Evolve Fundamentals HESI Complete Solutions for
Each Question With Comprehensive Explanations
and Solutions Chosen from Top Universities Expert-
Verified Questions and Answers
Three days following surgery, a male client observes his colostomy for the first time. He
becomes quite upset and tells the nurse that it is much bigger than he expected. What is
the best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma appearance in time.
B. Instruct the client that the stoma will become smaller when the initial swelling
diminishes.
C. Offer to contact a member of the local ostomy support group to help him with his
concerns.
D. Encourage the client to handle the stoma equipment to gain confidence with the
procedure. - CORRECT ANSWER- -Postoperative swelling causes enlargement of the
stoma. The nurse can teach the client that the stoma will become smaller when the
swelling is diminished (B). This will help reduce the client's anxiety and promote
acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is a
useful action, and may be taken after the nurse provides pertinent teaching. The client is
not yet demonstrating readiness to learn colostomy care (D).
Correct Answer: B
At the time of the first dressing change, the client refuses to look at her mastectomy
incision. The nurse tells the client that the incision is healing well, but the client refuses to
talk about it. What would be an appropriate response to this client's silence?
,A. "It is normal to feel angry and depressed, but the sooner you deal with this surgery, the
better you will feel."
B. "Looking at your incision can be frightening, but facing this fear is a necessary part of
your recovery."
C. "It is OK if you don't want to talk about your surgery. I will be available when you are
ready."
D. "I will ask a woman who has had a mastectomy to come by and share her experiences
with you." - CORRECT ANSWER- -(C) displays sensitivity and understanding without judging
the client. (A) is judgmental in that it is telling the client how she feels and is also
insensitive. (B) would give the client a chance to talk, but is also demanding and
demeaning. (D) displays a positive action, but, because the nurse's personal support is not
offered, this response could be interpreted as dismissing the client and avoiding the
problem.
Correct Answer: C
The nurse witnesses the signature of a client who has signed an informed consent. Which
statement best explains this nursing responsibility?
A. The client voluntarily signed the form.
B. The client fully understands the procedure.
C. The client agrees with the procedure to be done.
D. The client authorizes continued treatment. - CORRECT ANSWER- -The nurse signs the
consent form to witness that the client voluntarily signs the consent (A), that the client's
signature is authentic, and that the client is otherwise competent to give consent. It is the
healthcare provider's responsibility to ensure the client fully understands the procedure
(B). The nurse's signature does not indicate (C or D).
Correct Answer: A
, The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions
should the nurse give the UAP?
A. Remain calm with the client and record abnormal results in the chart.
B. Notify the medication nurse immediately if the pulse or blood pressure is low.
C. Report the results of the vital signs to the nurse.
D. Reassure the client that the vital signs are normal. - CORRECT ANSWER- -Interpretation
of vital signs is the responsibility of the nurse, so the UAP should report vital sign
measurements to the nurse (C). (A, B, and D) require the UAP to interpret the vital signs,
which is beyond the scope of the UAP's authority.
Correct Answer: C
An adult male client with a history of hypertension tells the nurse that he is tired of taking
antihypertensive medications and is going to try spiritual meditation instead. What should
be the nurse's first response?
A. "It is important that you continue your medication while learning to meditate."
B. "Spiritual meditation requires a time commitment of 15 to 20 minutes daily."
C. "Obtain your healthcare provider's permission before starting meditation."
D. "Complementary therapy and western medicine can be effective for you." - CORRECT
ANSWER- -The prolonged practice of meditation may lead to a reduced need for
antihypertensive medications. However, the medications must be continued (A) while the
physiologic response to meditation is monitored. (B) is not as important as continuing the
medication. The healthcare provider should be informed, but permission is not required to
meditate (C). Although it is true that this complimentary therapy might be effective (D), it is
essential that the client continue with antihypertensive medications until the effect of
meditation can be measured.
Correct Answer: A
Each Question With Comprehensive Explanations
and Solutions Chosen from Top Universities Expert-
Verified Questions and Answers
Three days following surgery, a male client observes his colostomy for the first time. He
becomes quite upset and tells the nurse that it is much bigger than he expected. What is
the best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma appearance in time.
B. Instruct the client that the stoma will become smaller when the initial swelling
diminishes.
C. Offer to contact a member of the local ostomy support group to help him with his
concerns.
D. Encourage the client to handle the stoma equipment to gain confidence with the
procedure. - CORRECT ANSWER- -Postoperative swelling causes enlargement of the
stoma. The nurse can teach the client that the stoma will become smaller when the
swelling is diminished (B). This will help reduce the client's anxiety and promote
acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is a
useful action, and may be taken after the nurse provides pertinent teaching. The client is
not yet demonstrating readiness to learn colostomy care (D).
Correct Answer: B
At the time of the first dressing change, the client refuses to look at her mastectomy
incision. The nurse tells the client that the incision is healing well, but the client refuses to
talk about it. What would be an appropriate response to this client's silence?
,A. "It is normal to feel angry and depressed, but the sooner you deal with this surgery, the
better you will feel."
B. "Looking at your incision can be frightening, but facing this fear is a necessary part of
your recovery."
C. "It is OK if you don't want to talk about your surgery. I will be available when you are
ready."
D. "I will ask a woman who has had a mastectomy to come by and share her experiences
with you." - CORRECT ANSWER- -(C) displays sensitivity and understanding without judging
the client. (A) is judgmental in that it is telling the client how she feels and is also
insensitive. (B) would give the client a chance to talk, but is also demanding and
demeaning. (D) displays a positive action, but, because the nurse's personal support is not
offered, this response could be interpreted as dismissing the client and avoiding the
problem.
Correct Answer: C
The nurse witnesses the signature of a client who has signed an informed consent. Which
statement best explains this nursing responsibility?
A. The client voluntarily signed the form.
B. The client fully understands the procedure.
C. The client agrees with the procedure to be done.
D. The client authorizes continued treatment. - CORRECT ANSWER- -The nurse signs the
consent form to witness that the client voluntarily signs the consent (A), that the client's
signature is authentic, and that the client is otherwise competent to give consent. It is the
healthcare provider's responsibility to ensure the client fully understands the procedure
(B). The nurse's signature does not indicate (C or D).
Correct Answer: A
, The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions
should the nurse give the UAP?
A. Remain calm with the client and record abnormal results in the chart.
B. Notify the medication nurse immediately if the pulse or blood pressure is low.
C. Report the results of the vital signs to the nurse.
D. Reassure the client that the vital signs are normal. - CORRECT ANSWER- -Interpretation
of vital signs is the responsibility of the nurse, so the UAP should report vital sign
measurements to the nurse (C). (A, B, and D) require the UAP to interpret the vital signs,
which is beyond the scope of the UAP's authority.
Correct Answer: C
An adult male client with a history of hypertension tells the nurse that he is tired of taking
antihypertensive medications and is going to try spiritual meditation instead. What should
be the nurse's first response?
A. "It is important that you continue your medication while learning to meditate."
B. "Spiritual meditation requires a time commitment of 15 to 20 minutes daily."
C. "Obtain your healthcare provider's permission before starting meditation."
D. "Complementary therapy and western medicine can be effective for you." - CORRECT
ANSWER- -The prolonged practice of meditation may lead to a reduced need for
antihypertensive medications. However, the medications must be continued (A) while the
physiologic response to meditation is monitored. (B) is not as important as continuing the
medication. The healthcare provider should be informed, but permission is not required to
meditate (C). Although it is true that this complimentary therapy might be effective (D), it is
essential that the client continue with antihypertensive medications until the effect of
meditation can be measured.
Correct Answer: A
