EVOLVE HESI FUNDAMENTALS FINAL EXAM . QUESTIONS WITH CORRECT AND VERIFIED ANSWERS & RATIONALES. GRADED A+.

EVOLVE HESI FUNDAMENTALS FINAL EXAM . QUESTIONS WITH CORRECT AND VERIFIED ANSWERS & RATIONALES. GRADED A+. 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: 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: 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: 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: 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: 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: 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 rou - 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 wheelchairmobile 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: 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. - 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: 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: 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 halflife, 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: 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: 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 t - 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