D441 Evolve HESI Fundamentals questions and
100% correct answers with explanation
Which action should the nurse implement when providing wound care instructions to a client
who does not speak English?
A. Ask an interpreter to provide wound care instructions.
B. Speak directly to the client, with an interpreter translating.
C. Request the accompanying family member to translate.
D. Instruct a bilingual employee to read the instructions.
Answer: B
Wound care instructions should be given directly to the client by the nurse with an interpreter
(B) who is trained to provide accurate and objective translation in the client's primary language,
so that the client has the opportunity to ask questions during the teaching process. The
interpreter usually does not have any health care experience, so the nurse must provide client
teaching (A). Family members should not be used to translate instructions (C) because the client
or family member may alter the instructions during conversation or be uncomfortable with the
topics discussed. The employee should be a trained interpreter (D) to ensure that the nurse's
instructions are understood accurately by the client.
An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and
is now requesting to go to the bathroom. Which action should the nurse implement?
A. Assist the client to walk to the bathroom and do not leave the client alone.
B. Request that the UAP assist the client onto a bedpan.
C. Ask if the client needs to have a bowel movement or void.
D. Assess the client's bladder to determine if the client needs to urinate.
,Answer: A
Barbiturates cause central nervous system (CNS) depression and individuals taking these
medications are at greater risk for falls. The nurse should assist the client to the bathroom (A). A
bedpan (B) is not necessary as long as safety is ensured. Whether the client needs to void or
have a bowel movement, (C) is irrelevant in terms of meeting this client's safety needs. There is
no indication that this client cannot voice her or his needs, so assessment of the bladder is not
needed (D).
One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a
female client tells the nurse, "I think I will plan a big party for all my friends." How should the
nurse respond?
A. "You may not have enough energy before long to hold a big party."
B. "Do you mean to say that you want to plan your funeral and wake?"
C. "Planning a party and thinking about all your friends sounds like fun."
D. "You should be thinking about spending your last days with your family."
Answer: C
Setting goals that bring pleasure are appropriate and should be encouraged by the nurse (C) as
long as the nurse does not perpetuate a client's denial. (A) is a negative response, implying that
the client should not plan a party. (B) puts words in the client's mouth that may not be accurate.
The nurse should support the client's goals rather than telling the client how to spend her time
(D).
The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which
observation of this procedure requires the nurse's intervention?
A. The cuff wraps around the girth of the leg.
B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.
C. The client is placed in a prone position.
,D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
Answer: B
When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for
auscultation when the blood pressure cuff is applied around the thigh. The nurse should
intervene with the UAP who has applied the cuff on the lower leg (B). (A) ensures an accurate
assessment, and (C) provides the best access to the artery. Systolic pressure in the popliteal
artery is usually 10 to 40 mm Hg higher (D) than in the brachial artery.
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of
infection?
A. Mode of transmission
B. Portal of entry
C. Reservoir
D. Portal of exit
Answer: A
The contaminated gloves serve as the mode of transmission (A) from the portal of exit (D) of the
reservoir (C) to a portal of entry (B).
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV
rate by gravity has slowed, even though the venous access site is healthy. What should the
nurse do next?
A. Apply a warm compress proximal to the site.
B. Check for kinks in the tubing and raise the IV pole.
C. Adjust the tape that stabilizes the needle.
D. Flush with normal saline and recount the drop rate.
Answer: B
, The nurse should first check the tubing and height of the bag on the IV pole (B), which are
common factors that may slow the rate. Gravity infusion rates are influenced by the height of
the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood
pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate and often
responds to warmth over the vessel (A), but the nurse should first adjust the IV pole height. The
nurse may need to adjust the stabilizing tape on a positional needle (C) or flush the venous
access with normal saline (D), but less invasive actions should be implemented first.
Which client is most likely to be at risk for spiritual distress?
A. Roman Catholic woman considering an abortion
B. Jewish man considering hospice care for his wife
C. Seventh-Day Adventist who needs a blood transfusion
D. Muslim man who needs a total knee replacement
Answer: A
In the Roman Catholic religion, any type of abortion is prohibited (A), so facing this decision may
place the client at risk for spiritual distress. There is no prohibition of hospice care for members
of the Jewish faith (B). Jehovah's Witnesses prohibit blood transfusions, not Seventh-Day
Adventists (C). There is no conflict in the Muslim faith with regard to joint replacement (D).
Which intervention is most important to include in the plan of care for a client at high risk for
the development of postoperative thrombus formation?
A. Instruct in the use of the incentive spirometer.
B. Elevate the head of the bed during all meals.
C. Use aseptic technique to change the dressing.
D. Encourage frequent ambulation in the hallway.
Answer: D
Thrombus (clot) formation can occur in the lower extremities of immobile clients, so the nurse
should plan to encourage activities to increase mobility, such as frequent ambulation (D) in the
100% correct answers with explanation
Which action should the nurse implement when providing wound care instructions to a client
who does not speak English?
A. Ask an interpreter to provide wound care instructions.
B. Speak directly to the client, with an interpreter translating.
C. Request the accompanying family member to translate.
D. Instruct a bilingual employee to read the instructions.
Answer: B
Wound care instructions should be given directly to the client by the nurse with an interpreter
(B) who is trained to provide accurate and objective translation in the client's primary language,
so that the client has the opportunity to ask questions during the teaching process. The
interpreter usually does not have any health care experience, so the nurse must provide client
teaching (A). Family members should not be used to translate instructions (C) because the client
or family member may alter the instructions during conversation or be uncomfortable with the
topics discussed. The employee should be a trained interpreter (D) to ensure that the nurse's
instructions are understood accurately by the client.
An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and
is now requesting to go to the bathroom. Which action should the nurse implement?
A. Assist the client to walk to the bathroom and do not leave the client alone.
B. Request that the UAP assist the client onto a bedpan.
C. Ask if the client needs to have a bowel movement or void.
D. Assess the client's bladder to determine if the client needs to urinate.
,Answer: A
Barbiturates cause central nervous system (CNS) depression and individuals taking these
medications are at greater risk for falls. The nurse should assist the client to the bathroom (A). A
bedpan (B) is not necessary as long as safety is ensured. Whether the client needs to void or
have a bowel movement, (C) is irrelevant in terms of meeting this client's safety needs. There is
no indication that this client cannot voice her or his needs, so assessment of the bladder is not
needed (D).
One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a
female client tells the nurse, "I think I will plan a big party for all my friends." How should the
nurse respond?
A. "You may not have enough energy before long to hold a big party."
B. "Do you mean to say that you want to plan your funeral and wake?"
C. "Planning a party and thinking about all your friends sounds like fun."
D. "You should be thinking about spending your last days with your family."
Answer: C
Setting goals that bring pleasure are appropriate and should be encouraged by the nurse (C) as
long as the nurse does not perpetuate a client's denial. (A) is a negative response, implying that
the client should not plan a party. (B) puts words in the client's mouth that may not be accurate.
The nurse should support the client's goals rather than telling the client how to spend her time
(D).
The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which
observation of this procedure requires the nurse's intervention?
A. The cuff wraps around the girth of the leg.
B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.
C. The client is placed in a prone position.
,D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
Answer: B
When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for
auscultation when the blood pressure cuff is applied around the thigh. The nurse should
intervene with the UAP who has applied the cuff on the lower leg (B). (A) ensures an accurate
assessment, and (C) provides the best access to the artery. Systolic pressure in the popliteal
artery is usually 10 to 40 mm Hg higher (D) than in the brachial artery.
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of
infection?
A. Mode of transmission
B. Portal of entry
C. Reservoir
D. Portal of exit
Answer: A
The contaminated gloves serve as the mode of transmission (A) from the portal of exit (D) of the
reservoir (C) to a portal of entry (B).
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV
rate by gravity has slowed, even though the venous access site is healthy. What should the
nurse do next?
A. Apply a warm compress proximal to the site.
B. Check for kinks in the tubing and raise the IV pole.
C. Adjust the tape that stabilizes the needle.
D. Flush with normal saline and recount the drop rate.
Answer: B
, The nurse should first check the tubing and height of the bag on the IV pole (B), which are
common factors that may slow the rate. Gravity infusion rates are influenced by the height of
the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood
pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate and often
responds to warmth over the vessel (A), but the nurse should first adjust the IV pole height. The
nurse may need to adjust the stabilizing tape on a positional needle (C) or flush the venous
access with normal saline (D), but less invasive actions should be implemented first.
Which client is most likely to be at risk for spiritual distress?
A. Roman Catholic woman considering an abortion
B. Jewish man considering hospice care for his wife
C. Seventh-Day Adventist who needs a blood transfusion
D. Muslim man who needs a total knee replacement
Answer: A
In the Roman Catholic religion, any type of abortion is prohibited (A), so facing this decision may
place the client at risk for spiritual distress. There is no prohibition of hospice care for members
of the Jewish faith (B). Jehovah's Witnesses prohibit blood transfusions, not Seventh-Day
Adventists (C). There is no conflict in the Muslim faith with regard to joint replacement (D).
Which intervention is most important to include in the plan of care for a client at high risk for
the development of postoperative thrombus formation?
A. Instruct in the use of the incentive spirometer.
B. Elevate the head of the bed during all meals.
C. Use aseptic technique to change the dressing.
D. Encourage frequent ambulation in the hallway.
Answer: D
Thrombus (clot) formation can occur in the lower extremities of immobile clients, so the nurse
should plan to encourage activities to increase mobility, such as frequent ambulation (D) in the
