EVOLVE HESI FUNDAMENTALS EXAM QUESTIONS WITH
COMPLETE SOLUTIONS WITH RATIONALE GUARANTEED PASS
BRAND NEW 2025
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 -
>-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" - 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. - 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. - 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. - 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 - 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. - 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.
D. Purchase a newer model wheelchair. - ANSWER - >-Answer: 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.
COMPLETE SOLUTIONS WITH RATIONALE GUARANTEED PASS
BRAND NEW 2025
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 -
>-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" - 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. - 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. - 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. - 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 - 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. - 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.
D. Purchase a newer model wheelchair. - ANSWER - >-Answer: 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.
