EVOLVE HESI FUNDAMENTALS PRACTICE EXAM 2024-
2025/ACTUAL 70 EXAM QUESTIONS WITH CORRECT
ANSWERS AND RATIONALES/ HESI FUNDAMENTALS
EXAM 2024/A+ GRADE
Urinary catheterization is prescribed for a postoperative female patient 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?
- Clamp the catheter and recheck it in 60 minutes.
- Pull the catheter back 3 inches and redirect upward.
- Leave the catheter in place and reattempt with another catheter.
- Notify the health care provider of a possible obstruction.
- CORRECT ANS:->> C
Rationale :->>
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).
The nurse is teaching an obese patient, newly diagnosed 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 patient?
- "Monitoring Your Blood Pressure at Home"
- "Smoking Cessation as a Lifelong Commitment"
- "Decreasing Cholesterol Levels Through Diet"
- "Stress Management for a Healthier You"
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- CORRECT ANS:->> C
Rationale :->> A health promotion brochure about decreasing cholesterol (C) is most important to provide this patient, 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 but are not as important as lowering cholesterol (C).
Ten minutes after signing an operative permit for a fractured hip, an older patient states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse implement next?
- Make the patient comfortable and allow the patient to sleep.
- Assess the patient's neurologic status.
- Notify the surgeon about the comment.
- Ask the patient's family to co-sign the operative permit.
- CORRECT ANS:->> B
This statement may indicate that the patient is confused. Informed consent must be provided by a mentally competent individual, so the nurse should further assess the patient's neurologic status (B) to be sure that the patient understands and can legally provide consent for surgery. (A) does not provide sufficient follow-up. If the nurse determines that the patient 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 ways to prevent complications of immobility. Which intervention should be included in this instruction?
- Perform range-of-motion exercises to prevent contractures.
- Decrease the patient's fluid intake to prevent diarrhea.
- Massage the patient's legs to reduce embolism occurrence. 2 / 4
- Turn the patient from side to back every shift.
- CORRECT ANS:->> A
Rationale :->>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 patient at risk of complications.
The nurse is assisting a patient to the bathroom. When the patient is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the patient to a chair, the patient starts to fall. Which is the priority action for the nurse to take?
- Check the patient's carotid pulse.
- Encourage the patient to get to the toilet.
- In a loud voice, call for help.
D. Gently lower the patient to the floor. - CORRECT ANS:->> D
Rationale :->> (D) is the most prudent intervention and is the priority nursing action to prevent injury to the patient and the nurse. Lowering the patient to the floor should be done when the patient cannot support his own weight. The patient 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 patient is in a safe position.Because the patient is not supporting himself, (B) is impractical. (C) is likely to cause chaos on the unit and might alarm the other patients.
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 patient's confidentiality. Which resource describes the nurse's legal responsibilities?
- Code of Ethics for Nurses
- State Nurse Practice Act 3 / 4
- Patient's Bill of Rights
- ANA Standards of Practice
- CORRECT ANS:->> B
Rationale :->>The State Nurse Practice Act (B) contains legal requirements for the protection of patient 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 expectations for nursing practice but do not address legal implications.
The nurse is teaching a patient how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the patient reports that he is still unable to sleep, despite following the same routine every night. Which action should the nurse take first?
- Instruct the patient to add regular exercise as a daily routine.
- Determine if the patient has been keeping a sleep diary.
- Encourage the patient to continue the routine until sleep is achieved.
- Ask the patient to describe the routine that the patient is currently following. -
CORRECT ANS:->> D
Rationale :->>The nurse should first evaluate whether the patient has been adhering to the original instructions (D). A verbal report of the patient's routine will provide more specific information than the patient's written diary (B). The nurse can then determine which changes need to be made (A). The routine practiced by the patient is clearly unsuccessful, so encouragement alone is insufficient (C).A 65-year-old patient 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.
- Change positions in the chair at least every hour.
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