pg. 1 Evolve HESI Fundamentals Latest 2024 Practice Exam/ Complete 250 Actual Questions with 100% Correct Detailed Answers (Verified Answers) Graded A+
A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse provide?
- Orange juice has vitamin C that deters bacterial growth.
- Apple juice is the most useful in acidifying the urine.
- Cranberry juice stops pathogens' adherence to the bladder.
- Grapefruit juice increases absorption of most antibiotics. - Correct Answer - Answer:
C Cranberry juice (C) maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder. (A, B, and D) have not been shown to be as effective as cranberry juice (C) in preventing UTIs.
The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition?
- Low serum albumin level
- Low serum transferrin level
- High hemoglobin level
D. High cholesterol level - Correct Answer - Answer: A
Long-term protein deficiency is required to cause significantly lowered serum albumin levels (A). Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. (B) is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Neither (C or D) are clinical measures of protein malnutrition.
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pg. 2 The nurse identifies a potential for infection in a patient with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection?
- Administration of plasma expanders
- Use of careful hand washing technique
- Application of a topical antibacterial cream
D. Limiting visitors to the client with burns - Correct Answer - Answer: B
Careful hand washing technique (B) is the single most effective intervention for the prevention of contamination to all clients. (A) reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. (C and D) are recommended by various burn centers as possible ways to reduce the chance of infection. (B) is a proven technique to prevent infection.
Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week?
- White blood cell count
- Albumin
- Calcium
D. Sodium - Correct Answer - Answer: D
Monitoring serum sodium levels (D) for hyponatremia is indicated during prolonged NG suctioning because of loss of fluids. Changes in levels of (A, B, or C) are not typically associated with prolonged NG suctioning.
In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?
- Witness the client's signature to the permit.
- Answer the client's questions about the surgery.
- Inform the surgeon that the operative permit is not signed and the client has
- Reassure the client that the surgeon will answer any questions before the anesthesia
questions about the surgery.
is administered. - Correct Answer - Answer: C 2 / 4
pg. 3 The surgeon should be informed immediately that the permit is not signed (C). It is the surgeon's responsibility to explain the procedure to the cliesxnt and obtain the client's signature on the permit. Although the nurse can witness an operative permit (A), the procedure must first be explained by the health care provider or surgeon, including answering the client's questions (B). The client's questions should be addressed before the permit is signed (D).
The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home?
- Determine how the client feels about changing the dressing.
- Ask the client to describe the procedure in writing.
- Seek a family member's evaluation of the client's ability to change the dressing.
- Observe the client change the dressing unassisted. - Correct Answer - Answer: D
Observing the client directly (D) will allow the nurse to determine if mastery of the skill has been obtained and provide an opportunity to affirm the skill. (A) may be therapeutic but will not provide an opportunity to evaluate the client's ability to perform the procedure. (B) may be threatening to an older client and will not determine his ability.(C) is not as effective as direct observation by the nurse.
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?
- Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
- Notify the health care provider and request a prescription for a large-volume enema.
- Assess the client's medical record to determine the client's normal bowel pattern.
- Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day. -
Correct 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
- may then be implemented, if warranted.
The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client?
- Steak, baked beans, and a salad 3 / 4
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- Broiled fish, green beans, and an apple
- Pork chops, macaroni and cheese, and grapes
D. Avocado salad, milk, and angel food cake - Correct Answer - Answer: B
Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet, such as (B). (A) is a high-protein diet and (C and D) contain high-fat foods, which are contraindicated for this client.
When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
- Remind the child to clean his genital area.
- Defer perineal care because of the child's age.
- Retract the foreskin gently to cleanse the penis.
- Ask the parents why the child is not circumcised. - Correct Answer - Answer: C
The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that could harbor bacteria (C). The child's cognitive development may not be at the level at which (A) would be effective. Perineal care needs to be provided daily regardless of the client's age (B). (D) is not indicated and may be perceived as intrusive.
The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained.Which action should the nurse take?
- Review the chart for a signed consent for hospitalization.
- Get the health care provider's permission to give the medication.
- Do not give the medication and document the reason.
- Complete an incident report and notify the parents. - Correct Answer - Answer: C
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The nurse should not give the medication and should document the reason (C) because the client is a minor and needs a guardian's permission to receive medications.Permission to give medications is not granted by a signed hospital consent (A) or a health care provider's permission (B), unless conditions are met to justify coerced treatment. (D) is not necessary unless the medication had previously been administered.