Fundamentals of Nursing Evolve HESI Real
Exams
Fundamentals of Nursing Evolve HESI Real
Exams 4 Questions Bank Review Latest |
Evolve Hesi Fundamentals Best Exam Prep
Test Bank- a Review of 340 Latest Correctly
Answered Questions with Rationales (New!)
Which action should the nurse implement when providing wound care instructions to a client
who does not speak English?
A. Ask an interpreter to provide wound care instructions.
P a g e 1 | 524
,Fundamentals of Nursing Evolve HESI Real
Exams
B. Speak directly to the client, with an interpreter translating.
C. Request the accompanying family member to translate.
D. Instruct a bilingual employee to read the instructions.
B
Rationale: Wound care instructions should be given directly to the client by the nurse with an
interpreter who is trained to provide accurate and objective translation in the client's primary
language, so that the client has the opportunity to ask questions during the teaching process.
The interpreter usually does not have any health care experience, so the nurse must provide
client teaching. Family members should not be used to translate instructions because the
client or family member may alter the instructions during conversation or be uncomfortable
with the topics discussed. The employee should be a trained interpreter to ensure that the
nurse's instructions are understood accurately by the client.
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: 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).
P a g e 2 | 524
,Fundamentals of Nursing Evolve HESI Real
Exams
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: 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: 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).
P a g e 3 | 524
, Fundamentals of Nursing Evolve HESI Real
Exams
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: 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: 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
P a g e 4 | 524
Exams
Fundamentals of Nursing Evolve HESI Real
Exams 4 Questions Bank Review Latest |
Evolve Hesi Fundamentals Best Exam Prep
Test Bank- a Review of 340 Latest Correctly
Answered Questions with Rationales (New!)
Which action should the nurse implement when providing wound care instructions to a client
who does not speak English?
A. Ask an interpreter to provide wound care instructions.
P a g e 1 | 524
,Fundamentals of Nursing Evolve HESI Real
Exams
B. Speak directly to the client, with an interpreter translating.
C. Request the accompanying family member to translate.
D. Instruct a bilingual employee to read the instructions.
B
Rationale: Wound care instructions should be given directly to the client by the nurse with an
interpreter who is trained to provide accurate and objective translation in the client's primary
language, so that the client has the opportunity to ask questions during the teaching process.
The interpreter usually does not have any health care experience, so the nurse must provide
client teaching. Family members should not be used to translate instructions because the
client or family member may alter the instructions during conversation or be uncomfortable
with the topics discussed. The employee should be a trained interpreter to ensure that the
nurse's instructions are understood accurately by the client.
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: 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).
P a g e 2 | 524
,Fundamentals of Nursing Evolve HESI Real
Exams
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: 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: 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).
P a g e 3 | 524
, Fundamentals of Nursing Evolve HESI Real
Exams
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: 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: 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
P a g e 4 | 524
