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Evolve HESI Fundamentals Practice Questions and answers
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Evolve HESI FundamentalsPractice Questions and
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A 20-year-old female client with a noticeable body odor has refused to
shower for the last 3 days. She states, "I have been told that it is harmful
to bathe during my period." Which action should the nurse take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D. Teach the importance of personal hygiene during menstruation with
the client. - answer ✅✅Answer: D
Because a shower is most beneficial for the client in terms of hygiene, the
client should receive teaching first (D), respecting any personal beliefs
such as cultural or spiritual values. After client teaching, the client may
still choose (A or B). Brochures reinforce the teaching (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.
A client becomes angry while waiting for a supervised break to smoke a
cigarette outside and states, "I want to go outside now and smoke. It
takes forever to get anything done here!" Which intervention is best for
the nurse to implement?
A. Encourage the client to use a nicotine patch.
B. Reassure the client that it is almost time for another break.
C. Have the client leave the unit with another staff.
D. Review the schedule of outdoor breaks with the client. - answer
✅✅Answer: D
The best nursing action is to review the schedule of outdoor breaks (D)
and provide concrete information about the schedule. (A) is
contraindicated if the client wants to continue smoking. (B) is insufficient
,to encourage a trusting relationship with the client. (C) is preferential for
this client only and is inconsistent with unit rules.
A client has a nasogastric tube connected to low intermittent suction.
When administering medications through the nasogastric tube, which
action should the nurse do first?
A. Clamp the nasogastric tube.
B. Confirm placement of the tube.
C. Use a syringe to instill the medications.
D. Turn off the intermittent suction device. - answer ✅✅Answer: D
The nurse should first turn off the suction (D) and then confirm
placement of the tube in the stomach (B) before instilling the medications
(C). To prevent immediate removal of the instilled medications and allow
absorption, the tube should be clamped for a period of time (A) before
reconnecting the suction.
A client has a nursing diagnosis of Altered sleep patterns related to
nocturia. Which client instruction is important for the nurse to provide?
A. Decrease intake of fluids after the evening meal.
B. Drink a glass of cranberry juice every day.
C. Drink a glass of warm decaffeinated beverage at bedtime.
D. Consult the health care provider about a sleeping pill. - answer
✅✅Answer: A
Nocturia is urination during the night. (A) is helpful to decrease the
production of urine, thus decreasing the need to void at night. (B) helps
, prevent bladder infections. (C) may promote sleep, but the fluid will
contribute to nocturia. (D) may result in urinary incontinence if the client
is sedated and does not awaken to void.
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.
A client's blood pressure reading is 156/94 mm Hg. Which action should
the nurse take first?
A. Tell the client that the blood pressure is high and that the reading
needs to be verified by another nurse.
B. Contact the health care provider to report the reading and obtain a
prescription for an antihypertensive medication.
C. Replace the cuff with a larger one to ensure an ample fit for the client
to increase arm comfort.
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