information. (C) is not based on a knowledge of physiology and is an unsafe action that may
harm the client.
Correct Answer: D
The nurse is instructing a client with high cholesterol about diet and life style modification. What
comment from the client indicates that the teaching has been effective?
A. "If I exercise at least two times weekly for one hour, I will lower my cholesterol."
B. "I need to avoid eating proteins, including red meat."
C. "I will limit my intake of beef to 4 ounces per week."
D. "My blood level of low density lipoproteins needs to increase." - CORRECT ANSWERS-
Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important
diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should
exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need
to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller
portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase.
Correct Answer: C
EXAM WITH 100% VERIFIED QUESTIONS AND CORRECT SOLUTIONS|
GUARANTEED VALUE PACK| ACE YOUR GRADES
Which intervention is most important for the nurse to implement for a male client who is experiencing
urinary retention?
A. Apply a condom catheter.
B. Apply a skin protectant.
C. Encourage increased fluid intake.
D. Assess for bladder distention. - CORRECT ANSWERS-Urinary retention is the inability to
void all urine collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B) are
useful actions to protect the skin of a client with urinary incontinence. (C) may worsen the bladder
distention.
Correct Answer: D
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate
to the nurse that this client understands the dietary restrictions?
A. Tossed salad, low-sodium dressing, bacon and tomato sandwich.
B. New England clam chowder, no-salt crackers, fresh fruit salad.
C. Skim milk, turkey salad, roll, and vanilla ice cream.
D. Macaroni and cheese, diet Coke, a slice of cherry pie. - CORRECT ANSWERS-Skim milk,
turkey, bread, and ice cream (C), while containing some sodium, are considered low-sodium foods.
Bacon (A), canned soups (B), especially those with seafood, hard cheeses, macaroni, and most diet drinks
(D) are very high in sodium.
Correct Answer: C
,Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an
adolescent?
A. Height in inches or centimeters.
B. Weight in kilograms or pounds.
C. Triceps skin fold thickness.
D. Upper arm circumference. - CORRECT ANSWERS-Upper arm circumference (D) is an
indirect measure of muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C)
is a measure of body fat.
Correct Answer: D
An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming
progressively weaker. The resident previously requested that no resuscitative efforts be performed, and
the family requests hospice care. What action should the nurse implement first?
A. Reaffirm the client's desire for no resuscitative efforts.
B. Transfer the client to a hospice inpatient facility.
C. Prepare the family for the client's impending death.
D. Notify the healthcare provider of the family's request. - CORRECT ANSWERS-The nurse
should first communicate with the healthcare provider (D). Hospice care is provided for clients with a
limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this
time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with
the hospice staff and healthcare provider to determine when (B and C) should be implemented.
Correct Answer: D
After completing an assessment and determining that a client has a problem, which action should the
nurse perform next?
A. Determine the etiology of the problem.
B. Prioritize nursing care interventions.
,C. Plan appropriate interventions.
D. Collaborate with the client to set goals. - CORRECT ANSWERS-Before planning care, the
nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C,
and D).
Correct Answer: A
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest
risk for a malpractice judgment?
A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
B. The nurse assigned to care for the client who was at lunch at the time of the fall.
C. The nurse who transferred the client to the chair when the fall occurred.
D. The charge nurse who completed rounds 30 minutes before the fall occurred. - CORRECT
ANSWERS-The four elements of malpractice are: breach of duty owed, failure to adhere to the
recognized standard of care, direct causation of injury, and evidence of actual injury. The hip fracture is
the actual injury and the standard of care was "frequent monitoring." (C) implies that duty was owed
and the injury occurred while the nurse was in charge of the client's care. There is no evidence of
negligence in (A, B, and D).
Correct Answer: C
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff
that is too small, but the blood pressure reading obtained is within the client's usual range. What action
is most important for the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure. - CORRECT ANSWERS-
The most important action is to ensure that an accurate BP reading is obtained. The nurse should
reassess the BP with the correct size cuff (B). Reassessment should not be postponed (A). Though (C and
D) are likely indicated, these actions do not have the priority of (B).
, Correct Answer: B
Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels
warm enough. What is the best response by the nurse?
A. "That means you have derived the maximum benefit, and the heat can be removed."
B. "Your blood vessels are becoming dilated and removing the heat from the site."
C. "We will increase the temperature 5 degrees when the pad no longer feels warm."
D. "The body's receptors adapt over time as they are exposed to heat." - CORRECT ANSWERS-
(D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B)
provide false information. (C) is not based on a knowledge of physiology and is an unsafe action that may
harm the client.
Correct Answer: D
The nurse is instructing a client with high cholesterol about diet and life style modification. What
comment from the client indicates that the teaching has been effective?
A. "If I exercise at least two times weekly for one hour, I will lower my cholesterol."
B. "I need to avoid eating proteins, including red meat."
C. "I will limit my intake of beef to 4 ounces per week."
D. "My blood level of low density lipoproteins needs to increase." - CORRECT ANSWERS-
Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important
diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should
exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need
to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller
portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase.
Correct Answer: C
