2026 Evolve HESI Fundamentals Exam (Versions 2) | Complete
Questions and Answers with Rationales
1. A nurse enters a client's room and finds the client
unresponsive. Which action should the nurse take first?
A. Obtain a blood pressure
B. Assess responsiveness and breathing
C. Document the finding
D. Call the family
Answer: B
Rationale: Immediate assessment of responsiveness and
breathing determines whether emergency intervention is
required.
2. Which assessment finding requires the most immediate
intervention?
A. Pain rated 6/10
B. Respiratory rate of 8/min
C. Temperature of 37.5°C
D. Pulse of 88/min
Answer: B
Rationale: Bradypnea may indicate respiratory depression and
threatens airway and breathing.
3. Which action is most effective in preventing healthcare-
associated infections?
A. Wearing a mask for every client
B. Performing appropriate hand hygiene
,C. Keeping the door closed
D. Using sterile gloves for every procedure
Answer: B
Rationale: Hand hygiene is one of the most effective ways to
interrupt transmission of microorganisms.
4. Which client statement indicates correct understanding of
fall prevention?
A. “I will get up quickly so I don't become dizzy.”
B. “I will call for assistance before getting out of bed.”
C. “I can walk without my prescribed device.”
D. “I should keep the floor clear by moving equipment myself.”
Answer: B
Rationale: Calling for assistance before ambulation reduces fall
risk.
5. Which finding is subjective data?
A. Blood pressure 142/88 mmHg
B. Respiratory rate 24/min
C. Client reports nausea
D. Skin is warm
Answer: C
Rationale: Subjective data are symptoms reported by the
client.
6. Which finding is objective data?
A. “I feel weak.”
B. “My pain is severe.”
C. “I am nauseated.”
,D. Oxygen saturation is 89%
Answer: D
Rationale: Objective data are measurable or observable
findings.
7. A nurse is caring for a client who reports severe pain. What
should the nurse do first?
A. Administer a placebo
B. Assess the pain characteristics
C. Tell the client to relax
D. Ask the family to assess the pain
Answer: B
Rationale: Pain should be comprehensively assessed before
selecting an intervention.
8. Which response is most therapeutic when a client says, “I'm
afraid about my surgery”?
A. “There is nothing to worry about.”
B. “Everyone feels that way.”
C. “Tell me what concerns you most.”
D. “You should try to think positively.”
Answer: C
Rationale: An open-ended response encourages the client to
express concerns.
9. Which task is appropriate to delegate to an experienced
UAP for a stable client?
A. Initial assessment
B. Nursing diagnosis
, C. Routine bathing
D. Evaluation of pain management
Answer: C
Rationale: Routine hygiene for a stable client may be delegated
when appropriate.
10. Which activity must remain with the registered nurse?
A. Making an occupied bed
B. Measuring routine intake
C. Initial assessment
D. Assisting with hygiene
Answer: C
Rationale: Initial assessment requires nursing judgment.
11. Which action demonstrates respect for client autonomy?
A. Making decisions for the client
B. Providing information and supporting informed choices
C. Withholding information to reduce anxiety
D. Asking family members to decide without the client
Answer: B
Rationale: Autonomy involves the client's right to make
informed decisions.
12. A client refuses a prescribed medication. What should the
nurse do first?
A. Hide it in food
B. Explore the reason for refusal
C. Tell the client refusal is not allowed
D. Document the medication as given
Questions and Answers with Rationales
1. A nurse enters a client's room and finds the client
unresponsive. Which action should the nurse take first?
A. Obtain a blood pressure
B. Assess responsiveness and breathing
C. Document the finding
D. Call the family
Answer: B
Rationale: Immediate assessment of responsiveness and
breathing determines whether emergency intervention is
required.
2. Which assessment finding requires the most immediate
intervention?
A. Pain rated 6/10
B. Respiratory rate of 8/min
C. Temperature of 37.5°C
D. Pulse of 88/min
Answer: B
Rationale: Bradypnea may indicate respiratory depression and
threatens airway and breathing.
3. Which action is most effective in preventing healthcare-
associated infections?
A. Wearing a mask for every client
B. Performing appropriate hand hygiene
,C. Keeping the door closed
D. Using sterile gloves for every procedure
Answer: B
Rationale: Hand hygiene is one of the most effective ways to
interrupt transmission of microorganisms.
4. Which client statement indicates correct understanding of
fall prevention?
A. “I will get up quickly so I don't become dizzy.”
B. “I will call for assistance before getting out of bed.”
C. “I can walk without my prescribed device.”
D. “I should keep the floor clear by moving equipment myself.”
Answer: B
Rationale: Calling for assistance before ambulation reduces fall
risk.
5. Which finding is subjective data?
A. Blood pressure 142/88 mmHg
B. Respiratory rate 24/min
C. Client reports nausea
D. Skin is warm
Answer: C
Rationale: Subjective data are symptoms reported by the
client.
6. Which finding is objective data?
A. “I feel weak.”
B. “My pain is severe.”
C. “I am nauseated.”
,D. Oxygen saturation is 89%
Answer: D
Rationale: Objective data are measurable or observable
findings.
7. A nurse is caring for a client who reports severe pain. What
should the nurse do first?
A. Administer a placebo
B. Assess the pain characteristics
C. Tell the client to relax
D. Ask the family to assess the pain
Answer: B
Rationale: Pain should be comprehensively assessed before
selecting an intervention.
8. Which response is most therapeutic when a client says, “I'm
afraid about my surgery”?
A. “There is nothing to worry about.”
B. “Everyone feels that way.”
C. “Tell me what concerns you most.”
D. “You should try to think positively.”
Answer: C
Rationale: An open-ended response encourages the client to
express concerns.
9. Which task is appropriate to delegate to an experienced
UAP for a stable client?
A. Initial assessment
B. Nursing diagnosis
, C. Routine bathing
D. Evaluation of pain management
Answer: C
Rationale: Routine hygiene for a stable client may be delegated
when appropriate.
10. Which activity must remain with the registered nurse?
A. Making an occupied bed
B. Measuring routine intake
C. Initial assessment
D. Assisting with hygiene
Answer: C
Rationale: Initial assessment requires nursing judgment.
11. Which action demonstrates respect for client autonomy?
A. Making decisions for the client
B. Providing information and supporting informed choices
C. Withholding information to reduce anxiety
D. Asking family members to decide without the client
Answer: B
Rationale: Autonomy involves the client's right to make
informed decisions.
12. A client refuses a prescribed medication. What should the
nurse do first?
A. Hide it in food
B. Explore the reason for refusal
C. Tell the client refusal is not allowed
D. Document the medication as given
