Evolve HESI Fundamentals Practice Qs
Study online at https://quizlet.com/_5sib53
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.: 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 arteriosclerosis,
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": 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 development 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.: 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
, Evolve HESI Fundamentals Practice Qs
Study online at https://quizlet.com/_5sib53
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).
4. 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: 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.
5. 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: 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.
6. 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: B
, Evolve HESI Fundamentals Practice Qs
Study online at https://quizlet.com/_5sib53
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 lega
guidelines. (C and D) describe expectations for nursing practice but do not address legal implications.
7. 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: 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 made (A). The routine practiced by the client is clearly unsuccessful, so
encouragement alone is insufficient (C).
8. A 65-year-old client who attends an adult daycare program and is wheel-
chair-mobile has redness in the sacral area. Which instruction is most impor-
tant 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: 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.
9. When turning an immobile bedridden client without assistance, which action
by the nurse best ensures client safety?
A. Securely grasp the client's arm and leg.
B. Put bed rails up on the side of bed opposite from the nurse.
C. Correctly position and use a turn sheet.
D. Lower the head of the client's bed slowly.: Answer: B
Study online at https://quizlet.com/_5sib53
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.: 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 arteriosclerosis,
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": 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 development 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.: 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
, Evolve HESI Fundamentals Practice Qs
Study online at https://quizlet.com/_5sib53
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).
4. 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: 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.
5. 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: 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.
6. 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: B
, Evolve HESI Fundamentals Practice Qs
Study online at https://quizlet.com/_5sib53
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 lega
guidelines. (C and D) describe expectations for nursing practice but do not address legal implications.
7. 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: 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 made (A). The routine practiced by the client is clearly unsuccessful, so
encouragement alone is insufficient (C).
8. A 65-year-old client who attends an adult daycare program and is wheel-
chair-mobile has redness in the sacral area. Which instruction is most impor-
tant 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: 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.
9. When turning an immobile bedridden client without assistance, which action
by the nurse best ensures client safety?
A. Securely grasp the client's arm and leg.
B. Put bed rails up on the side of bed opposite from the nurse.
C. Correctly position and use a turn sheet.
D. Lower the head of the client's bed slowly.: Answer: B
