Evolve HESI Fundamentals Practice Qs
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. - ANSAnswer: 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).
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" - ANSAnswer: 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. - ANSAnswer: 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).
,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. - ANSAnswer: 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. - ANSAnswer: 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
confidentiality. Which resource describes the nurse's legal responsibilities?
A. Code of Ethics for Nurses
B. State Nurse Practice Act
C. Patient's Bill of Rights
D. ANA Standards of Practice - ANSAnswer: B
The State Nurse Practice Act (B) contains legal requirements for the protection of client
confidentiality and the consequences for breaches in confidentiality. (A) outlines ethical
standards for nursing care but does not include legal guidelines. (C and D) describe
expectations for nursing practice but do not address legal implications.
The nurse is teaching a client how to perform progressive muscle relaxation techniques to
relieve insomnia. A week later the client reports that he is still unable to sleep, despite following
the same routine every night. Which action should the nurse take first?
A. Instruct the client to add regular exercise 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. - ANSAnswer: D
, The nurse should first evaluate whether the client has been adhering to the original instructions
(D). A verbal report of the client's routine will provide more specific information than the client's
written diary (B). The nurse can then determine which changes need to be made (A). The
routine practiced by the client is clearly unsuccessful, so encouragement alone is insufficient
(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.
When turning an immobile bedridden client without assistance, which action by the nurse best
ensures client safety?
A. Securely grasp the client's arm and leg.
B. Put bed rails up on the side of bed opposite from the nurse.
C. Correctly position and use a turn sheet.
D. Lower the head of the client's bed slowly. - ANSAnswer: B
Because the nurse can only stand on one side of the bed, bed rails should be up on the
opposite side to ensure that the client does not fall out of bed (B). (A) can cause client injury to
the skin or joint. (C and D) are useful techniques while turning a client but have less priority in
terms of safety than use of the bed rails.
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
Cranberry juice (C) maintains urinary tract health by reducing the adherence of Escherichia coli
bacteria to cells within the bladder. (A, B, and D) have not been shown to be as effective as
cranberry juice (C) in preventing UTIs.
The nurse is aware that malnutrition is a common problem among clients served by a
community health clinic for the homeless. Which laboratory value is the most reliable indicator of
chronic protein malnutrition?
A. Low serum albumin level
B. Low serum transferrin level
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. - ANSAnswer: 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).
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" - ANSAnswer: 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. - ANSAnswer: 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).
,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. - ANSAnswer: 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. - ANSAnswer: 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
confidentiality. Which resource describes the nurse's legal responsibilities?
A. Code of Ethics for Nurses
B. State Nurse Practice Act
C. Patient's Bill of Rights
D. ANA Standards of Practice - ANSAnswer: B
The State Nurse Practice Act (B) contains legal requirements for the protection of client
confidentiality and the consequences for breaches in confidentiality. (A) outlines ethical
standards for nursing care but does not include legal guidelines. (C and D) describe
expectations for nursing practice but do not address legal implications.
The nurse is teaching a client how to perform progressive muscle relaxation techniques to
relieve insomnia. A week later the client reports that he is still unable to sleep, despite following
the same routine every night. Which action should the nurse take first?
A. Instruct the client to add regular exercise 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. - ANSAnswer: D
, The nurse should first evaluate whether the client has been adhering to the original instructions
(D). A verbal report of the client's routine will provide more specific information than the client's
written diary (B). The nurse can then determine which changes need to be made (A). The
routine practiced by the client is clearly unsuccessful, so encouragement alone is insufficient
(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.
When turning an immobile bedridden client without assistance, which action by the nurse best
ensures client safety?
A. Securely grasp the client's arm and leg.
B. Put bed rails up on the side of bed opposite from the nurse.
C. Correctly position and use a turn sheet.
D. Lower the head of the client's bed slowly. - ANSAnswer: B
Because the nurse can only stand on one side of the bed, bed rails should be up on the
opposite side to ensure that the client does not fall out of bed (B). (A) can cause client injury to
the skin or joint. (C and D) are useful techniques while turning a client but have less priority in
terms of safety than use of the bed rails.
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
Cranberry juice (C) maintains urinary tract health by reducing the adherence of Escherichia coli
bacteria to cells within the bladder. (A, B, and D) have not been shown to be as effective as
cranberry juice (C) in preventing UTIs.
The nurse is aware that malnutrition is a common problem among clients served by a
community health clinic for the homeless. Which laboratory value is the most reliable indicator of
chronic protein malnutrition?
A. Low serum albumin level
B. Low serum transferrin level
