2026 Evolve HESI Fundamentals Exam (Versions 1) | Complete
Questions and Answers with Rationales
Question 1
A nurse is caring for several clients. Which client should the nurse
assess first?
A. A client reporting pain rated 8/10
B. A client with an oxygen saturation of 88%
C. A client requesting assistance to the bathroom
D. A client scheduled for discharge teaching
Answer: B. A client with an oxygen saturation of 88%
Rationale: Airway and breathing problems take priority. An oxygen
saturation of 88% may indicate inadequate oxygenation and requires
immediate assessment and intervention.
Question 2
Which action is most effective in preventing the spread of infection?
A. Wearing a mask with every client
B. Administering antibiotics as prescribed
C. Performing proper hand hygiene
D. Wearing sterile gloves during all procedures
Answer: C. Performing proper hand hygiene
Rationale: Hand hygiene is the most effective measure for preventing
the transmission of microorganisms in healthcare settings.
Question 3
A nurse is preparing to administer medication. Which action is essential
before giving the medication?
,A. Ask another client to identify the medication
B. Compare the medication label with the medication administration
record
C. Prepare medications for multiple clients at the same time
D. Document administration before giving the medication
Answer: B. Compare the medication label with the medication
administration record
Rationale: The nurse should verify the medication against the
medication administration record and follow medication safety checks
before administration.
Question 4
Which client statement demonstrates understanding of fall prevention?
A. “I will get out of bed whenever I feel ready.”
B. “I will call for assistance before walking if I feel weak.”
C. “I should keep my bed in the highest position.”
D. “I do not need nonskid footwear in my room.”
Answer: B. “I will call for assistance before walking if I feel weak.”
Rationale: Clients at risk for falls should request assistance before
ambulating when weak, dizzy, or unfamiliar with their surroundings.
Question 5
A nurse observes redness over a client's sacral area. What is the priority
intervention?
A. Massage the reddened area
B. Apply heat directly to the area
C. Relieve pressure from the area
D. Scrub the area vigorously
,Answer: C. Relieve pressure from the area
Rationale: Persistent pressure contributes to skin breakdown. The
nurse should reposition the client and reduce pressure on the affected
area.
Question 6
Which finding should the nurse report immediately?
A. Temperature of 37.2°C (99°F)
B. Respiratory rate of 8 breaths/min
C. Heart rate of 88 beats/min
D. Blood pressure of 128/76 mm Hg
Answer: B. Respiratory rate of 8 breaths/min
Rationale: A respiratory rate of 8 breaths/min indicates respiratory
depression and requires immediate assessment.
Question 7
A client refuses a prescribed treatment. What is the nurse's best
action?
A. Force the client to receive the treatment
B. Ask the family to consent for the client
C. Explain the treatment and document the refusal
D. Tell the client that refusal is not allowed
Answer: C. Explain the treatment and document the refusal
Rationale: Competent clients have the right to refuse treatment. The
nurse should provide appropriate information, assess understanding,
notify the provider when necessary, and document the refusal.
Question 8
, Which communication technique is therapeutic?
A. “Everything will be fine.”
B. “Why did you do that?”
C. “Tell me more about how you are feeling.”
D. “You should not feel that way.”
Answer: C. “Tell me more about how you are feeling.”
Rationale: Open-ended statements encourage the client to express
feelings and provide additional information.
Question 9
A nurse is documenting client care. Which entry is appropriate?
A. “Client was difficult today.”
B. “Client appears much better.”
C. “Client ambulated 30 feet with one-person assistance.”
D. “Client had a good response to treatment.”
Answer: C. “Client ambulated 30 feet with one-person assistance.”
Rationale: Documentation should be objective, factual, specific, and
measurable.
Question 10
A nurse is preparing a sterile field. Which action contaminates the
sterile field?
A. Keeping the field above waist level
B. Turning away from the sterile field
C. Opening the far flap away from the body
D. Keeping sterile objects within view
Answer: B. Turning away from the sterile field
Questions and Answers with Rationales
Question 1
A nurse is caring for several clients. Which client should the nurse
assess first?
A. A client reporting pain rated 8/10
B. A client with an oxygen saturation of 88%
C. A client requesting assistance to the bathroom
D. A client scheduled for discharge teaching
Answer: B. A client with an oxygen saturation of 88%
Rationale: Airway and breathing problems take priority. An oxygen
saturation of 88% may indicate inadequate oxygenation and requires
immediate assessment and intervention.
Question 2
Which action is most effective in preventing the spread of infection?
A. Wearing a mask with every client
B. Administering antibiotics as prescribed
C. Performing proper hand hygiene
D. Wearing sterile gloves during all procedures
Answer: C. Performing proper hand hygiene
Rationale: Hand hygiene is the most effective measure for preventing
the transmission of microorganisms in healthcare settings.
Question 3
A nurse is preparing to administer medication. Which action is essential
before giving the medication?
,A. Ask another client to identify the medication
B. Compare the medication label with the medication administration
record
C. Prepare medications for multiple clients at the same time
D. Document administration before giving the medication
Answer: B. Compare the medication label with the medication
administration record
Rationale: The nurse should verify the medication against the
medication administration record and follow medication safety checks
before administration.
Question 4
Which client statement demonstrates understanding of fall prevention?
A. “I will get out of bed whenever I feel ready.”
B. “I will call for assistance before walking if I feel weak.”
C. “I should keep my bed in the highest position.”
D. “I do not need nonskid footwear in my room.”
Answer: B. “I will call for assistance before walking if I feel weak.”
Rationale: Clients at risk for falls should request assistance before
ambulating when weak, dizzy, or unfamiliar with their surroundings.
Question 5
A nurse observes redness over a client's sacral area. What is the priority
intervention?
A. Massage the reddened area
B. Apply heat directly to the area
C. Relieve pressure from the area
D. Scrub the area vigorously
,Answer: C. Relieve pressure from the area
Rationale: Persistent pressure contributes to skin breakdown. The
nurse should reposition the client and reduce pressure on the affected
area.
Question 6
Which finding should the nurse report immediately?
A. Temperature of 37.2°C (99°F)
B. Respiratory rate of 8 breaths/min
C. Heart rate of 88 beats/min
D. Blood pressure of 128/76 mm Hg
Answer: B. Respiratory rate of 8 breaths/min
Rationale: A respiratory rate of 8 breaths/min indicates respiratory
depression and requires immediate assessment.
Question 7
A client refuses a prescribed treatment. What is the nurse's best
action?
A. Force the client to receive the treatment
B. Ask the family to consent for the client
C. Explain the treatment and document the refusal
D. Tell the client that refusal is not allowed
Answer: C. Explain the treatment and document the refusal
Rationale: Competent clients have the right to refuse treatment. The
nurse should provide appropriate information, assess understanding,
notify the provider when necessary, and document the refusal.
Question 8
, Which communication technique is therapeutic?
A. “Everything will be fine.”
B. “Why did you do that?”
C. “Tell me more about how you are feeling.”
D. “You should not feel that way.”
Answer: C. “Tell me more about how you are feeling.”
Rationale: Open-ended statements encourage the client to express
feelings and provide additional information.
Question 9
A nurse is documenting client care. Which entry is appropriate?
A. “Client was difficult today.”
B. “Client appears much better.”
C. “Client ambulated 30 feet with one-person assistance.”
D. “Client had a good response to treatment.”
Answer: C. “Client ambulated 30 feet with one-person assistance.”
Rationale: Documentation should be objective, factual, specific, and
measurable.
Question 10
A nurse is preparing a sterile field. Which action contaminates the
sterile field?
A. Keeping the field above waist level
B. Turning away from the sterile field
C. Opening the far flap away from the body
D. Keeping sterile objects within view
Answer: B. Turning away from the sterile field
