Evolve Fundamentals HESI Newest Exam 2024 -2025

pg. 1 Evolve Fundamentals HESI Newest Exam 2024 -2025/ Complete 300 Actual Exam Questions with 100% Correct Detailed Answers (Verified Answers) AGRADE

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults?

• It is more difficult to find a superficial vein in the feet and ankles.
• A decreased flow rate could result in the formation of a thrombosis.
• A cannulated extremity is more difficult to move when the leg or foot is used.
• Veins are located deep in the feet and ankles, resulting in a more painful procedure. -

Correct Answer - Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities.Pain (D) is not a consideration.

The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?

• Tell the UAP to use a larger cuff at the next scheduled assessment.
• Reassess the client's blood pressure using a larger cuff.
• Have the unit educator review this procedure with the UAPs.
• Teach the UAP the correct technique for assessing blood pressure. - Correct Answer
• The most important action is to ensure that an accurate BP reading is obtained. The

nurse should reassess the BP with the correct size cuff (B). Reassessment should not be postponed (A). Though (C and D) are likely indicated, these actions do not have the priority of (B). 1 / 4

pg. 2 During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement?

• Provide additional coffee on the client's breakfast tray.
• Exchange the client's grape juice for cranberry juice.
• Bring the client additional fruit at mid-morning.
• Encourage additional oral intake of juices and water. - Correct Answer - Dark amber

urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection. The client needs to restore fluid volume more than solid foods (C).

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?

• Apply a condom catheter.
• Apply a skin protectant.
• Encourage increased fluid intake.
• Assess for bladder distention. - Correct Answer - Urinary retention is the inability to

void all urine collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of a client with urinary incontinence.(C) may worsen the bladder distention.

The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions?

• Tossed salad, low-sodium dressing, bacon and tomato sandwich.
• New England clam chowder, no-salt crackers, fresh fruit salad.
• Skim milk, turkey salad, roll, and vanilla ice cream.
• Macaroni and cheese, diet Coke, a slice of cherry pie. - Correct Answer - Skim milk,

turkey, bread, and ice cream (C), while containing some sodium, are considered low- sodium foods. Bacon (A), canned soups (B), especially those with seafood, hard cheeses, macaroni, and most diet drinks (D) are very high in sodium. 2 / 4

pg. 3 Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent?

• Height in inches or centimeters.
• Weight in kilograms or pounds.
• Triceps skin fold thickness.
• Upper arm circumference. - Correct Answer - Upper arm circumference (D) is an

indirect measure of muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C) is a measure of body fat.

An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first?

• Reaffirm the client's desire for no resuscitative efforts.
• Transfer the client to a hospice inpatient facility.
• Prepare the family for the client's impending death.
• Notify the healthcare provider of the family's request. - Correct Answer - The nurse

should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented.

After completing an assessment and determining that a client has a problem, which action should the nurse perform next?

• Determine the etiology of the problem.
• Prioritize nursing care interventions.
• Plan appropriate interventions.
• Collaborate with the client to set goals. - Correct Answer - Before planning care, the

nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C, and D). 3 / 4

pg. 4 An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment?

• A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
• The nurse assigned to care for the client who was at lunch at the time of the fall.
• The nurse who transferred the client to the chair when the fall occurred.
• The charge nurse who completed rounds 30 minutes before the fall occurred. -

Correct Answer - The four elements of malpractice are: breach of duty owed, failure to adhere to the recognized standard of care, direct causation of injury, and evidence of actual injury. The hip fracture is the actual injury and the standard of care was "frequent monitoring." (C) implies that duty was owed and the injury occurred while the nurse was in charge of the client's care. There is no evidence of negligence in (A, B, and D).

A postoperative client will need to perform daily dressing changes after discharge.Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client

• asks relevant questions regarding the dressing change.
• states he will be able to complete the wound care regimen.
• demonstrates the wound care procedure correctly.
• has all the necessary supplies for wound care. - Correct Answer - A return

demonstration of a procedure (C) provides an objective assessment of the client's ability to perform a task, while (A and B) are subjective measures. (D) is important, but is less of a priority prior to discharge than the nurse's assessment of the client's ability to complete the wound care.

Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?

• "That means you have derived the maximum benefit, and the heat can be removed."
• "Your blood vessels are becoming dilated and removing the heat from the site."
• "We will increase the temperature 5 degrees when the pad no longer feels warm."
• "The body's receptors adapt over time as they are exposed to heat." - Correct

Answer - (D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B) provide false information. (C) is not based on a knowledge of physiology and is an unsafe action that may harm the client.

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