2026 Evolve HESI Fundamentals Final Exam | Complete
Questions and Answers with Rationales
1. A nurse enters a client's room and finds the client lying on the floor.
What should the nurse do first?
A. Help the client back into bed
B. Assess the client for injury
C. Notify the healthcare provider
D. Complete an incident report
Answer: B
Rationale: The nurse should first assess the client for injury and
determine immediate needs before moving the client or notifying
others.
2. Which action is most effective for preventing transmission of
infection?
A. Wearing a mask for every client
B. Performing hand hygiene
C. Administering prophylactic antibiotics
D. Wearing sterile gloves
Answer: B
Rationale: Proper hand hygiene is the most important routine measure
for preventing transmission of microorganisms.
3. A nurse is preparing to administer an oral medication. Which
identification method is appropriate?
A. Room number
B. Diagnosis
C. Two client identifiers
D. Bed number
,Answer: C
Rationale: At least two approved identifiers, such as name and date of
birth, should be used before medication administration.
4. Which finding requires immediate intervention?
A. Respiratory rate of 18/min
B. Oxygen saturation of 97%
C. New-onset confusion
D. Temperature of 37.1°C (98.8°F)
Answer: C
Rationale: Acute confusion can indicate hypoxia, infection, metabolic
disturbance, or another serious change in condition.
5. Which position is generally appropriate for a client experiencing
difficulty breathing?
A. Supine
B. High-Fowler's
C. Prone
D. Trendelenburg
Answer: B
Rationale: High-Fowler's positioning promotes maximum lung
expansion and can improve ventilation.
6. A nurse is removing personal protective equipment after caring for a
client on contact precautions. Which item is generally removed first?
A. Gloves
B. Mask
C. Goggles
D. Hair cover
,Answer: A
Rationale: Gloves are highly contaminated and are generally removed
first, followed by other PPE according to facility protocol.
7. Which assessment finding is most concerning in a client receiving an
opioid analgesic?
A. Mild nausea
B. Respiratory rate of 8/min
C. Constipation
D. Drowsiness
Answer: B
Rationale: Significant respiratory depression is a potentially life-
threatening opioid adverse effect requiring immediate assessment and
intervention.
8. A nurse is teaching a client how to use an incentive spirometer.
Which instruction is correct?
A. Exhale forcefully into the device
B. Inhale slowly and deeply through the mouthpiece
C. Use it only when experiencing shortness of breath
D. Breathe rapidly through the mouthpiece
Answer: B
Rationale: Slow, deep inhalation through an incentive spirometer
promotes alveolar expansion and helps prevent atelectasis.
9. Which intervention best reduces the risk of pressure injury in an
immobile client?
A. Massage reddened areas
B. Reposition the client regularly
C. Restrict fluids
D. Keep the head of bed elevated continuously
, Answer: B
Rationale: Regular repositioning relieves prolonged pressure and
supports tissue perfusion.
10. A client reports pain rated 8/10. What should the nurse do?
A. Ignore the rating because pain is subjective
B. Assess the pain further and provide appropriate intervention
C. Tell the client that the pain medication is not due
D. Document the pain without intervention
Answer: B
Rationale: Pain is subjective and should be assessed systematically,
treated appropriately, and reassessed.
11. Which action contaminates a sterile field?
A. Keeping sterile objects above waist level
B. Turning away from the sterile field
C. Opening a sterile package away from the body
D. Keeping the sterile field dry
Answer: B
Rationale: A sterile field must remain continuously visible. Turning
away means sterility can no longer be ensured.
12. A client has a pulse deficit. What does this finding mean?
A. The pulse is too fast
B. The apical and peripheral pulse rates differ
C. The blood pressure is low
D. The pulse is irregular
Answer: B
Rationale: A pulse deficit occurs when the apical heart rate exceeds the
peripheral pulse rate.
Questions and Answers with Rationales
1. A nurse enters a client's room and finds the client lying on the floor.
What should the nurse do first?
A. Help the client back into bed
B. Assess the client for injury
C. Notify the healthcare provider
D. Complete an incident report
Answer: B
Rationale: The nurse should first assess the client for injury and
determine immediate needs before moving the client or notifying
others.
2. Which action is most effective for preventing transmission of
infection?
A. Wearing a mask for every client
B. Performing hand hygiene
C. Administering prophylactic antibiotics
D. Wearing sterile gloves
Answer: B
Rationale: Proper hand hygiene is the most important routine measure
for preventing transmission of microorganisms.
3. A nurse is preparing to administer an oral medication. Which
identification method is appropriate?
A. Room number
B. Diagnosis
C. Two client identifiers
D. Bed number
,Answer: C
Rationale: At least two approved identifiers, such as name and date of
birth, should be used before medication administration.
4. Which finding requires immediate intervention?
A. Respiratory rate of 18/min
B. Oxygen saturation of 97%
C. New-onset confusion
D. Temperature of 37.1°C (98.8°F)
Answer: C
Rationale: Acute confusion can indicate hypoxia, infection, metabolic
disturbance, or another serious change in condition.
5. Which position is generally appropriate for a client experiencing
difficulty breathing?
A. Supine
B. High-Fowler's
C. Prone
D. Trendelenburg
Answer: B
Rationale: High-Fowler's positioning promotes maximum lung
expansion and can improve ventilation.
6. A nurse is removing personal protective equipment after caring for a
client on contact precautions. Which item is generally removed first?
A. Gloves
B. Mask
C. Goggles
D. Hair cover
,Answer: A
Rationale: Gloves are highly contaminated and are generally removed
first, followed by other PPE according to facility protocol.
7. Which assessment finding is most concerning in a client receiving an
opioid analgesic?
A. Mild nausea
B. Respiratory rate of 8/min
C. Constipation
D. Drowsiness
Answer: B
Rationale: Significant respiratory depression is a potentially life-
threatening opioid adverse effect requiring immediate assessment and
intervention.
8. A nurse is teaching a client how to use an incentive spirometer.
Which instruction is correct?
A. Exhale forcefully into the device
B. Inhale slowly and deeply through the mouthpiece
C. Use it only when experiencing shortness of breath
D. Breathe rapidly through the mouthpiece
Answer: B
Rationale: Slow, deep inhalation through an incentive spirometer
promotes alveolar expansion and helps prevent atelectasis.
9. Which intervention best reduces the risk of pressure injury in an
immobile client?
A. Massage reddened areas
B. Reposition the client regularly
C. Restrict fluids
D. Keep the head of bed elevated continuously
, Answer: B
Rationale: Regular repositioning relieves prolonged pressure and
supports tissue perfusion.
10. A client reports pain rated 8/10. What should the nurse do?
A. Ignore the rating because pain is subjective
B. Assess the pain further and provide appropriate intervention
C. Tell the client that the pain medication is not due
D. Document the pain without intervention
Answer: B
Rationale: Pain is subjective and should be assessed systematically,
treated appropriately, and reassessed.
11. Which action contaminates a sterile field?
A. Keeping sterile objects above waist level
B. Turning away from the sterile field
C. Opening a sterile package away from the body
D. Keeping the sterile field dry
Answer: B
Rationale: A sterile field must remain continuously visible. Turning
away means sterility can no longer be ensured.
12. A client has a pulse deficit. What does this finding mean?
A. The pulse is too fast
B. The apical and peripheral pulse rates differ
C. The blood pressure is low
D. The pulse is irregular
Answer: B
Rationale: A pulse deficit occurs when the apical heart rate exceeds the
peripheral pulse rate.
