EVOLVE HESI FUNDAMENTALS ACTUAL
EXAM PRACTICE QUESTIONS WITH
RATIONALE ANSWERS
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. ANSWER -Answer: 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. ANSWER -Answer: 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
C. High hemoglobin level
,D. High cholesterol level ANSWER -Answer: A
Long-term protein deficiency is required to cause significantly lowered serum albumin
levels (A). Albumin is made by the liver only when adequate amounts of amino acids (from
protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not
significantly alter serum levels. (B) is a serum protein with a half-life of only 8 to 10 days, so
it will drop with an acute protein deficiency. Neither (C or D) are clinical measures of
protein malnutrition.
The nurse identifies a potential for infection in a patient with partial-thickness (second-
degree) and full-thickness (third-degree) burns. What intervention has the highest priority
in decreasing the client's risk of infection?
A. Administration of plasma expanders
B. Use of careful hand washing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns ANSWER -Answer: B
Careful hand washing technique (B) is the single most effective intervention for the
prevention of contamination to all clients. (A) reverses the hypovolemia that initially
accompanies burn trauma but is not related to decreasing the proliferation of infective
organisms. (C and D) are recommended by various burn centers as possible ways to reduce
the chance of infection. (B) is a proven technique to prevent infection.
Which serum laboratory value should the nurse monitor carefully for a client who has a
nasogastric (NG) tube to suction for the past week?
A. White blood cell count
B. Albumin
C. Calcium
D. Sodium ANSWER -Answer: D
Monitoring serum sodium levels (D) for hyponatremia is indicated during prolonged NG
suctioning because of loss of fluids. Changes in levels of (A, B, or C) are not typically
associated with prolonged NG suctioning.
In completing a client's preoperative routine, the nurse finds that the operative permit is not
signed. The client begins to ask more questions about the surgical procedure. Which action
should the nurse take next?
A. Witness the client's signature to the permit.
,B. Answer the client's questions about the surgery.
C. Inform the surgeon that the operative permit is not signed and the client has questions
about the surgery.
D. Reassure the client that the surgeon will answer any questions before the anesthesia is
administered. ANSWER -Answer: C
The surgeon should be informed immediately that the permit is not signed (C). It is the
surgeon's responsibility to explain the procedure to the cliesxnt and obtain the client's
signature on the permit. Although the nurse can witness an operative permit (A), the
procedure must first be explained by the health care provider or surgeon, including
answering the client's questions (B). The client's questions should be addressed before the
permit is signed (D).
The nurse is preparing an older client for discharge. Which method is best for the nurse to
use when evaluating the client's ability to perform a dressing change at home?
A. Determine how the client feels about changing the dressing.
B. Ask the client to describe the procedure in writing.
C. Seek a family member's evaluation of the client's ability to change the dressing.
D. Observe the client change the dressing unassisted. ANSWER -Answer: D
Observing the client directly (D) will allow the nurse to determine if mastery of the skill has
been obtained and provide an opportunity to affirm the skill. (A) may be therapeutic but will
not provide an opportunity to evaluate the client's ability to perform the procedure. (B) may
be threatening to an older client and will not determine his ability. (C) is not as effective as
direct observation by the nurse.
A client in a long-term care facility reports to the nurse that he has not had a bowel
movement in 2 days. Which intervention should the nurse implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
B. Notify the health care provider and request a prescription for a large-volume enema.
C. Assess the client's medical record to determine the client's normal bowel pattern.
D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.
ANSWER -Answer: C
This client may not routinely have a daily bowel movement, so the nurse should first assess
this client's normal bowel habits before attempting any intervention (C). (A, B, or D) may
then be implemented, if warranted.
, The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best
meets the dietary needs of this client?
A. Steak, baked beans, and a salad
B. Broiled fish, green beans, and an apple
C. Pork chops, macaroni and cheese, and grapes
D. Avocado salad, milk, and angel food cake ANSWER -Answer: B
Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet,
such as (B). (A) is a high-protein diet and (C and D) contain high-fat foods, which are
contraindicated for this client.
When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
A. Remind the child to clean his genital area.
B. Defer perineal care because of the child's age.
C. Retract the foreskin gently to cleanse the penis.
D. Ask the parents why the child is not circumcised. ANSWER -Answer: C
The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that could
harbor bacteria (C). The child's cognitive development may not be at the level at which (A)
would be effective. Perineal care needs to be provided daily regardless of the client's age (B).
(D) is not indicated and may be perceived as intrusive.
The nurse who is preparing to give an adolescent client a prescribed antipsychotic
medication notes that parental consent has not been obtained. Which action should the
nurse take?
A. Review the chart for a signed consent for hospitalization.
B. Get the health care provider's permission to give the medication.
C. Do not give the medication and document the reason.
D. Complete an incident report and notify the parents. ANSWER -Answer: C
The nurse should not give the medication and should document the reason (C) because the
client is a minor and needs a guardian's permission to receive medications. Permission to
give medications is not granted by a signed hospital consent (A) or a health care provider's
permission (B), unless conditions are met to justify coerced treatment. (D) is not necessary
unless the medication had previously been administered.
EXAM PRACTICE QUESTIONS WITH
RATIONALE ANSWERS
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. ANSWER -Answer: 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. ANSWER -Answer: 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
C. High hemoglobin level
,D. High cholesterol level ANSWER -Answer: A
Long-term protein deficiency is required to cause significantly lowered serum albumin
levels (A). Albumin is made by the liver only when adequate amounts of amino acids (from
protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not
significantly alter serum levels. (B) is a serum protein with a half-life of only 8 to 10 days, so
it will drop with an acute protein deficiency. Neither (C or D) are clinical measures of
protein malnutrition.
The nurse identifies a potential for infection in a patient with partial-thickness (second-
degree) and full-thickness (third-degree) burns. What intervention has the highest priority
in decreasing the client's risk of infection?
A. Administration of plasma expanders
B. Use of careful hand washing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns ANSWER -Answer: B
Careful hand washing technique (B) is the single most effective intervention for the
prevention of contamination to all clients. (A) reverses the hypovolemia that initially
accompanies burn trauma but is not related to decreasing the proliferation of infective
organisms. (C and D) are recommended by various burn centers as possible ways to reduce
the chance of infection. (B) is a proven technique to prevent infection.
Which serum laboratory value should the nurse monitor carefully for a client who has a
nasogastric (NG) tube to suction for the past week?
A. White blood cell count
B. Albumin
C. Calcium
D. Sodium ANSWER -Answer: D
Monitoring serum sodium levels (D) for hyponatremia is indicated during prolonged NG
suctioning because of loss of fluids. Changes in levels of (A, B, or C) are not typically
associated with prolonged NG suctioning.
In completing a client's preoperative routine, the nurse finds that the operative permit is not
signed. The client begins to ask more questions about the surgical procedure. Which action
should the nurse take next?
A. Witness the client's signature to the permit.
,B. Answer the client's questions about the surgery.
C. Inform the surgeon that the operative permit is not signed and the client has questions
about the surgery.
D. Reassure the client that the surgeon will answer any questions before the anesthesia is
administered. ANSWER -Answer: C
The surgeon should be informed immediately that the permit is not signed (C). It is the
surgeon's responsibility to explain the procedure to the cliesxnt and obtain the client's
signature on the permit. Although the nurse can witness an operative permit (A), the
procedure must first be explained by the health care provider or surgeon, including
answering the client's questions (B). The client's questions should be addressed before the
permit is signed (D).
The nurse is preparing an older client for discharge. Which method is best for the nurse to
use when evaluating the client's ability to perform a dressing change at home?
A. Determine how the client feels about changing the dressing.
B. Ask the client to describe the procedure in writing.
C. Seek a family member's evaluation of the client's ability to change the dressing.
D. Observe the client change the dressing unassisted. ANSWER -Answer: D
Observing the client directly (D) will allow the nurse to determine if mastery of the skill has
been obtained and provide an opportunity to affirm the skill. (A) may be therapeutic but will
not provide an opportunity to evaluate the client's ability to perform the procedure. (B) may
be threatening to an older client and will not determine his ability. (C) is not as effective as
direct observation by the nurse.
A client in a long-term care facility reports to the nurse that he has not had a bowel
movement in 2 days. Which intervention should the nurse implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
B. Notify the health care provider and request a prescription for a large-volume enema.
C. Assess the client's medical record to determine the client's normal bowel pattern.
D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.
ANSWER -Answer: C
This client may not routinely have a daily bowel movement, so the nurse should first assess
this client's normal bowel habits before attempting any intervention (C). (A, B, or D) may
then be implemented, if warranted.
, The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best
meets the dietary needs of this client?
A. Steak, baked beans, and a salad
B. Broiled fish, green beans, and an apple
C. Pork chops, macaroni and cheese, and grapes
D. Avocado salad, milk, and angel food cake ANSWER -Answer: B
Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet,
such as (B). (A) is a high-protein diet and (C and D) contain high-fat foods, which are
contraindicated for this client.
When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
A. Remind the child to clean his genital area.
B. Defer perineal care because of the child's age.
C. Retract the foreskin gently to cleanse the penis.
D. Ask the parents why the child is not circumcised. ANSWER -Answer: C
The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that could
harbor bacteria (C). The child's cognitive development may not be at the level at which (A)
would be effective. Perineal care needs to be provided daily regardless of the client's age (B).
(D) is not indicated and may be perceived as intrusive.
The nurse who is preparing to give an adolescent client a prescribed antipsychotic
medication notes that parental consent has not been obtained. Which action should the
nurse take?
A. Review the chart for a signed consent for hospitalization.
B. Get the health care provider's permission to give the medication.
C. Do not give the medication and document the reason.
D. Complete an incident report and notify the parents. ANSWER -Answer: C
The nurse should not give the medication and should document the reason (C) because the
client is a minor and needs a guardian's permission to receive medications. Permission to
give medications is not granted by a signed hospital consent (A) or a health care provider's
permission (B), unless conditions are met to justify coerced treatment. (D) is not necessary
unless the medication had previously been administered.
