EVOLVE HESI FUNDAMENTALS PRACTICE Q&A 2026/2027 |
Updated Edition Aligned with NCLEX-RN Test Plan | 100%
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Domain 1: Safe and Effective Care Environment (15 Questions)
Q1
A nurse enters a client's room and finds the client unresponsive, not breathing, and
without a pulse. After activating the emergency response system, what is the nurse's
next priority action?
A. Open the airway and deliver two rescue breaths
B. Begin high-quality chest compressions at a rate of 100-120 per minute [CORRECT]
C. Check for a carotid pulse for at least 10 seconds
D. Administer epinephrine 1 mg IV push
Correct Answer: B
Rationale: According to the American Heart Association Basic Life Support (BLS)
guidelines and the CAB (Compressions-Airway-Breathing) sequence, high-quality chest
compressions are the immediate priority after activating the emergency response
system. Early compressions maintain minimal circulation to vital organs. Option A is
incorrect because breaths are no longer the first step in adult BLS. Option C is incorrect
because pulse checks should not delay compressions; the nurse has already assessed
no pulse. Option D is incorrect because medications are not part of BLS and require
Advanced Cardiac Life Support (ACLS) protocols and established IV access.
,Q2
A nurse is caring for four clients on a medical-surgical unit. Which task is most
appropriate to delegate to an unlicensed assistive personnel (UAP)?
A. Assessing a postoperative client's incision for signs of infection
B. Administering oral antibiotics to a client with pneumonia
C. Assisting an ambulatory client to the bathroom [CORRECT]
D. Teaching a newly diagnosed diabetic client about insulin administration
Correct Answer: C
Rationale: The nurse maintains accountability for assessment (Option A), medication
administration (Option B), and client education (Option D)—all requiring professional
nursing judgment and licensure. Assisting with ambulation and toileting (Option C) is
within the UAP's training scope and does not require clinical judgment or assessment
skills. The nurse must ensure the client is stable and the task is appropriate before
delegation.
Q3
A client with tuberculosis (TB) is admitted to the hospital. Which infection control
precaution must the nurse implement?
A. Standard Precautions only
B. Contact Precautions
C. Droplet Precautions
,D. Airborne Precautions [CORRECT]
Correct Answer: D
Rationale: Tuberculosis is transmitted via airborne droplet nuclei (particles <5 microns)
that remain suspended in air and can travel long distances. Airborne Precautions
require a private room with negative pressure ventilation and N95 respirator masks for
healthcare workers. Option A (Standard Precautions) is insufficient for TB. Option B
(Contact Precautions) is for direct/indirect contact transmission. Option C (Droplet
Precautions) is for larger respiratory droplets (>5 microns) that travel short distances
(e.g., influenza, pertussis).
Q4
A nurse discovers a medication error where a client received the wrong dose of
antihypertensive medication. The client's blood pressure is now 88/52 mmHg. What is
the nurse's first priority action?
A. Complete the incident report immediately
B. Assess the client and implement appropriate interventions [CORRECT]
C. Notify the physician after the client's condition stabilizes
D. Document the error in the medical record using the word "error"
Correct Answer: B
Rationale: Client safety is the priority. The nurse must first assess the client (vital signs,
level of consciousness, symptoms) and implement interventions (positioning, fluids,
monitoring) to address the hypotension. Option A is necessary but not the first
priority—client care precedes documentation. Option C delays critical communication;
, the physician must be notified promptly while interventions are initiated. Option D is
inappropriate; objective factual documentation is required without labeling the event.
Q5
A nurse is preparing to administer a scheduled dose of warfarin to a client. The client's
INR is 4.8 (therapeutic range 2.0-3.0). What is the nurse's best action?
A. Administer the warfarin as scheduled
B. Hold the warfarin and notify the healthcare provider [CORRECT]
C. Administer half the prescribed dose
D. Administer vitamin K without consulting the provider
Correct Answer: B
Rationale: An INR of 4.8 indicates supratherapeutic anticoagulation with increased
bleeding risk. The nurse must hold the dose and notify the provider for further orders.
Option A is unsafe and could cause hemorrhage. Option C requires a provider order;
nurses cannot independently alter anticoagulant doses. Option D is inappropriate; while
vitamin K reverses warfarin, administration requires provider orders and clinical
assessment of bleeding risk versus thrombosis risk.
Q6
A client with a known latex allergy is scheduled for surgery. Which nursing action is
essential to prevent an allergic reaction?
A. Apply petroleum jelly to the client's skin preoperatively
Updated Edition Aligned with NCLEX-RN Test Plan | 100%
Correct Answers | Pass Guaranteed - A+ Graded
Domain 1: Safe and Effective Care Environment (15 Questions)
Q1
A nurse enters a client's room and finds the client unresponsive, not breathing, and
without a pulse. After activating the emergency response system, what is the nurse's
next priority action?
A. Open the airway and deliver two rescue breaths
B. Begin high-quality chest compressions at a rate of 100-120 per minute [CORRECT]
C. Check for a carotid pulse for at least 10 seconds
D. Administer epinephrine 1 mg IV push
Correct Answer: B
Rationale: According to the American Heart Association Basic Life Support (BLS)
guidelines and the CAB (Compressions-Airway-Breathing) sequence, high-quality chest
compressions are the immediate priority after activating the emergency response
system. Early compressions maintain minimal circulation to vital organs. Option A is
incorrect because breaths are no longer the first step in adult BLS. Option C is incorrect
because pulse checks should not delay compressions; the nurse has already assessed
no pulse. Option D is incorrect because medications are not part of BLS and require
Advanced Cardiac Life Support (ACLS) protocols and established IV access.
,Q2
A nurse is caring for four clients on a medical-surgical unit. Which task is most
appropriate to delegate to an unlicensed assistive personnel (UAP)?
A. Assessing a postoperative client's incision for signs of infection
B. Administering oral antibiotics to a client with pneumonia
C. Assisting an ambulatory client to the bathroom [CORRECT]
D. Teaching a newly diagnosed diabetic client about insulin administration
Correct Answer: C
Rationale: The nurse maintains accountability for assessment (Option A), medication
administration (Option B), and client education (Option D)—all requiring professional
nursing judgment and licensure. Assisting with ambulation and toileting (Option C) is
within the UAP's training scope and does not require clinical judgment or assessment
skills. The nurse must ensure the client is stable and the task is appropriate before
delegation.
Q3
A client with tuberculosis (TB) is admitted to the hospital. Which infection control
precaution must the nurse implement?
A. Standard Precautions only
B. Contact Precautions
C. Droplet Precautions
,D. Airborne Precautions [CORRECT]
Correct Answer: D
Rationale: Tuberculosis is transmitted via airborne droplet nuclei (particles <5 microns)
that remain suspended in air and can travel long distances. Airborne Precautions
require a private room with negative pressure ventilation and N95 respirator masks for
healthcare workers. Option A (Standard Precautions) is insufficient for TB. Option B
(Contact Precautions) is for direct/indirect contact transmission. Option C (Droplet
Precautions) is for larger respiratory droplets (>5 microns) that travel short distances
(e.g., influenza, pertussis).
Q4
A nurse discovers a medication error where a client received the wrong dose of
antihypertensive medication. The client's blood pressure is now 88/52 mmHg. What is
the nurse's first priority action?
A. Complete the incident report immediately
B. Assess the client and implement appropriate interventions [CORRECT]
C. Notify the physician after the client's condition stabilizes
D. Document the error in the medical record using the word "error"
Correct Answer: B
Rationale: Client safety is the priority. The nurse must first assess the client (vital signs,
level of consciousness, symptoms) and implement interventions (positioning, fluids,
monitoring) to address the hypotension. Option A is necessary but not the first
priority—client care precedes documentation. Option C delays critical communication;
, the physician must be notified promptly while interventions are initiated. Option D is
inappropriate; objective factual documentation is required without labeling the event.
Q5
A nurse is preparing to administer a scheduled dose of warfarin to a client. The client's
INR is 4.8 (therapeutic range 2.0-3.0). What is the nurse's best action?
A. Administer the warfarin as scheduled
B. Hold the warfarin and notify the healthcare provider [CORRECT]
C. Administer half the prescribed dose
D. Administer vitamin K without consulting the provider
Correct Answer: B
Rationale: An INR of 4.8 indicates supratherapeutic anticoagulation with increased
bleeding risk. The nurse must hold the dose and notify the provider for further orders.
Option A is unsafe and could cause hemorrhage. Option C requires a provider order;
nurses cannot independently alter anticoagulant doses. Option D is inappropriate; while
vitamin K reverses warfarin, administration requires provider orders and clinical
assessment of bleeding risk versus thrombosis risk.
Q6
A client with a known latex allergy is scheduled for surgery. Which nursing action is
essential to prevent an allergic reaction?
A. Apply petroleum jelly to the client's skin preoperatively
