2025 EVOLVE HESI FUNDAMENTALS REAL EXAM
TEST BANK/RN HESI EVOLVE FUNDAMENTALS
COMPLETE ALL 500 QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
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>>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).
,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>>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).
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>>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 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).
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>>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.
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>>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.
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>>Answer: B
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 legal guidelines. (C and D)
describe expectations for nursing practice but do not address
legal implications.
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.
TEST BANK/RN HESI EVOLVE FUNDAMENTALS
COMPLETE ALL 500 QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
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>>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).
,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>>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).
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>>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 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).
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>>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.
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>>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.
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>>Answer: B
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 legal guidelines. (C and D)
describe expectations for nursing practice but do not address
legal implications.
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.
