EVOLVE HESI FUNDAMENTALS
PRACTICE QS
Urinary44catheterization44is44prescribed44for44a44postoperative44female44client44who44ha
s44been44unable44to44void44for44844hours.44The44nurse44inserts44the44catheter,44but44no44
urine44is44seen44in44the44tubing.44Which44action44will44the44nurse44take44next?
A.44Clamp44the44catheter44and44recheck44it44in446044minutes.
B.44Pull44the44catheter44back44344inches44and44redirect44upward.
C.44Leave44the44catheter44in44place44and44reattempt44with44another44catheter.
D.44Notify44the44health44care44provider44of44a44possible44obstruction.44-44answer--
Answer:44C
It44is44likely44that44the44first44catheter44is44in44the44vagina,44rather44than44the44bladder.44
Leaving44the44first44catheter44in44place44will44help44locate44the44meatus44when44attempti
ng44the44second44catheterization44(C).44The44client44should44have44at44least4424044mL44
of44urine44after44844hours.44(A)44does44not44resolve44the44problem.44(B)44will44not44chan
ge44the44location44of44the44catheter44unless44it44is44completely44removed,44in44which44ca
se44a44new44catheter44must44be44used.44There44is44no44evidence44of44a44urinary44tract44
obstruction44if44the44catheter44could44be44easily44inserted44(D).
The44nurse44is44teaching44an44obese44client,44newly44diagnosed44with44arteriosclerosis,4
4about44reducing44the44risk44of44a44heart44attack44or44stroke.44Which44health44promotion
44brochure44is44most44important44for44the44nurse44to44provide44to44this44client?
A.44"Monitoring44Your44Blood44Pressure44at44Home"
B.44"Smoking44Cessation44as44a44Lifelong44Commitment"
C.44"Decreasing44Cholesterol44Levels44Through44Diet"
D.44"Stress44Management44for44a44Healthier44You"44-44answer--Answer:44C
A44health44promotion44brochure44about44decreasing44cholesterol44(C)44is44most44import
ant44to44provide44this44client,44because44the44most44significant44risk44factor44contributing
44to44development44of44arteriosclerosis44is44excess44dietary44fat,44particularly44saturated
44fat44and44cholesterol.44(A)44does44not44address44the44underlying44causes44of44arterios
clerosis.44(B44and44D)44are44also44important44factors44for44reversing44arteriosclerosis44b
ut44are44not44as44important44as44lowering44cholesterol44(C).
,Ten44minutes44after44signing44an44operative44permit44for44a44fractured44hip,44an44older44
client44states,44"The44aliens44will44be44coming44to44get44me44soon!"44and44falls44asleep.4
4Which44action44should44the44nurse44implement44next?
A.44Make44the44client44comfortable44and44allow44the44client44to44sleep.
B.44Assess44the44client's44neurologic44status.
C.44Notify44the44surgeon44about44the44comment.
D.44Ask44the44client's44family44to44co-sign44the44operative44permit.44-44answer--
Answer:44B
This44statement44may44indicate44that44the44client44is44confused.44Informed44consent44m
ust44be44provided44by44a44mentally44competent44individual,44so44the44nurse44should44furt
her44assess44the44client's44neurologic44status44(B)44to44be44sure44that44the44client44unde
rstands44and44can44legally44provide44consent44for44surgery.44(A)44does44not44provide44s
ufficient44follow-
up.44If44the44nurse44determines44that44the44client44is44confused,44the44surgeon44must44b
e44notified44(C)44and44permission44obtained44from44the44next44of44kin44(D).
The44nurse-
manager44of44a44skilled44nursing44(chronic44care)44unit44is44instructing44UAPs44on44ways
44to44prevent44complications44of44immobility.44Which44intervention44should44be44included
44in44this44instruction?
A.44Perform44range-of-motion44exercises44to44prevent44contractures.
B.44Decrease44the44client's44fluid44intake44to44prevent44diarrhea.
C.44Massage44the44client's44legs44to44reduce44embolism44occurrence.
D.44Turn44the44client44from44side44to44back44every44shift.44-44answer--Answer:44A
Performing44range-of-
motion44exercises44(A)44is44beneficial44in44reducing44contractures44around44joints.44(B,44
C,44and44D)44are44all44potentially44harmful44practices44that44place44the44immobile44client
44at44risk44of44complications.
The44nurse44is44assisting44a44client44to44the44bathroom.44When44the44client44is44544feet44
from44the44bathroom44door,44he44states,44"I44feel44faint."44Before44the44nurse44can44get44
the44client44to44a44chair,44the44client44starts44to44fall.44Which44is44the44priority44action44for
44the44nurse44to44take?
A.44Check44the44client's44carotid44pulse.
B.44Encourage44the44client44to44get44to44the44toilet.
C.44In44a44loud44voice,44call44for44help.
D.44Gently44lower44the44client44to44the44floor.44-44answer--Answer:44D
(D)44is44the44most44prudent44intervention44and44is44the44priority44nursing44action44to44pre
vent44injury44to44the44client44and44the44nurse.44Lowering44the44client44to44the44floor44sho
uld44be44done44when44the44client44cannot44support44his44own44weight.44The44client44sho
uld44be44placed44in44a44bed44or44chair44only44when44sufficient44help44is44available44to44p
revent44injury.44(A)44is44important44but44should44be44done44after44the44client44is44in44a44s
afe44position.44Because44the44client44is44not44supporting44himself,44(B)44is44impractical.44
(C)44is44likely44to44cause44chaos44on44the44unit44and44might44alarm44the44other44clients.
, A44female44nurse44is44assigned44to44care44for44a44close44friend,44who44says,44"I44am44w
orried44that44friends44will44find44out44about44my44diagnosis."44The44nurse44tells44her44frie
nd44that44legally44she44must44protect44a44client's44confidentiality.44Which44resource44des
cribes44the44nurse's44legal44responsibilities?
A.44Code44of44Ethics44for44Nurses
B.44State44Nurse44Practice44Act
C.44Patient's44Bill44of44Rights
D.44ANA44Standards44of44Practice44-44answer--Answer:44B
The44State44Nurse44Practice44Act44(B)44contains44legal44requirements44for44the44protecti
on44of44client44confidentiality44and44the44consequences44for44breaches44in44confidentialit
y.44(A)44outlines44ethical44standards44for44nursing44care44but44does44not44include44legal4
4guidelines.44(C44and44D)44describe44expectations44for44nursing44practice44but44do44not4
4address44legal44implications.
The44nurse44is44teaching44a44client44how44to44perform44progressive44muscle44relaxation4
4techniques44to44relieve44insomnia.44A44week44later44the44client44reports44that44he44is44st
ill44unable44to44sleep,44despite44following44the44same44routine44every44night.44Which44ac
tion44should44the44nurse44take44first?
A.44Instruct44the44client44to44add44regular44exercise44as44a44daily44routine.
B.44Determine44if44the44client44has44been44keeping44a44sleep44diary.
C.44Encourage44the44client44to44continue44the44routine44until44sleep44is44achieved.
D.44Ask44the44client44to44describe44the44routine44that44the44client44is44currently44following
.44-44answer--Answer:44D
The44nurse44should44first44evaluate44whether44the44client44has44been44adhering44to44the
44original44instructions44(D).44A44verbal44report44of44the44client's44routine44will44provide44
more44specific44information44than44the44client's44written44diary44(B).44The44nurse44can44t
hen44determine44which44changes44need44to44be44made44(A).44The44routine44practiced44
by44the44client44is44clearly44unsuccessful,44so44encouragement44alone44is44insufficient44(
C).
A4465-year-
old44client44who44attends44an44adult44daycare44program44and44is44wheelchair-
mobile44has44redness44in44the44sacral44area.44Which44instruction44is44most44important44f
or44the44nurse44to44provide?
A.44Take44a44vitamin44supplement44tablet44once44a44day.
B.44Change44positions44in44the44chair44at44least44every44hour.
C.44Increase44daily44intake44of44water44or44other44oral44fluids.
D.44Purchase44a44newer44model44wheelchair.44-44answer--Answer:44B
The44most44important44teaching44is44to44change44positions44frequently44(B)44because44p
ressure44is44the44most44significant44factor44related44to44the44development44of44pressure4
4ulcers.44Increased44vitamin44and44fluid44intake44(A44and44C)44may44also44be44beneficial
44promote44healing44and44reduce44further44risk.44(D)44is44an44intervention44of44last44reso
rt44because44this44will44be44very44expensive44for44the44client.
When44turning44an44immobile44bedridden44client44without44assistance,44which44action44b
y44the44nurse44best44ensures44client44safety?
PRACTICE QS
Urinary44catheterization44is44prescribed44for44a44postoperative44female44client44who44ha
s44been44unable44to44void44for44844hours.44The44nurse44inserts44the44catheter,44but44no44
urine44is44seen44in44the44tubing.44Which44action44will44the44nurse44take44next?
A.44Clamp44the44catheter44and44recheck44it44in446044minutes.
B.44Pull44the44catheter44back44344inches44and44redirect44upward.
C.44Leave44the44catheter44in44place44and44reattempt44with44another44catheter.
D.44Notify44the44health44care44provider44of44a44possible44obstruction.44-44answer--
Answer:44C
It44is44likely44that44the44first44catheter44is44in44the44vagina,44rather44than44the44bladder.44
Leaving44the44first44catheter44in44place44will44help44locate44the44meatus44when44attempti
ng44the44second44catheterization44(C).44The44client44should44have44at44least4424044mL44
of44urine44after44844hours.44(A)44does44not44resolve44the44problem.44(B)44will44not44chan
ge44the44location44of44the44catheter44unless44it44is44completely44removed,44in44which44ca
se44a44new44catheter44must44be44used.44There44is44no44evidence44of44a44urinary44tract44
obstruction44if44the44catheter44could44be44easily44inserted44(D).
The44nurse44is44teaching44an44obese44client,44newly44diagnosed44with44arteriosclerosis,4
4about44reducing44the44risk44of44a44heart44attack44or44stroke.44Which44health44promotion
44brochure44is44most44important44for44the44nurse44to44provide44to44this44client?
A.44"Monitoring44Your44Blood44Pressure44at44Home"
B.44"Smoking44Cessation44as44a44Lifelong44Commitment"
C.44"Decreasing44Cholesterol44Levels44Through44Diet"
D.44"Stress44Management44for44a44Healthier44You"44-44answer--Answer:44C
A44health44promotion44brochure44about44decreasing44cholesterol44(C)44is44most44import
ant44to44provide44this44client,44because44the44most44significant44risk44factor44contributing
44to44development44of44arteriosclerosis44is44excess44dietary44fat,44particularly44saturated
44fat44and44cholesterol.44(A)44does44not44address44the44underlying44causes44of44arterios
clerosis.44(B44and44D)44are44also44important44factors44for44reversing44arteriosclerosis44b
ut44are44not44as44important44as44lowering44cholesterol44(C).
,Ten44minutes44after44signing44an44operative44permit44for44a44fractured44hip,44an44older44
client44states,44"The44aliens44will44be44coming44to44get44me44soon!"44and44falls44asleep.4
4Which44action44should44the44nurse44implement44next?
A.44Make44the44client44comfortable44and44allow44the44client44to44sleep.
B.44Assess44the44client's44neurologic44status.
C.44Notify44the44surgeon44about44the44comment.
D.44Ask44the44client's44family44to44co-sign44the44operative44permit.44-44answer--
Answer:44B
This44statement44may44indicate44that44the44client44is44confused.44Informed44consent44m
ust44be44provided44by44a44mentally44competent44individual,44so44the44nurse44should44furt
her44assess44the44client's44neurologic44status44(B)44to44be44sure44that44the44client44unde
rstands44and44can44legally44provide44consent44for44surgery.44(A)44does44not44provide44s
ufficient44follow-
up.44If44the44nurse44determines44that44the44client44is44confused,44the44surgeon44must44b
e44notified44(C)44and44permission44obtained44from44the44next44of44kin44(D).
The44nurse-
manager44of44a44skilled44nursing44(chronic44care)44unit44is44instructing44UAPs44on44ways
44to44prevent44complications44of44immobility.44Which44intervention44should44be44included
44in44this44instruction?
A.44Perform44range-of-motion44exercises44to44prevent44contractures.
B.44Decrease44the44client's44fluid44intake44to44prevent44diarrhea.
C.44Massage44the44client's44legs44to44reduce44embolism44occurrence.
D.44Turn44the44client44from44side44to44back44every44shift.44-44answer--Answer:44A
Performing44range-of-
motion44exercises44(A)44is44beneficial44in44reducing44contractures44around44joints.44(B,44
C,44and44D)44are44all44potentially44harmful44practices44that44place44the44immobile44client
44at44risk44of44complications.
The44nurse44is44assisting44a44client44to44the44bathroom.44When44the44client44is44544feet44
from44the44bathroom44door,44he44states,44"I44feel44faint."44Before44the44nurse44can44get44
the44client44to44a44chair,44the44client44starts44to44fall.44Which44is44the44priority44action44for
44the44nurse44to44take?
A.44Check44the44client's44carotid44pulse.
B.44Encourage44the44client44to44get44to44the44toilet.
C.44In44a44loud44voice,44call44for44help.
D.44Gently44lower44the44client44to44the44floor.44-44answer--Answer:44D
(D)44is44the44most44prudent44intervention44and44is44the44priority44nursing44action44to44pre
vent44injury44to44the44client44and44the44nurse.44Lowering44the44client44to44the44floor44sho
uld44be44done44when44the44client44cannot44support44his44own44weight.44The44client44sho
uld44be44placed44in44a44bed44or44chair44only44when44sufficient44help44is44available44to44p
revent44injury.44(A)44is44important44but44should44be44done44after44the44client44is44in44a44s
afe44position.44Because44the44client44is44not44supporting44himself,44(B)44is44impractical.44
(C)44is44likely44to44cause44chaos44on44the44unit44and44might44alarm44the44other44clients.
, A44female44nurse44is44assigned44to44care44for44a44close44friend,44who44says,44"I44am44w
orried44that44friends44will44find44out44about44my44diagnosis."44The44nurse44tells44her44frie
nd44that44legally44she44must44protect44a44client's44confidentiality.44Which44resource44des
cribes44the44nurse's44legal44responsibilities?
A.44Code44of44Ethics44for44Nurses
B.44State44Nurse44Practice44Act
C.44Patient's44Bill44of44Rights
D.44ANA44Standards44of44Practice44-44answer--Answer:44B
The44State44Nurse44Practice44Act44(B)44contains44legal44requirements44for44the44protecti
on44of44client44confidentiality44and44the44consequences44for44breaches44in44confidentialit
y.44(A)44outlines44ethical44standards44for44nursing44care44but44does44not44include44legal4
4guidelines.44(C44and44D)44describe44expectations44for44nursing44practice44but44do44not4
4address44legal44implications.
The44nurse44is44teaching44a44client44how44to44perform44progressive44muscle44relaxation4
4techniques44to44relieve44insomnia.44A44week44later44the44client44reports44that44he44is44st
ill44unable44to44sleep,44despite44following44the44same44routine44every44night.44Which44ac
tion44should44the44nurse44take44first?
A.44Instruct44the44client44to44add44regular44exercise44as44a44daily44routine.
B.44Determine44if44the44client44has44been44keeping44a44sleep44diary.
C.44Encourage44the44client44to44continue44the44routine44until44sleep44is44achieved.
D.44Ask44the44client44to44describe44the44routine44that44the44client44is44currently44following
.44-44answer--Answer:44D
The44nurse44should44first44evaluate44whether44the44client44has44been44adhering44to44the
44original44instructions44(D).44A44verbal44report44of44the44client's44routine44will44provide44
more44specific44information44than44the44client's44written44diary44(B).44The44nurse44can44t
hen44determine44which44changes44need44to44be44made44(A).44The44routine44practiced44
by44the44client44is44clearly44unsuccessful,44so44encouragement44alone44is44insufficient44(
C).
A4465-year-
old44client44who44attends44an44adult44daycare44program44and44is44wheelchair-
mobile44has44redness44in44the44sacral44area.44Which44instruction44is44most44important44f
or44the44nurse44to44provide?
A.44Take44a44vitamin44supplement44tablet44once44a44day.
B.44Change44positions44in44the44chair44at44least44every44hour.
C.44Increase44daily44intake44of44water44or44other44oral44fluids.
D.44Purchase44a44newer44model44wheelchair.44-44answer--Answer:44B
The44most44important44teaching44is44to44change44positions44frequently44(B)44because44p
ressure44is44the44most44significant44factor44related44to44the44development44of44pressure4
4ulcers.44Increased44vitamin44and44fluid44intake44(A44and44C)44may44also44be44beneficial
44promote44healing44and44reduce44further44risk.44(D)44is44an44intervention44of44last44reso
rt44because44this44will44be44very44expensive44for44the44client.
When44turning44an44immobile44bedridden44client44without44assistance,44which44action44b
y44the44nurse44best44ensures44client44safety?
