Evolve HESI
Fundamentals
Practice Qs
LATEST TEST BANK
COMPLETE
QUESTIONS ANSD
CORRECT ANSWERS
WITH WELL
ELABORATED
RATIONALE
,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. - CORRECT ANSWERS -
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" - CORRECT ANSWERS -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. - CORRECT ANSWERS -
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. - CORRECT ANSWERS -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. - CORRECT ANSWERS -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 - CORRECT ANSWERS -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. -
CORRECT ANSWERS -Answer: D
Fundamentals
Practice Qs
LATEST TEST BANK
COMPLETE
QUESTIONS ANSD
CORRECT ANSWERS
WITH WELL
ELABORATED
RATIONALE
,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. - CORRECT ANSWERS -
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" - CORRECT ANSWERS -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. - CORRECT ANSWERS -
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. - CORRECT ANSWERS -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. - CORRECT ANSWERS -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 - CORRECT ANSWERS -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. -
CORRECT ANSWERS -Answer: D
