Western Governors University D 440
ACTUAL QUESTIONS AND
ANSWERS FROM HESI
FUNDAMENTALS ON
EVOLVE
Terms in this set (105)
,A male client arrives at the outpatient B) Verify the client's consent with the healthcare provider.
surgery center for a scheduled needle
aspiration of the knee. He tells the nurse that Rationale
he has already given verbal consent for Written informed consent is required prior to any invasive
the procedure to the healthcare provider. procedure. The healthcare provider must explain the
Which action should the nurse pursue procedure to the client, but the nurse can witness the client's
next? signature on a consent form. If the nurse was not present
when the HCP explained the procedure/surgery, then the first
A) Witness the client's signature on action before witnessing the client's signature on the consent
the consent form. should be to verify that the HCP indeed, received verbal
consent from the client.
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.
A client is admitted with a stage four C) No dressing.
pressure injury that has a black, hardened
surface (eschar) that is stable. Which Rationale
dressing is best for the nurse to use first? 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
A) Hydrogel. physiological cover.
B) Exudate absorber.
C) No dressing.
D)Transparent adhesive film
Which statement is an example of D) Ineffective coping related to an inadequate level of
a correctly written nursing perception of control.
problem statement?
Rationale
A) Altered tissue perfusion related to heart The first part of the nursing problem statement is the
failure. diagnostic label. This is followed by the cause of the problem
which was identified. The etiology is the "related to" which
B)Altered urinary elimination related directs the nurse to the appropriate interventions.
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.
,Which activity should the nurse use in the D) Examine the effectiveness of nursing interventions toward
evaluation phase of the nursing process? meeting client outcomes.
A) Ask a client to evaluate the nursing Rationale
care provided. In the nursing process, the evaluation component
examines the effectiveness of nursing interventions in
B) Document the nursing care plan in achieving client outcomes.
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.
The nurse encounters a slight resistance D) Ask the client to relax and twist the tube gently through the
when inserting the tubing into a client's sphincter.
rectum for a tap water enema. Which action
should the nurse implement? Rationale
If a slight resistance is encountered during the initial insertion
A) Withdraw the tube and apply additional of an enema tube, the nurse should instruct the client to
lubricant to the tip of the tube. breathe through the mouth which relaxes the anal sphincter
and allows the tube to pass through.
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.
After a client has been premedicated for A) Notify the surgeon that the consent form has not
surgery with an opioid analgesic, the nurse been signed.
discovers that the operative permit has not
been signed. Which action should the nurse Rationale
implement? Once a client has been premedicated for surgery with any
type of sedative, legal informed consent is not possible, so
A) Notify the surgeon that the consent the nurse must notify the surgeon.
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.
, How should the nurse handle linens that are C) Place the soiled linens in the designated fluid-resistant
soiled with incontinent feces? dirty linen bag and deposit them in the dirty linen
hamper.
A) Put the soiled linens in an isolation
bag, then place it in the dirty linen Rationale
hamper. The nurse should be careful to keep the soiled linens from
contaminating the fresh linens and should handle the soiled
B) Place an isolation hamper in the linens like any other dirty linens as outlined in the facility
client's room and discard the linens in guidelines/protocols.
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.
On the third postoperative day following B) Provide warm prune juice before the client goes to bed at
thoracic surgery, a client reports feeling night.
constipated. Which intervention should the
nurse implement to promote bowel Rationale
elimination? Prune juice is a natural laxative that stimulates peristalsis, and
warming the prune juice facilitates peristalsis.
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.
ACTUAL QUESTIONS AND
ANSWERS FROM HESI
FUNDAMENTALS ON
EVOLVE
Terms in this set (105)
,A male client arrives at the outpatient B) Verify the client's consent with the healthcare provider.
surgery center for a scheduled needle
aspiration of the knee. He tells the nurse that Rationale
he has already given verbal consent for Written informed consent is required prior to any invasive
the procedure to the healthcare provider. procedure. The healthcare provider must explain the
Which action should the nurse pursue procedure to the client, but the nurse can witness the client's
next? signature on a consent form. If the nurse was not present
when the HCP explained the procedure/surgery, then the first
A) Witness the client's signature on action before witnessing the client's signature on the consent
the consent form. should be to verify that the HCP indeed, received verbal
consent from the client.
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.
A client is admitted with a stage four C) No dressing.
pressure injury that has a black, hardened
surface (eschar) that is stable. Which Rationale
dressing is best for the nurse to use first? 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
A) Hydrogel. physiological cover.
B) Exudate absorber.
C) No dressing.
D)Transparent adhesive film
Which statement is an example of D) Ineffective coping related to an inadequate level of
a correctly written nursing perception of control.
problem statement?
Rationale
A) Altered tissue perfusion related to heart The first part of the nursing problem statement is the
failure. diagnostic label. This is followed by the cause of the problem
which was identified. The etiology is the "related to" which
B)Altered urinary elimination related directs the nurse to the appropriate interventions.
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.
,Which activity should the nurse use in the D) Examine the effectiveness of nursing interventions toward
evaluation phase of the nursing process? meeting client outcomes.
A) Ask a client to evaluate the nursing Rationale
care provided. In the nursing process, the evaluation component
examines the effectiveness of nursing interventions in
B) Document the nursing care plan in achieving client outcomes.
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.
The nurse encounters a slight resistance D) Ask the client to relax and twist the tube gently through the
when inserting the tubing into a client's sphincter.
rectum for a tap water enema. Which action
should the nurse implement? Rationale
If a slight resistance is encountered during the initial insertion
A) Withdraw the tube and apply additional of an enema tube, the nurse should instruct the client to
lubricant to the tip of the tube. breathe through the mouth which relaxes the anal sphincter
and allows the tube to pass through.
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.
After a client has been premedicated for A) Notify the surgeon that the consent form has not
surgery with an opioid analgesic, the nurse been signed.
discovers that the operative permit has not
been signed. Which action should the nurse Rationale
implement? Once a client has been premedicated for surgery with any
type of sedative, legal informed consent is not possible, so
A) Notify the surgeon that the consent the nurse must notify the surgeon.
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.
, How should the nurse handle linens that are C) Place the soiled linens in the designated fluid-resistant
soiled with incontinent feces? dirty linen bag and deposit them in the dirty linen
hamper.
A) Put the soiled linens in an isolation
bag, then place it in the dirty linen Rationale
hamper. The nurse should be careful to keep the soiled linens from
contaminating the fresh linens and should handle the soiled
B) Place an isolation hamper in the linens like any other dirty linens as outlined in the facility
client's room and discard the linens in guidelines/protocols.
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.
On the third postoperative day following B) Provide warm prune juice before the client goes to bed at
thoracic surgery, a client reports feeling night.
constipated. Which intervention should the
nurse implement to promote bowel Rationale
elimination? Prune juice is a natural laxative that stimulates peristalsis, and
warming the prune juice facilitates peristalsis.
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.
