EVOLVE FUNDAMENTALS HESI EXAM
WITH CORRECT ANSWERS.
An elderly client with a fractured left hip is on strict bedrest. Which nursing
measure is essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position. - CorreCt
Answers -To avoid shearing forces when repositioning, the client should be
lifted gently across a surface (D). Reddened areas should not be massaged
(A) since this may increase the damage to already traumatized skin. To
control pain and muscle spasms, active range of motion (B) may be limited
on the affected leg. The position described in (C) is contraindicated for a
client with a fractured left hip.
Correct Answer: D
The nurse providing care for a client with a diagnosis of neutropenia
reviews isolation procedures with the client's spouse. The nurse determines
that the teaching was effective when the spouse states that protective
environment isolation helps prevent the spread of infection in which
direction? - CorreCt Answers -To the client from outside sources
Which statement is true about the nursing model "team nursing"? - CorreCt
Answers -Hierarchical communication exists from charge nurse to charge
nurse, charge nurse to team leader, and team leader to team members.
,A nurse is teaching continuing care assistants about ways to prevent the
spread of infection. It would be appropriate for the nurse to emphasize that
the cycle of the infectious process must be broken, which is accomplished
primarily through what? - CorreCt Answers -Hand washing before and after
providing client care
Which developmental changes should be evaluated in girls around 12 years
of age? - CorreCt Answers -Skeletal growth
Which action made by the client indicates that they are in the
precontemplation stage of Transtheoretical Model of Change? - CorreCt
Answers -Refuses to think about changing
The nurse observes that a male client has removed the covering from an ice
pack applied to his knee. What action should the nurse take first?
A) Observe the appearance of the skin under the ice pack
B) Instruct the client regarding the need for the covering.
C) Reapply the covering after filling with fresh ice.
D) Ask the client how long the ice was applied to the skin. - CorreCt
Answers -A) Observe the appearance of the skin under the ice pack.
Which assessment data provides the most accurate determination of proper
placement of a nasogastric tube?
A) Aspirating gastric contents to assure a pH value of 4 or less.
B) Hearing air pass in the stomach after injecting air into the tubing.
C) Examining a chest x-ray obtained after the tubing was inserted.
,D) Checking the remaining length of tubing to ensure that the correct
length was inserted. - CorreCt Answers -C) Examining a chest x-ray
obtained after the tubing was inserted.
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 Answers -B) Instruct the client that the stoma
will become smaller when the initial swelling diminishes.
A female client with a nasogastric tube attached to low suction states that
she is nauseated. The nurse assesses that there has been no drainage
through the nasogastric tube in the last two hours. What action should the
nurse take first?
A) Irrigate the nasogastric tube with sterile normal saline.
B) Reposition the client on her side.
C) Advance the nasogastric tube an additional five centimeters.
D) Administer an intravenous antiemetic prescribed for PRN use. - CorreCt
Answers -B) Reposition the client on her side.
A hospitalized male client is receiving nasogastric tube feedings via a small-
bore tube and a continuous pump infusions. He reports that he had a bad
, bout of severe coughing a few minutes ago, but feels fine now. What action
is best for the nurse to take?
A) Record the coughing incident. No further action is required at this time.
B) Stop the feeding, explain to the family why it is being stopped and notify
the healthcare provider.
C) After clearing the tube with 30 mL of air, check the pH of fluid
withdrawn from the tube.
D) Inject 30 mL of air into the tube while auscultating the epigastrium for
gurgling. - CorreCt Answers -C) After clearing the tube with 30 ml of air,
check the pH of fluid withdrawn from the tube.
A male client tells the nurse that he does not know where he is or what year
it is. What data should the nurse document that is most accurate?
A) demonstrate loss of remote memory.
B) exhibits expressive dysphasia
C) has a diminished attention span
D) is disoriented to place and time - CorreCt Answers -D) is disoriented to
place and time
A client with chronic kidney disease selects scrambled egg for his breakfast.
What action should the nurse take?
A) Commend the client for selecting a high biologic value protein.
B) Remind the client that protein in the diet should be avoided.
C) Suggest that the client also select orange juice, to promote absorption.
D) Encourage the client to attend classes on dietary management of CKD. -
CorreCt Answers -A) Commend the client for selecting a high biologic value
protein.
WITH CORRECT ANSWERS.
An elderly client with a fractured left hip is on strict bedrest. Which nursing
measure is essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position. - CorreCt
Answers -To avoid shearing forces when repositioning, the client should be
lifted gently across a surface (D). Reddened areas should not be massaged
(A) since this may increase the damage to already traumatized skin. To
control pain and muscle spasms, active range of motion (B) may be limited
on the affected leg. The position described in (C) is contraindicated for a
client with a fractured left hip.
Correct Answer: D
The nurse providing care for a client with a diagnosis of neutropenia
reviews isolation procedures with the client's spouse. The nurse determines
that the teaching was effective when the spouse states that protective
environment isolation helps prevent the spread of infection in which
direction? - CorreCt Answers -To the client from outside sources
Which statement is true about the nursing model "team nursing"? - CorreCt
Answers -Hierarchical communication exists from charge nurse to charge
nurse, charge nurse to team leader, and team leader to team members.
,A nurse is teaching continuing care assistants about ways to prevent the
spread of infection. It would be appropriate for the nurse to emphasize that
the cycle of the infectious process must be broken, which is accomplished
primarily through what? - CorreCt Answers -Hand washing before and after
providing client care
Which developmental changes should be evaluated in girls around 12 years
of age? - CorreCt Answers -Skeletal growth
Which action made by the client indicates that they are in the
precontemplation stage of Transtheoretical Model of Change? - CorreCt
Answers -Refuses to think about changing
The nurse observes that a male client has removed the covering from an ice
pack applied to his knee. What action should the nurse take first?
A) Observe the appearance of the skin under the ice pack
B) Instruct the client regarding the need for the covering.
C) Reapply the covering after filling with fresh ice.
D) Ask the client how long the ice was applied to the skin. - CorreCt
Answers -A) Observe the appearance of the skin under the ice pack.
Which assessment data provides the most accurate determination of proper
placement of a nasogastric tube?
A) Aspirating gastric contents to assure a pH value of 4 or less.
B) Hearing air pass in the stomach after injecting air into the tubing.
C) Examining a chest x-ray obtained after the tubing was inserted.
,D) Checking the remaining length of tubing to ensure that the correct
length was inserted. - CorreCt Answers -C) Examining a chest x-ray
obtained after the tubing was inserted.
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 Answers -B) Instruct the client that the stoma
will become smaller when the initial swelling diminishes.
A female client with a nasogastric tube attached to low suction states that
she is nauseated. The nurse assesses that there has been no drainage
through the nasogastric tube in the last two hours. What action should the
nurse take first?
A) Irrigate the nasogastric tube with sterile normal saline.
B) Reposition the client on her side.
C) Advance the nasogastric tube an additional five centimeters.
D) Administer an intravenous antiemetic prescribed for PRN use. - CorreCt
Answers -B) Reposition the client on her side.
A hospitalized male client is receiving nasogastric tube feedings via a small-
bore tube and a continuous pump infusions. He reports that he had a bad
, bout of severe coughing a few minutes ago, but feels fine now. What action
is best for the nurse to take?
A) Record the coughing incident. No further action is required at this time.
B) Stop the feeding, explain to the family why it is being stopped and notify
the healthcare provider.
C) After clearing the tube with 30 mL of air, check the pH of fluid
withdrawn from the tube.
D) Inject 30 mL of air into the tube while auscultating the epigastrium for
gurgling. - CorreCt Answers -C) After clearing the tube with 30 ml of air,
check the pH of fluid withdrawn from the tube.
A male client tells the nurse that he does not know where he is or what year
it is. What data should the nurse document that is most accurate?
A) demonstrate loss of remote memory.
B) exhibits expressive dysphasia
C) has a diminished attention span
D) is disoriented to place and time - CorreCt Answers -D) is disoriented to
place and time
A client with chronic kidney disease selects scrambled egg for his breakfast.
What action should the nurse take?
A) Commend the client for selecting a high biologic value protein.
B) Remind the client that protein in the diet should be avoided.
C) Suggest that the client also select orange juice, to promote absorption.
D) Encourage the client to attend classes on dietary management of CKD. -
CorreCt Answers -A) Commend the client for selecting a high biologic value
protein.
