Evolve HESI Fundamentals Practice Questions and Answers 2022
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Course
HESI Fundamentals
Institution
HESI Fundamentals
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 ba...
Evolve HESI Fundamentals Practice Questions and Answers 2022 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 Answer: C It is likely that the first catheter is in the vag ina, 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 chan ge 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 diag nosed 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 Com mitment" C. "Decreasing Cholesterol Levels Through Diet" D. "Stress Management for a Healthier You" - Correct 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 b ut 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 Answer: B This statement may indicate that t he 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 way s 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 re duce embolism occurrence. D. Turn the client from side to back every shift. - Correct 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 th e 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 t he 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 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 suppo rt 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 impr actical. (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 Answer: B The State Nurse Pra ctice 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 expectati ons 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 sle ep is achieved. D. Ask the client to describe the routine that the client is currently following. - Correct 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 rou tine 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 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. - Correct 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.
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