Nightingale College BSN 246
Evolve HESI Fundamentals Practice Qs EXAM QUESTIONS
AND CORRECT VERIFIED ANSWERS/ ALREADY GRADED A+
(MOST RECENT!!)
Students also studied
C
Terms in this set (74)
Urinary catheterization is prescribed for a Answer: C
postoperative female client who has been It is likely that the first catheter is in the vagina, rather than the
unable to void for 8 hours. The nurse inserts bladder. Leaving the first catheter in place will help
locate the the catheter, but no urine is seen in the meatus when attempting the second catheterization
(C). The tubing. Which action will the nurse take client should have at least 240 mL of urine after 8
hours. (A) next? does not resolve the problem. (B) will not change the location
A. Clamp the catheter and recheck it in 60 of the catheter unless it is completely removed, in which case
minutes. a new catheter must be used. There is no evidence of a
urinary
B.Pull the catheter back 3 inches and tract obstruction if the catheter could be easily inserted
(D). redirect upward.
C. Leave the catheter in place and
reattempt with another catheter.
D.Notify the health care provider of a
possible obstruction.
The nurse is teaching an obese client, newly Answer: C
diagnosed with arteriosclerosis, about A health promotion brochure about decreasing
cholesterol reducing the risk of a heart attack or stroke. (C) is most important to provide this
client, because the most Which health promotion brochure is most significant risk factor
contributing to development of
important for the nurse to provide to this arteriosclerosis is excess dietary fat, particularly saturated fat
client? and cholesterol. (A) does not address the underlying causes
A. "Monitoring Your Blood Pressure at of arteriosclerosis. (B and D) are also important factors for
Home" reversing arteriosclerosis but are not as important as
lowering
B."Smoking Cessation as a Lifelong cholesterol (C).
Commitment"
C. "Decreasing Cholesterol Levels Through
Diet"
D."Stress Management for a Healthier You"
,Ten minutes after signing an operative Answer: B
permit for a fractured hip, an older client This statement may indicate that the client is confused.
states, "The aliens will be coming to get me Informed consent must be provided by a mentally competent
soon!" and falls asleep. Which action shouldindividual, so the nurse should further assess the client's
the nurse implement next? neurologic status (B) to be sure that the client understands
A. Make the client comfortable and allow and can legally provide consent for surgery. (A) does
not the client to sleep. provide sufficient follow-up. If the nurse determines that
the
B. Assess the client's neurologic status. client is confused, the
surgeon must be notified (C) and
C. Notify the surgeon about the comment. permission obtained from the next of kin (D).
D.Ask the client's family to co-sign
the operative permit.
The nurse-manager of a skilled nursing Answer: A
(chronic care) unit is instructing UAPs on Performing range-of-motion exercises (A) is beneficial in
ways to prevent complications of immobility. reducing contractures around joints. (B, C, and D)
are all Which intervention should be included in potentially harmful practices that place the
immobile client at this instruction? risk of complications.
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.
The nurse is assisting a client to the Answer: D
bathroom. When the client is 5 feet from the (D) is the most prudent intervention and is the priority
nursing bathroom door, he states, "I feel faint." action to prevent injury to the client and the nurse.
Lowering Before the nurse can get the client to a the client to the floor should be done when the
client cannot chair, the client starts to fall. Which is the support his own weight. The client
should be placed in a bed priority action for the nurse to take? or chair only when sufficient help is
available to prevent injury.
A. Check the client's carotid pulse. (A) is important but should be done after the client is in a safe
B.Encourage the client to get to the toilet. position. Because the client is not supporting himself, (B) is
C. In a loud voice, call for help. impractical. (C) is likely to cause chaos on the unit and might
D.Gently lower the client to the floor. alarm the other clients.
A female nurse is assigned to care for a Answer: B
close friend, who says, "I am worried that The State Nurse Practice Act (B) contains legal
requirements friends will find out about my diagnosis." The for the protection of client
confidentiality and the
nurse tells her friend that legally she must consequences for breaches in confidentiality. (A) outlines
protect a client's confidentiality. Which ethical standards for nursing care but does not include legal
resource describes the nurse's legal guidelines. (C and D) describe expectations for nursing
responsibilities? practice but do not address legal implications.
A. Code of Ethics for Nurses
B.State Nurse Practice Act
C. Patient's Bill of Rights
D.ANA Standards of Practice
, The nurse is teaching a client how to Answer: D
perform progressive muscle relaxation The nurse should first evaluate whether the client has
been techniques to relieve insomnia. A week later adhering to the original instructions (D). A verbal
report of the the client reports that he is still unable to client's routine will provide more specific
information than the sleep, despite following the same routine client's written diary (B). The nurse can
then determine which every night. Which action should the nurse changes need to be made (A).
The routine practiced by the take first? client is clearly unsuccessful, so encouragement alone is
A. Instruct the client to add regular exercise insufficient (C).
as a daily routine.
B.Determine if the client has been
keeping a sleep diary.
C. Encourage the client to continue the
routine until sleep is achieved.
D.Ask the client to describe the routine
that the client is currently following.
A 65-year-old client who attends an adult Answer: B
daycare program and is wheelchair-mobile The most important teaching is to change positions
frequently has redness in the sacral area. Which (B) because pressure is the most significant factor
related to instruction is most important for the nurse to the development of pressure ulcers.
Increased vitamin and
provide? fluid intake (A and C) may also be beneficial promote healing
A. Take a vitamin supplement tablet once a and reduce further risk. (D) is an intervention of last resort
day. because this will be very expensive for the client.
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.
When turning an immobile bedridden client Answer: B
without assistance, which action by the Because the nurse can only stand on one side of the bed, bed
nurse best ensures client safety? rails should be up on the opposite side to ensure that the
A. Securely grasp the client's arm and leg. client does not fall out of bed (B). (A) can cause client injury to
B.Put bed rails up on the side of bed the skin or joint. (C and D) are useful techniques while
turning opposite from the nurse. a client but have less priority in terms of safety than use of
the
C. Correctly position and use a turn sheet. bed rails.
D.Lower the head of the client's bed slowly.
A female client with frequent urinary tract Answer: C
infections (UTIs) asks the nurse to explain Cranberry juice (C) maintains urinary tract health by
reducing her friend's advice about drinking a glass of the adherence of Escherichia coli
bacteria to cells within the juice daily to prevent future UTIs. Which bladder. (A, B, and D) have not
been shown to be as effective response is best for the nurse provide? as cranberry juice (C) in
preventing UTIs.
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.
Evolve HESI Fundamentals Practice Qs EXAM QUESTIONS
AND CORRECT VERIFIED ANSWERS/ ALREADY GRADED A+
(MOST RECENT!!)
Students also studied
C
Terms in this set (74)
Urinary catheterization is prescribed for a Answer: C
postoperative female client who has been It is likely that the first catheter is in the vagina, rather than the
unable to void for 8 hours. The nurse inserts bladder. Leaving the first catheter in place will help
locate the the catheter, but no urine is seen in the meatus when attempting the second catheterization
(C). The tubing. Which action will the nurse take client should have at least 240 mL of urine after 8
hours. (A) next? does not resolve the problem. (B) will not change the location
A. Clamp the catheter and recheck it in 60 of the catheter unless it is completely removed, in which case
minutes. a new catheter must be used. There is no evidence of a
urinary
B.Pull the catheter back 3 inches and tract obstruction if the catheter could be easily inserted
(D). redirect upward.
C. Leave the catheter in place and
reattempt with another catheter.
D.Notify the health care provider of a
possible obstruction.
The nurse is teaching an obese client, newly Answer: C
diagnosed with arteriosclerosis, about A health promotion brochure about decreasing
cholesterol reducing the risk of a heart attack or stroke. (C) is most important to provide this
client, because the most Which health promotion brochure is most significant risk factor
contributing to development of
important for the nurse to provide to this arteriosclerosis is excess dietary fat, particularly saturated fat
client? and cholesterol. (A) does not address the underlying causes
A. "Monitoring Your Blood Pressure at of arteriosclerosis. (B and D) are also important factors for
Home" reversing arteriosclerosis but are not as important as
lowering
B."Smoking Cessation as a Lifelong cholesterol (C).
Commitment"
C. "Decreasing Cholesterol Levels Through
Diet"
D."Stress Management for a Healthier You"
,Ten minutes after signing an operative Answer: B
permit for a fractured hip, an older client This statement may indicate that the client is confused.
states, "The aliens will be coming to get me Informed consent must be provided by a mentally competent
soon!" and falls asleep. Which action shouldindividual, so the nurse should further assess the client's
the nurse implement next? neurologic status (B) to be sure that the client understands
A. Make the client comfortable and allow and can legally provide consent for surgery. (A) does
not the client to sleep. provide sufficient follow-up. If the nurse determines that
the
B. Assess the client's neurologic status. client is confused, the
surgeon must be notified (C) and
C. Notify the surgeon about the comment. permission obtained from the next of kin (D).
D.Ask the client's family to co-sign
the operative permit.
The nurse-manager of a skilled nursing Answer: A
(chronic care) unit is instructing UAPs on Performing range-of-motion exercises (A) is beneficial in
ways to prevent complications of immobility. reducing contractures around joints. (B, C, and D)
are all Which intervention should be included in potentially harmful practices that place the
immobile client at this instruction? risk of complications.
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.
The nurse is assisting a client to the Answer: D
bathroom. When the client is 5 feet from the (D) is the most prudent intervention and is the priority
nursing bathroom door, he states, "I feel faint." action to prevent injury to the client and the nurse.
Lowering Before the nurse can get the client to a the client to the floor should be done when the
client cannot chair, the client starts to fall. Which is the support his own weight. The client
should be placed in a bed priority action for the nurse to take? or chair only when sufficient help is
available to prevent injury.
A. Check the client's carotid pulse. (A) is important but should be done after the client is in a safe
B.Encourage the client to get to the toilet. position. Because the client is not supporting himself, (B) is
C. In a loud voice, call for help. impractical. (C) is likely to cause chaos on the unit and might
D.Gently lower the client to the floor. alarm the other clients.
A female nurse is assigned to care for a Answer: B
close friend, who says, "I am worried that The State Nurse Practice Act (B) contains legal
requirements friends will find out about my diagnosis." The for the protection of client
confidentiality and the
nurse tells her friend that legally she must consequences for breaches in confidentiality. (A) outlines
protect a client's confidentiality. Which ethical standards for nursing care but does not include legal
resource describes the nurse's legal guidelines. (C and D) describe expectations for nursing
responsibilities? practice but do not address legal implications.
A. Code of Ethics for Nurses
B.State Nurse Practice Act
C. Patient's Bill of Rights
D.ANA Standards of Practice
, The nurse is teaching a client how to Answer: D
perform progressive muscle relaxation The nurse should first evaluate whether the client has
been techniques to relieve insomnia. A week later adhering to the original instructions (D). A verbal
report of the the client reports that he is still unable to client's routine will provide more specific
information than the sleep, despite following the same routine client's written diary (B). The nurse can
then determine which every night. Which action should the nurse changes need to be made (A).
The routine practiced by the take first? client is clearly unsuccessful, so encouragement alone is
A. Instruct the client to add regular exercise insufficient (C).
as a daily routine.
B.Determine if the client has been
keeping a sleep diary.
C. Encourage the client to continue the
routine until sleep is achieved.
D.Ask the client to describe the routine
that the client is currently following.
A 65-year-old client who attends an adult Answer: B
daycare program and is wheelchair-mobile The most important teaching is to change positions
frequently has redness in the sacral area. Which (B) because pressure is the most significant factor
related to instruction is most important for the nurse to the development of pressure ulcers.
Increased vitamin and
provide? fluid intake (A and C) may also be beneficial promote healing
A. Take a vitamin supplement tablet once a and reduce further risk. (D) is an intervention of last resort
day. because this will be very expensive for the client.
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.
When turning an immobile bedridden client Answer: B
without assistance, which action by the Because the nurse can only stand on one side of the bed, bed
nurse best ensures client safety? rails should be up on the opposite side to ensure that the
A. Securely grasp the client's arm and leg. client does not fall out of bed (B). (A) can cause client injury to
B.Put bed rails up on the side of bed the skin or joint. (C and D) are useful techniques while
turning opposite from the nurse. a client but have less priority in terms of safety than use of
the
C. Correctly position and use a turn sheet. bed rails.
D.Lower the head of the client's bed slowly.
A female client with frequent urinary tract Answer: C
infections (UTIs) asks the nurse to explain Cranberry juice (C) maintains urinary tract health by
reducing her friend's advice about drinking a glass of the adherence of Escherichia coli
bacteria to cells within the juice daily to prevent future UTIs. Which bladder. (A, B, and D) have not
been shown to be as effective response is best for the nurse provide? as cranberry juice (C) in
preventing UTIs.
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.
