EVOLVE HESI FUNDAMENTALS
ACTUAL EXAM 2023/2024 EXPERT
VERIFIED WITH DETAILED ANSWERS
LATEST UPDATE
When the nurse enters a client's room to do an initial assessment, the client
shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse
respond? - ANSWER>>What is concerning you this morning?
The nurse is completing the plan of care for a client who is admitted for benign
prostatic hypertrophy. Which data should the nurse document as a subjective
finding? - ANSWER>>Complains of inability to empty bladder.
When preparing to administer an intravenous medication through a central
venous catheter, the nurse aspirates a blood return in one of the lumens of the
triple lumen catheter. Which action should the nurse implement? -
ANSWER>>Flush the lumen with the saline solution and administer the
medication through the lumen.
A nurse is preparing to insert a rectal suppository and observes a small amount
of rectal bleeding. Which action should the nurse implement? -
ANSWER>>Withhold the administration of the suppository until contacting the
healthcare provider.
The nurse formulates the nursing diagnosis of, "Ineffective health maintenance
related to lack of motivation" for a client with Type 2 diabetes. Which finding
,supports this nursing diagnosis? - ANSWER>>Eats anything and dose not think
diet makes a difference in health.
A client who has been on bedrest for several days now has a prescription to
progress activity as tolerated. When the nurse assists the client out of the bed for
the first time, the client becomes dizzy. What action should the nurse
implement? - ANSWER>>Advise the client to sit on the side of the bed for a few
minutes before standing again.
On the third postoperative day following thoracic surgery, a client reports feeling
constipated. Which intervention should the nurse implement to promote bowel
elimination? - ANSWER>>Provide warm prune juice before the client goes to
bed at night.
The nurse is preparing a male client who has an indwelling catheter and an IV
infusion to ambulate from the bed to a chair for the first time following
abdominal surgery. What action should the nurse implement prior to assisting
the client to the chair? - ANSWER>>-Pre-medicate the client with an analgesic
-inform the client of the plan for moving the chair
-Ask the client to push the IV pole to the chair
-assess the client's bp
A healthcare provider is preforming a sterile procedure at a client's bedside. Near
the end of the procedure, the nurse observes the healthcare provider
contaminate a sterile glove and the sterile field. What is the best action for the
nurse to implement? - ANSWER>>Identify the break in surgical asepsis and
provide another set of sterile supplies.
, The charge nurse assigns a nursing procedure to a new staff nurse who has not
previously performed the procedure. What action is most important for the new
staff nurse to take? - ANSWER>>Refuse to preform the task that is beyond the
nurse's experience.
Prior to administering a newly prescribed medication to a client, the nurse
reviews the adverse effects of the medication listed in a drug reference guide
and determines the priority risks to the client. While performing this action, the
nurse is engaged in which step of the nursing process? - ANSWER>>Analysis
A female client who has breast cancer with metastasis to the liver and spin is
admitted with constant, sever pain despite the around the clock use of
oxycodone and amitriptyline for pain control at home. During the admission
assessment, which information for the nurse to obtain? - ANSWER>>Sensory
pattern, area, intensity, and nature of the pain.
The nurse is digitally removing a fecal impaction for a client. The nurse should
stop the procedure and take corrective action if which client reaction is noted? -
ANSWER>>Pulse rate decreases from 78 to 52 beats per min
A male client with an infected wound tells the nurse that he follows a
macrobiotic diet. Which type of foods should the nurse recommend that the
client select from the hospital menu? - ANSWER>>Combination of plant proteins
to provide essential amino acids
Which statement is an example of a correctly written nursing diagnosis
statement? - ANSWER>>Ineffective coping related to response to positive
biopsy test results
ACTUAL EXAM 2023/2024 EXPERT
VERIFIED WITH DETAILED ANSWERS
LATEST UPDATE
When the nurse enters a client's room to do an initial assessment, the client
shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse
respond? - ANSWER>>What is concerning you this morning?
The nurse is completing the plan of care for a client who is admitted for benign
prostatic hypertrophy. Which data should the nurse document as a subjective
finding? - ANSWER>>Complains of inability to empty bladder.
When preparing to administer an intravenous medication through a central
venous catheter, the nurse aspirates a blood return in one of the lumens of the
triple lumen catheter. Which action should the nurse implement? -
ANSWER>>Flush the lumen with the saline solution and administer the
medication through the lumen.
A nurse is preparing to insert a rectal suppository and observes a small amount
of rectal bleeding. Which action should the nurse implement? -
ANSWER>>Withhold the administration of the suppository until contacting the
healthcare provider.
The nurse formulates the nursing diagnosis of, "Ineffective health maintenance
related to lack of motivation" for a client with Type 2 diabetes. Which finding
,supports this nursing diagnosis? - ANSWER>>Eats anything and dose not think
diet makes a difference in health.
A client who has been on bedrest for several days now has a prescription to
progress activity as tolerated. When the nurse assists the client out of the bed for
the first time, the client becomes dizzy. What action should the nurse
implement? - ANSWER>>Advise the client to sit on the side of the bed for a few
minutes before standing again.
On the third postoperative day following thoracic surgery, a client reports feeling
constipated. Which intervention should the nurse implement to promote bowel
elimination? - ANSWER>>Provide warm prune juice before the client goes to
bed at night.
The nurse is preparing a male client who has an indwelling catheter and an IV
infusion to ambulate from the bed to a chair for the first time following
abdominal surgery. What action should the nurse implement prior to assisting
the client to the chair? - ANSWER>>-Pre-medicate the client with an analgesic
-inform the client of the plan for moving the chair
-Ask the client to push the IV pole to the chair
-assess the client's bp
A healthcare provider is preforming a sterile procedure at a client's bedside. Near
the end of the procedure, the nurse observes the healthcare provider
contaminate a sterile glove and the sterile field. What is the best action for the
nurse to implement? - ANSWER>>Identify the break in surgical asepsis and
provide another set of sterile supplies.
, The charge nurse assigns a nursing procedure to a new staff nurse who has not
previously performed the procedure. What action is most important for the new
staff nurse to take? - ANSWER>>Refuse to preform the task that is beyond the
nurse's experience.
Prior to administering a newly prescribed medication to a client, the nurse
reviews the adverse effects of the medication listed in a drug reference guide
and determines the priority risks to the client. While performing this action, the
nurse is engaged in which step of the nursing process? - ANSWER>>Analysis
A female client who has breast cancer with metastasis to the liver and spin is
admitted with constant, sever pain despite the around the clock use of
oxycodone and amitriptyline for pain control at home. During the admission
assessment, which information for the nurse to obtain? - ANSWER>>Sensory
pattern, area, intensity, and nature of the pain.
The nurse is digitally removing a fecal impaction for a client. The nurse should
stop the procedure and take corrective action if which client reaction is noted? -
ANSWER>>Pulse rate decreases from 78 to 52 beats per min
A male client with an infected wound tells the nurse that he follows a
macrobiotic diet. Which type of foods should the nurse recommend that the
client select from the hospital menu? - ANSWER>>Combination of plant proteins
to provide essential amino acids
Which statement is an example of a correctly written nursing diagnosis
statement? - ANSWER>>Ineffective coping related to response to positive
biopsy test results
