Evolve HESI Fundamentals Practice Questions 2024 Update
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Evolve HESI Fundamentals Practice
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Evolve HESI Fundamentals Practice
Evolve HESI Fundamentals Practice Questions 2024 Update
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 ...
Evolve HESI Fundamentals
Practice Questions 2024
Update
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.
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-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.
,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-
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).
When assisting a client from the bed to a chair, which procedure is best for the
nurse to follow?
A. Place the chair parallel to the bed, with its back toward the head of the bed and
assist the client in moving to the chair.
B. With the nurse's feet spread apart and knees aligned with the client's knees,
stand and pivot the client into the chair.
C. Assist the client to a standing position by gently lifting upward, underneath the
axillae.
D. Stand beside the client, place the client's arms around the nurse's neck, and
gently move the client to the chair. - ✔✔✔ANSWER-Answer: B
(B) describes the correct positioning of the nurse and affords the nurse a wide base
of support while stabilizing the client's knees when assisting to a standing position.
The chair should be placed at a 45-degree angle to the bed, with the back of the
chair toward the head of the bed (A). Clients should never be lifted under the
axillae (C); this could damage nerves and strain the nurse's back. The client should
, be instructed to use the arms of the chair and should never place his or her arms
around the nurse's neck (D); this places undue stress on the nurse's neck and back
and increases the risk for a fall.
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.
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