ACTUAL QUESTIONS AND ANSWERS FROM HESI
FUNDAMENTALS ON EVOLVE\\\HESI
Fundamentals Exam on Evolve – Verified
Questions & Step-by-Step Answers
A male client arrives at THE outpatient surgery center for a scheduled needle aspiration of THE knee.
He tells THE nurse that he has already given verbal consent for THE procedure to THE healthcare
provider. Which action should THE nurse pursue next?
A) Witness THE client's signature on THE consent form.
B) Verify THE client's consent with THE healthcare provider.
C) Notify THE healthcare provider that THE client is ready for THE procedure.
D) Document that THE client has given consent for THE needle aspiration.
B) Verify THE client's consent with THE healthcare provider.
Rationale
Written informed consent is required prior to any invasive procedure. THE healthcare provider must
explain THE procedure to THE client, but THE nurse can witness THE client's signature on a consent
form. If THE nurse was not present when THE HCP explained THE procedure/surgery, THEn THE first
action before witnessing THE client's signature on THE consent should be to verify that THE HCP indeed,
received verbal consent from THE client.
A client is admitted with a stage four pressure injury that has a black, hardened surface (eschar) that
is stable. Which dressing is best for THE nurse to use first?
A) Hydrogel.
B) Exudate absorber.
C) No dressing.
D) Transparent adhesive film
C) No dressing.
Rationale
If eschar is dry and intact and debridement is not part of THE plan of care, no dressing is used, allowing
eschar to act as physiological cover.
Which statement is an example of a correctly written nursing problem statement?
A) Altered tissue perfusion related to heart failure.
,B) Altered urinary elimination related to urinary tract infection.
C) Risk for impaired tissue integrity related to THE client's refusal to turn.
D) Ineffective coping related to an inadequate level of perception of control.
D) Ineffective coping related to an inadequate level of perception of control.
Rationale
THE first part of THE nursing problem statement is THE diagnostic label. This is followed by THE cause of
THE problem which was identified. THE etiology is THE "related to" which directs THE nurse to THE
appropriate interventions.
Which activity should THE nurse use in THE evaluation phase of THE nursing process?
A) Ask a client to evaluate THE nursing care provided.
B) Document THE nursing care plan in THE progress notes.
C) Determine wheTHEr a client's health problems have been alleviated.
D) Examine THE effectiveness of nursing interventions toward meeting client outcomes.
D) Examine THE effectiveness of nursing interventions toward meeting client outcomes.
Rationale
In THE nursing process, THE evaluation component examines THE effectiveness of nursing interventions
in achieving client outcomes.
THE nurse encounters a slight resistance when inserting THE tubing into a client's rectum for a tap
water enema. Which action should THE nurse implement?
A) Withdraw THE tube and apply additional lubricant to THE tip of THE tube.
B) Encourage THE client to bear down and continue to insert THE tube.
C) Remove THE tube and re-position THE client to reinsert THE tube.
D) Ask THE client to relax and twist THE tube gently through THE sphincter.
D) Ask THE client to relax and twist THE tube gently through THE sphincter.
Rationale
If a slight resistance is encountered during THE initial insertion of an enema tube, THE nurse should
instruct THE client to breaTHE through THE mouth which relaxes THE anal sphincter and allows THE tube
to pass through.
,After a client has been premedicated for surgery with an opioid analgesic, THE nurse discovers that
THE operative permit has not been signed. Which action should THE nurse implement?
A) Notify THE surgeon that THE consent form has not been signed.
B) Read THE consent form to THE client before witnessing THE client's signature.
C) Determine if THE client's spouse is willing to sign THE consent form.
D)Administer an opioid antagonist prior to obtaining THE client's signature.
A) Notify THE surgeon that THE consent form has not been signed.
Rationale
Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not
possible, so THE nurse must notify THE surgeon.
How should THE nurse handle linens that are soiled with incontinent feces?
A) Put THE soiled linens in an isolation bag, THEn place it in THE dirty linen hamper.
B) Place an isolation hamper in THE client's room and discard THE linens in it.
C) Place THE soiled linens in THE designated fluid-resistant dirty linen bag and deposit THEm in THE
dirty linen hamper.
D) Ask THE housekeeping staff to pick up THE soiled linen from THE dirty utility room.
C) Place THE soiled linens in THE designated fluid-resistant dirty linen bag and deposit THEm in THE dirty
linen hamper.
Rationale
THE nurse should be careful to keep THE soiled linens from contaminating THE fresh linens and should
handle THE soiled linens like any oTHEr dirty linens as outlined in THE facility guidelines/protocols.
On THE third postoperative day following thoracic surgery, a client reports feeling constipated. Which
intervention should THE nurse implement to promote bowel elimination?
A) Remind THE client to turn every two hours while lying in bed.
B) Provide warm prune juice before THE client goes to bed at night.
C) Teach THE client to splint THE incision while walking to THE bathroom.
D) Administer an analgesic before THE client attempts to defecate.
, B) Provide warm prune juice before THE client goes to bed at night.
Rationale
Prune juice is a natural laxative that stimulates peristalsis, and warming THE prune juice facilitates
peristalsis.
A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and
tells THE nurse he does not want to be resuscitated if his breathing stops. Which action should THE
nurse implement?
A) Document THE client's request in THE medical record.
B) Ask THE client if this decision has been discussed with his healthcare provider.
C) Inform THE client that a written, notarized advance directive, is required to withhold resuscitation
efforts.
D) Advise THE client to designate a person to make healthcare decisions when THE client is unable to
do so.
B) Ask THE client if this decision has been discussed with his healthcare provider.
Rationale
Advance directives are written statements of a person's wishes regarding medical care, and verbal
directives may be given to a healthcare provider with specific instructions in THE presence of two
witnesses. To obtain this prescription, THE client should discuss his choice with THE healthcare provider.
Before administering a client's medication, THE nurse assesses a change in THE client's condition and
decides to withhold THE medication until consulting with THE healthcare provider. After consultation
with THE healthcare provider, THE dose of THE medication is changed and THE nurse administers THE
newly prescribed dose an hour later than THE originally scheduled time. Which action should THE
nurse implement in response to this situation?
A) Notify THE charge nurse that a medication error occurred.
B) Submit a medication variance report to THE supervisor.
C) Document THE events that occurred in THE nurses' notes.
D) Discard THE original medication administration record.
C) Document THE events that occurred in THE nurses' notes.
Rationale
THE nurse took THE correct action and should document THE events that occurred in THE nurses' notes.
FUNDAMENTALS ON EVOLVE\\\HESI
Fundamentals Exam on Evolve – Verified
Questions & Step-by-Step Answers
A male client arrives at THE outpatient surgery center for a scheduled needle aspiration of THE knee.
He tells THE nurse that he has already given verbal consent for THE procedure to THE healthcare
provider. Which action should THE nurse pursue next?
A) Witness THE client's signature on THE consent form.
B) Verify THE client's consent with THE healthcare provider.
C) Notify THE healthcare provider that THE client is ready for THE procedure.
D) Document that THE client has given consent for THE needle aspiration.
B) Verify THE client's consent with THE healthcare provider.
Rationale
Written informed consent is required prior to any invasive procedure. THE healthcare provider must
explain THE procedure to THE client, but THE nurse can witness THE client's signature on a consent
form. If THE nurse was not present when THE HCP explained THE procedure/surgery, THEn THE first
action before witnessing THE client's signature on THE consent should be to verify that THE HCP indeed,
received verbal consent from THE client.
A client is admitted with a stage four pressure injury that has a black, hardened surface (eschar) that
is stable. Which dressing is best for THE nurse to use first?
A) Hydrogel.
B) Exudate absorber.
C) No dressing.
D) Transparent adhesive film
C) No dressing.
Rationale
If eschar is dry and intact and debridement is not part of THE plan of care, no dressing is used, allowing
eschar to act as physiological cover.
Which statement is an example of a correctly written nursing problem statement?
A) Altered tissue perfusion related to heart failure.
,B) Altered urinary elimination related to urinary tract infection.
C) Risk for impaired tissue integrity related to THE client's refusal to turn.
D) Ineffective coping related to an inadequate level of perception of control.
D) Ineffective coping related to an inadequate level of perception of control.
Rationale
THE first part of THE nursing problem statement is THE diagnostic label. This is followed by THE cause of
THE problem which was identified. THE etiology is THE "related to" which directs THE nurse to THE
appropriate interventions.
Which activity should THE nurse use in THE evaluation phase of THE nursing process?
A) Ask a client to evaluate THE nursing care provided.
B) Document THE nursing care plan in THE progress notes.
C) Determine wheTHEr a client's health problems have been alleviated.
D) Examine THE effectiveness of nursing interventions toward meeting client outcomes.
D) Examine THE effectiveness of nursing interventions toward meeting client outcomes.
Rationale
In THE nursing process, THE evaluation component examines THE effectiveness of nursing interventions
in achieving client outcomes.
THE nurse encounters a slight resistance when inserting THE tubing into a client's rectum for a tap
water enema. Which action should THE nurse implement?
A) Withdraw THE tube and apply additional lubricant to THE tip of THE tube.
B) Encourage THE client to bear down and continue to insert THE tube.
C) Remove THE tube and re-position THE client to reinsert THE tube.
D) Ask THE client to relax and twist THE tube gently through THE sphincter.
D) Ask THE client to relax and twist THE tube gently through THE sphincter.
Rationale
If a slight resistance is encountered during THE initial insertion of an enema tube, THE nurse should
instruct THE client to breaTHE through THE mouth which relaxes THE anal sphincter and allows THE tube
to pass through.
,After a client has been premedicated for surgery with an opioid analgesic, THE nurse discovers that
THE operative permit has not been signed. Which action should THE nurse implement?
A) Notify THE surgeon that THE consent form has not been signed.
B) Read THE consent form to THE client before witnessing THE client's signature.
C) Determine if THE client's spouse is willing to sign THE consent form.
D)Administer an opioid antagonist prior to obtaining THE client's signature.
A) Notify THE surgeon that THE consent form has not been signed.
Rationale
Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not
possible, so THE nurse must notify THE surgeon.
How should THE nurse handle linens that are soiled with incontinent feces?
A) Put THE soiled linens in an isolation bag, THEn place it in THE dirty linen hamper.
B) Place an isolation hamper in THE client's room and discard THE linens in it.
C) Place THE soiled linens in THE designated fluid-resistant dirty linen bag and deposit THEm in THE
dirty linen hamper.
D) Ask THE housekeeping staff to pick up THE soiled linen from THE dirty utility room.
C) Place THE soiled linens in THE designated fluid-resistant dirty linen bag and deposit THEm in THE dirty
linen hamper.
Rationale
THE nurse should be careful to keep THE soiled linens from contaminating THE fresh linens and should
handle THE soiled linens like any oTHEr dirty linens as outlined in THE facility guidelines/protocols.
On THE third postoperative day following thoracic surgery, a client reports feeling constipated. Which
intervention should THE nurse implement to promote bowel elimination?
A) Remind THE client to turn every two hours while lying in bed.
B) Provide warm prune juice before THE client goes to bed at night.
C) Teach THE client to splint THE incision while walking to THE bathroom.
D) Administer an analgesic before THE client attempts to defecate.
, B) Provide warm prune juice before THE client goes to bed at night.
Rationale
Prune juice is a natural laxative that stimulates peristalsis, and warming THE prune juice facilitates
peristalsis.
A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and
tells THE nurse he does not want to be resuscitated if his breathing stops. Which action should THE
nurse implement?
A) Document THE client's request in THE medical record.
B) Ask THE client if this decision has been discussed with his healthcare provider.
C) Inform THE client that a written, notarized advance directive, is required to withhold resuscitation
efforts.
D) Advise THE client to designate a person to make healthcare decisions when THE client is unable to
do so.
B) Ask THE client if this decision has been discussed with his healthcare provider.
Rationale
Advance directives are written statements of a person's wishes regarding medical care, and verbal
directives may be given to a healthcare provider with specific instructions in THE presence of two
witnesses. To obtain this prescription, THE client should discuss his choice with THE healthcare provider.
Before administering a client's medication, THE nurse assesses a change in THE client's condition and
decides to withhold THE medication until consulting with THE healthcare provider. After consultation
with THE healthcare provider, THE dose of THE medication is changed and THE nurse administers THE
newly prescribed dose an hour later than THE originally scheduled time. Which action should THE
nurse implement in response to this situation?
A) Notify THE charge nurse that a medication error occurred.
B) Submit a medication variance report to THE supervisor.
C) Document THE events that occurred in THE nurses' notes.
D) Discard THE original medication administration record.
C) Document THE events that occurred in THE nurses' notes.
Rationale
THE nurse took THE correct action and should document THE events that occurred in THE nurses' notes.
