EVOLVE HESI FUNDAMENTALS
PRACTICE QUESTIONS WITH
ANSWERS.
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. - Correct
Answer-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).
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" - Correct Answer-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. - Correct
Answer-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).
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. - Correct Answer-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. - Correct Answer-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 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 - Correct Answer-Answer: 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. - Correct Answer-Answer: 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.
PRACTICE QUESTIONS WITH
ANSWERS.
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. - Correct
Answer-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).
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" - Correct Answer-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. - Correct
Answer-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).
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. - Correct Answer-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. - Correct Answer-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 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 - Correct Answer-Answer: 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. - Correct Answer-Answer: 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.
