Evolve HESI Fundamentals Exam Prep:
Questions, Answers & Rationales for
Nursing Success
Safety & Infection Control
1. A client receiving a blood transfusion develops chills, fever, and low
back pain. Which action should the nurse take first?
A) Slow the infusion rate
B) Administer an antihistamine
C) Stop the transfusion immediately
D) Notify the healthcare provider
Rationale: These symptoms indicate a possible hemolytic transfusion
reaction, which requires immediate discontinuation of the transfusion to
prevent further complications. The healthcare provider should be notified
after stopping the transfusion .
2. The nurse is performing a sterile dressing change. Which action
breaks sterile technique?
A) Opening the sterile package away from the body
B) Placing sterile items within the 1-inch border of the field
C) Reaching across the sterile field to obtain an item
D) Keeping sterile objects above waist level
,Rationale: Reaching across the sterile field contaminates the field; the
nurse should reach around the edges. The 1-inch border of a sterile field is
considered contaminated .
3. Which intervention is most effective in preventing falls in a
hospitalized elderly client?
A) Keeping the bed in the lowest position
B) Using a bed alarm
C) Placing the call light within reach
D) Applying wrist restraints
Rationale: Keeping the bed in the lowest position is the most effective fall
prevention measure. All other options are supportive but secondary to bed
height management .
4. When turning an immobile bedfast client without assistance, which
action by the nurse best ensures client safety?
A) Securely grasp the client's arm and leg
B) Put bed rails up on the side of bed opposite from the nurse
C) Correctly position and use a turn sheet
D) Lower the head of the client's bed slowly
Rationale: Since the nurse can only stand on one side of the bed, bed rails
should be up on the opposite side to ensure the client does not fall out of
bed .
,5. A nurse witnesses a person fall. The person becomes unresponsive
and pulseless. The nurse plans to use an AED. What should the nurse
do first?
A) Remove all jewelry
B) Wash the chest area
C) Use a grounded electrical source
D) Remove medication patches on the chest
Rationale: Medication patches interfere with electrode placement and
must be removed before application because of possible burn caused by
electrical conduction. Jewelry usually is not a problem with AED function .
6. The nurse is preparing to insert a Foley catheter in a female client.
Which position is most appropriate?
A) Supine with legs extended
B) Dorsal recumbent
C) Lateral recumbent
D) Sim's position
Rationale: The dorsal recumbent position (supine with knees flexed and
feet flat) provides optimal visualization of the urethral meatus .
, 7. The nurse is performing hand hygiene. Which statement about hand
hygiene is correct?
A) Alcohol-based hand sanitizers are effective against Clostridium
difficile spores
B) Handwashing with soap and water is required when hands are
visibly soiled
C) Alcohol-based hand sanitizers are preferred for all situations
D) Hand sanitizers eliminate all microorganisms
Rationale: Handwashing with soap and water is required when hands are
visibly soiled. Alcohol-based hand sanitizers are not effective against C.
difficile spores .
8. The nurse is providing education to a client about a low-sodium
diet. Which food item should the client avoid?
A) Fresh apple
B) Canned chicken noodle soup
C) Unsalted almonds
D) Grilled chicken breast
Rationale: Canned soups are notoriously high in sodium due to
preservatives and flavoring. Fresh fruits, unsalted nuts, and fresh meats are
naturally low in sodium .
Questions, Answers & Rationales for
Nursing Success
Safety & Infection Control
1. A client receiving a blood transfusion develops chills, fever, and low
back pain. Which action should the nurse take first?
A) Slow the infusion rate
B) Administer an antihistamine
C) Stop the transfusion immediately
D) Notify the healthcare provider
Rationale: These symptoms indicate a possible hemolytic transfusion
reaction, which requires immediate discontinuation of the transfusion to
prevent further complications. The healthcare provider should be notified
after stopping the transfusion .
2. The nurse is performing a sterile dressing change. Which action
breaks sterile technique?
A) Opening the sterile package away from the body
B) Placing sterile items within the 1-inch border of the field
C) Reaching across the sterile field to obtain an item
D) Keeping sterile objects above waist level
,Rationale: Reaching across the sterile field contaminates the field; the
nurse should reach around the edges. The 1-inch border of a sterile field is
considered contaminated .
3. Which intervention is most effective in preventing falls in a
hospitalized elderly client?
A) Keeping the bed in the lowest position
B) Using a bed alarm
C) Placing the call light within reach
D) Applying wrist restraints
Rationale: Keeping the bed in the lowest position is the most effective fall
prevention measure. All other options are supportive but secondary to bed
height management .
4. When turning an immobile bedfast client without assistance, which
action by the nurse best ensures client safety?
A) Securely grasp the client's arm and leg
B) Put bed rails up on the side of bed opposite from the nurse
C) Correctly position and use a turn sheet
D) Lower the head of the client's bed slowly
Rationale: Since the nurse can only stand on one side of the bed, bed rails
should be up on the opposite side to ensure the client does not fall out of
bed .
,5. A nurse witnesses a person fall. The person becomes unresponsive
and pulseless. The nurse plans to use an AED. What should the nurse
do first?
A) Remove all jewelry
B) Wash the chest area
C) Use a grounded electrical source
D) Remove medication patches on the chest
Rationale: Medication patches interfere with electrode placement and
must be removed before application because of possible burn caused by
electrical conduction. Jewelry usually is not a problem with AED function .
6. The nurse is preparing to insert a Foley catheter in a female client.
Which position is most appropriate?
A) Supine with legs extended
B) Dorsal recumbent
C) Lateral recumbent
D) Sim's position
Rationale: The dorsal recumbent position (supine with knees flexed and
feet flat) provides optimal visualization of the urethral meatus .
, 7. The nurse is performing hand hygiene. Which statement about hand
hygiene is correct?
A) Alcohol-based hand sanitizers are effective against Clostridium
difficile spores
B) Handwashing with soap and water is required when hands are
visibly soiled
C) Alcohol-based hand sanitizers are preferred for all situations
D) Hand sanitizers eliminate all microorganisms
Rationale: Handwashing with soap and water is required when hands are
visibly soiled. Alcohol-based hand sanitizers are not effective against C.
difficile spores .
8. The nurse is providing education to a client about a low-sodium
diet. Which food item should the client avoid?
A) Fresh apple
B) Canned chicken noodle soup
C) Unsalted almonds
D) Grilled chicken breast
Rationale: Canned soups are notoriously high in sodium due to
preservatives and flavoring. Fresh fruits, unsalted nuts, and fresh meats are
naturally low in sodium .
