Evolve HESI Fundamentals Practice Qs for Nursing
A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I
have been told that it is harmful to bathe during my period." Which action should the nurse take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D. Teach the importance of personal hygiene during menstruation with the client. - ansAnswer: D
Because a shower is most beneficial for the client in terms of hygiene, the client should receive teaching first
(D), respecting any personal beliefs such as cultural or spiritual values. After client teaching, the client may still
choose (A or B). Brochures reinforce the teaching (C).
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral
area. Which instruction is most important 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. - ansAnswer: 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.
A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to
go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the
nurse to implement?
A. Encourage the client to use a nicotine patch.
B. Reassure the client that it is almost time for another break.
C. Have the client leave the unit with another staff.
D. Review the schedule of outdoor breaks with the client. - ansAnswer: D
The best nursing action is to review the schedule of outdoor breaks (D) and provide concrete information about
,the schedule. (A) is contraindicated if the client wants to continue smoking. (B) is insufficient to encourage a
trusting relationship with the client. (C) is preferential for this client only and is inconsistent with unit rules.
A client has a nasogastric tube connected to low intermittent suction. When administering medications
through the nasogastric tube, which action should the nurse do first?
A. Clamp the nasogastric tube.
B. Confirm placement of the tube.
C. Use a syringe to instill the medications.
D. Turn off the intermittent suction device. - ansAnswer: D
The nurse should first turn off the suction (D) and then confirm placement of the tube in the stomach (B)
before instilling the medications (C). To prevent immediate removal of the instilled medications and allow
absorption, the tube should be clamped for a period of time (A) before reconnecting the suction.
A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is
important for the nurse to provide?
A. Decrease intake of fluids after the evening meal.
B. Drink a glass of cranberry juice every day.
C. Drink a glass of warm decaffeinated beverage at bedtime.
D. Consult the health care provider about a sleeping pill. - ansAnswer: A
Nocturia is urination during the night. (A) is helpful to decrease the production of urine, thus decreasing the
need to void at night. (B) helps prevent bladder infections. (C) may promote sleep, but the fluid will contribute
to nocturia. (D) may result in urinary incontinence if the client is sedated and does not awaken to void.
A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days.
Which intervention should the nurse implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
B. Notify the health care provider and request a prescription for a large-volume enema.
C. Assess the client's medical record to determine the client's normal bowel pattern.
D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day. - ansAnswer: C
This client may not routinely have a daily bowel movement, so the nurse should first assess this client's normal
, bowel habits before attempting any intervention (C). (A, B, or D) may then be implemented, if warranted.
A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?
A. Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse.
B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive
medication.
C. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort.
D. Compare the current reading with the client's previously documented blood pressure readings. - ansAnswer:
D
Comparing this reading with previous readings (D) will provide information about what is normal for this client;
this action should be taken first. (A) might unnecessarily alarm the client. (B) is premature. Further assessment
is needed to determine if the reading is abnormal for this client. (C) could falsely decrease the reading and is
not the correct procedure for obtaining a blood pressure reading.
A community hospital is opening a mental health services department. Which document should the nurse use
to develop the unit's nursing guidelines?
A. Americans with Disability Act of 1990
B. ANA Code of Ethics with Interpretative Statements
C. ANA's Scope and Standards of Nursing Practice
D. Patient's Bill of Rights of 1990 - ansAnswer: C
The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing (C) serves to direct the
philosophy and standards of psychiatric nursing practice. (A and D) define the client's rights. (B) provides
ethical guidelines for nursing.
A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about
drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse provide?
A. Orange juice has vitamin C that deters bacterial growth.
B. Apple juice is the most useful in acidifying the urine.
C. Cranberry juice stops pathogens' adherence to the bladder.
D. Grapefruit juice increases absorption of most antibiotics. - ansAnswer: C
A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I
have been told that it is harmful to bathe during my period." Which action should the nurse take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D. Teach the importance of personal hygiene during menstruation with the client. - ansAnswer: D
Because a shower is most beneficial for the client in terms of hygiene, the client should receive teaching first
(D), respecting any personal beliefs such as cultural or spiritual values. After client teaching, the client may still
choose (A or B). Brochures reinforce the teaching (C).
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral
area. Which instruction is most important 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. - ansAnswer: 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.
A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to
go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the
nurse to implement?
A. Encourage the client to use a nicotine patch.
B. Reassure the client that it is almost time for another break.
C. Have the client leave the unit with another staff.
D. Review the schedule of outdoor breaks with the client. - ansAnswer: D
The best nursing action is to review the schedule of outdoor breaks (D) and provide concrete information about
,the schedule. (A) is contraindicated if the client wants to continue smoking. (B) is insufficient to encourage a
trusting relationship with the client. (C) is preferential for this client only and is inconsistent with unit rules.
A client has a nasogastric tube connected to low intermittent suction. When administering medications
through the nasogastric tube, which action should the nurse do first?
A. Clamp the nasogastric tube.
B. Confirm placement of the tube.
C. Use a syringe to instill the medications.
D. Turn off the intermittent suction device. - ansAnswer: D
The nurse should first turn off the suction (D) and then confirm placement of the tube in the stomach (B)
before instilling the medications (C). To prevent immediate removal of the instilled medications and allow
absorption, the tube should be clamped for a period of time (A) before reconnecting the suction.
A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is
important for the nurse to provide?
A. Decrease intake of fluids after the evening meal.
B. Drink a glass of cranberry juice every day.
C. Drink a glass of warm decaffeinated beverage at bedtime.
D. Consult the health care provider about a sleeping pill. - ansAnswer: A
Nocturia is urination during the night. (A) is helpful to decrease the production of urine, thus decreasing the
need to void at night. (B) helps prevent bladder infections. (C) may promote sleep, but the fluid will contribute
to nocturia. (D) may result in urinary incontinence if the client is sedated and does not awaken to void.
A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days.
Which intervention should the nurse implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
B. Notify the health care provider and request a prescription for a large-volume enema.
C. Assess the client's medical record to determine the client's normal bowel pattern.
D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day. - ansAnswer: C
This client may not routinely have a daily bowel movement, so the nurse should first assess this client's normal
, bowel habits before attempting any intervention (C). (A, B, or D) may then be implemented, if warranted.
A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?
A. Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse.
B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive
medication.
C. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort.
D. Compare the current reading with the client's previously documented blood pressure readings. - ansAnswer:
D
Comparing this reading with previous readings (D) will provide information about what is normal for this client;
this action should be taken first. (A) might unnecessarily alarm the client. (B) is premature. Further assessment
is needed to determine if the reading is abnormal for this client. (C) could falsely decrease the reading and is
not the correct procedure for obtaining a blood pressure reading.
A community hospital is opening a mental health services department. Which document should the nurse use
to develop the unit's nursing guidelines?
A. Americans with Disability Act of 1990
B. ANA Code of Ethics with Interpretative Statements
C. ANA's Scope and Standards of Nursing Practice
D. Patient's Bill of Rights of 1990 - ansAnswer: C
The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing (C) serves to direct the
philosophy and standards of psychiatric nursing practice. (A and D) define the client's rights. (B) provides
ethical guidelines for nursing.
A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about
drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse provide?
A. Orange juice has vitamin C that deters bacterial growth.
B. Apple juice is the most useful in acidifying the urine.
C. Cranberry juice stops pathogens' adherence to the bladder.
D. Grapefruit juice increases absorption of most antibiotics. - ansAnswer: C
