Actual Exam Questions and Answers from HESI Fundamentals on Evolve
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 the Written informed consent is required prior to any invasive
procedure to the healthcare provider. Which procedure. The healthcare provider must explain the
action should the nurse pursue next? procedure to the client, but the nurse can witness the client's
signature on a consent form. If the nurse was not present
A) Witness the client's signature on the when the HCP explained the procedure/surgery, then the first
consent form. action before witnessing the client's signature on the consent
should be to verify that the HCP indeed, received verbal
B) Verify the client's consent with the consent from the client.
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 a D) Ineffective coping related to an inadequate level of
correctly written nursing problem perception of control.
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 to directs the nurse to the appropriate interventions.
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.
Actual Exam Questions and Answers from HESI Fundamentals on Evolve
,Actual Exam Questions and Answers from HESI Fundamentals on Evolve
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 care Rationale
provided. In the nursing process, the evaluation component examines
the effectiveness of nursing interventions in achieving client
B) Document the nursing care plan in the outcomes.
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 been
surgery with an opioid analgesic, the nurse 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 form the nurse must notify the surgeon.
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.
Actual Exam Questions and Answers from HESI Fundamentals on Evolve
,Actual Exam Questions and Answers from HESI Fundamentals on Evolve
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, Rationale
then place it in the dirty linen 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 client's linens like any other dirty linens as outlined in the facility
room and discard the linens in it. guidelines/protocols.
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.
A male client with acquired B) Ask the client if this decision has been discussed with his
immunodeficiency syndrome (AIDS) healthcare provider.
develops cryptococcal meningitis and tells
the nurse he does not want to be Rationale
resuscitated if his breathing stops. Which Advance directives are written statements of a person's wishes
action should the nurse implement? regarding medical care, and verbal directives may be given to
a healthcare provider with specific instructions in the
A) Document the client's request in the presence of two witnesses. To obtain this prescription, the
medical record. client should discuss his choice with the healthcare provider.
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.
Actual Exam Questions and Answers from HESI Fundamentals on Evolve
, Actual Exam Questions and Answers from HESI Fundamentals on Evolve
Before administering a client's medication, C) Document the events that occurred in the nurses' notes.
the nurse assesses a change in the client's
condition and decides to withhold the Rationale
medication until consulting with the The nurse took the correct action and should document the
healthcare provider. After consultation with events that occurred in the nurses' notes.
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.
A client has a nursing problem of, "Spiritual B) Assist and support the client in establishing short-term
distress related to a loss of hope, secondary goals.
to impending death." Which intervention is
best for the nurse to implement when caring Rationale
for this client? Hopefulness is necessary to sustain a meaningful existence,
even close to death. The nurse should help the client set
A) Help the client to accept the final stage short-term goals, and recognize the achievement of
of life. immediate goals, such as seeing a family member or listening
to music.
B) Assist and support the client in
establishing short-term goals.
C) Encourage the client to make future
plans, even if they are unrealistic.
D) Instruct the client's family to focus on
positive aspects of the client's life.
Actual Exam Questions and Answers from HESI Fundamentals on Evolve
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 the Written informed consent is required prior to any invasive
procedure to the healthcare provider. Which procedure. The healthcare provider must explain the
action should the nurse pursue next? procedure to the client, but the nurse can witness the client's
signature on a consent form. If the nurse was not present
A) Witness the client's signature on the when the HCP explained the procedure/surgery, then the first
consent form. action before witnessing the client's signature on the consent
should be to verify that the HCP indeed, received verbal
B) Verify the client's consent with the consent from the client.
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 a D) Ineffective coping related to an inadequate level of
correctly written nursing problem perception of control.
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 to directs the nurse to the appropriate interventions.
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.
Actual Exam Questions and Answers from HESI Fundamentals on Evolve
,Actual Exam Questions and Answers from HESI Fundamentals on Evolve
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 care Rationale
provided. In the nursing process, the evaluation component examines
the effectiveness of nursing interventions in achieving client
B) Document the nursing care plan in the outcomes.
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 been
surgery with an opioid analgesic, the nurse 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 form the nurse must notify the surgeon.
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.
Actual Exam Questions and Answers from HESI Fundamentals on Evolve
,Actual Exam Questions and Answers from HESI Fundamentals on Evolve
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, Rationale
then place it in the dirty linen 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 client's linens like any other dirty linens as outlined in the facility
room and discard the linens in it. guidelines/protocols.
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.
A male client with acquired B) Ask the client if this decision has been discussed with his
immunodeficiency syndrome (AIDS) healthcare provider.
develops cryptococcal meningitis and tells
the nurse he does not want to be Rationale
resuscitated if his breathing stops. Which Advance directives are written statements of a person's wishes
action should the nurse implement? regarding medical care, and verbal directives may be given to
a healthcare provider with specific instructions in the
A) Document the client's request in the presence of two witnesses. To obtain this prescription, the
medical record. client should discuss his choice with the healthcare provider.
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.
Actual Exam Questions and Answers from HESI Fundamentals on Evolve
, Actual Exam Questions and Answers from HESI Fundamentals on Evolve
Before administering a client's medication, C) Document the events that occurred in the nurses' notes.
the nurse assesses a change in the client's
condition and decides to withhold the Rationale
medication until consulting with the The nurse took the correct action and should document the
healthcare provider. After consultation with events that occurred in the nurses' notes.
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.
A client has a nursing problem of, "Spiritual B) Assist and support the client in establishing short-term
distress related to a loss of hope, secondary goals.
to impending death." Which intervention is
best for the nurse to implement when caring Rationale
for this client? Hopefulness is necessary to sustain a meaningful existence,
even close to death. The nurse should help the client set
A) Help the client to accept the final stage short-term goals, and recognize the achievement of
of life. immediate goals, such as seeing a family member or listening
to music.
B) Assist and support the client in
establishing short-term goals.
C) Encourage the client to make future
plans, even if they are unrealistic.
D) Instruct the client's family to focus on
positive aspects of the client's life.
Actual Exam Questions and Answers from HESI Fundamentals on Evolve
