EVOLVE HESI FUNDAMENTAL ACTUAL EXAM QUESTIONS AND ANSWERS
WITH RATIONALES UPDATED 2025 |WELL STRUCTURED|100% VERIFIED|
Answer: C
Urinary catheterization is prescribed for a postoperative female
It is likely that the first catheter is in the vagina, rather than the
client who has been unable to void for 8 hours. The nurse inserts
bladder. Leaving the first catheter in place will help locate the
the catheter, but no urine is seen in the tubing. Which action will
meatus when attempting the second catheterization (C).The client
the nurse take next?
should have at least 240 mL of urine after 8 hours. (A) does not
A. Clamp the catheter and recheck it in 60 minutes.
B. resolve the problem. (B) will not change the location of the catheter
C. Pull the catheter back 3 inches and redirect upward. unless it is completely removed, in which case a new catheter must
Leave the catheter in place and reattempt with another catheter.
be used. There is no evidence of a urinary tract obstruction if the
D. Notify the health care provider of a possible obstruction.
catheter could be easily inserted (D).
The nurse is teaching an obese client, newly diagnosed with Answer: C
arteriosclerosis, about reducing the risk of a heart attack or stroke. A health promotion brochure about decreasing cholesterol (C) is
Which health promotion brochure is most important for the nurse most important to provide this client, because the most significant
to provide to this client? risk factor contributing to development of arteriosclerosis is excess
A. "Monitoring Your Blood Pressure at Home" dietary fat, particularly saturated fat and cholesterol. (A) does not
B. "Smoking Cessation as a Lifelong Commitment" address the underlying causes of arteriosclerosis. (B and D) are
C. "Decreasing Cholesterol Levels Through Diet" also important factors for reversing arteriosclerosis but are not as
D. "Stress Management for a Healthier You" important as lowering cholesterol (C).
Ten minutes after signing an operative permit for a fractured hip, Answer: B
This statement may indicate that the client is confused. Informed
an older client states, "The aliens will be coming to get me soon!"
consent must be provided by a mentally competent individual, so
and falls asleep. Which action should the nurse implement next?
the nurse should further assess the client's neurologic status (B)
A. Make the client comfortable and allow the client to sleep.
to be sure that the client understands and can legally provide
B. Assess the client's neurologic status.
consent for surgery. (A) does not provide sufficient follow-up. If the
C. Notify the surgeon about the comment.
nurse determines that the client is confused, the surgeon must be
D. Ask the client's family to co-sign the operative permit.
notified (C) and permission obtained from the next of kin (D).
The nurse-manager of a skilled nursing (chronic care) unit is
instructing UAPs on ways to prevent complications of immobility.
Answer: A
Which intervention should be included in this instruction?
Performing range-of-motion exercises (A) is beneficial in reducing
A. Perform range-of-motion exercises to prevent contractures.
contractures around joints. (B, C, and D) are all potentially harmful
B. Decrease the client's fluid intake to prevent diarrhea.
practices that place the immobile client at risk of complications.
C. Massage the client's legs to reduce embolism occurrence.
D. Turn the client from side to back every shift.
Answer: D
The nurse is assisting a client to the bathroom. When the client is
(D) is the most prudent intervention and is the priority nursing
5 feet from the bathroom door, he states, "I feel faint." Before the
action to prevent injury to the client and the nurse. Lowering the
nurse can get the client to a chair, the client starts to fall. Which is
client to the floor should be done when the client cannot support
the priority action for the nurse to take?
his own weight. The client should be placed in a bed or chair only
A. Check the client's carotid pulse.
when sufficient help is available to prevent injury. (A) is important
B. Encourage the client to get to the toilet.
but should be done after the client is in a safe position. Because
C. In a loud voice, call for help.
the client is not supporting himself, (B) is impractical. (C) is likely
D. Gently lower the client to the floor.
to cause chaos on the unit and might alarm the other clients.
A female nurse is assigned to care for a close friend, who says,
"I am worried that friends will find out about my diagnosis." The Answer: B
nurse tells her friend that legally she must protect a client's con- The State Nurse Practice Act (B) contains legal requirements
fidentiality. Which resource describes the nurse's legal responsi- for the protection of client confidentiality and the consequences
bilities? for breaches in confidentiality. (A) outlines ethical standards for
A. Code of Ethics for Nurses nursing care but does not include legal guidelines. (C and D)
B. State Nurse Practice Act describe expectations for nursing practice but do not address legal
C. Patient's Bill of Rights implications.
D. ANA Standards of Practice
The nurse is teaching a client how to perform progressive muscle
relaxation techniques to relieve insomnia. A week later the client
Answer: D
reports that he is still unable to sleep, despite following the same
The nurse should first evaluate whether the client has been ad-
routine every night. Which action should the nurse take first?
hering to the original instructions (D). A verbal report of the client's
A. Instruct the client to add regular exercise as a daily routine.
routine will provide more specific information than the client's
B. Determine if the client has been keeping a sleep diary.
written diary (B). The nurse can then determine which changes
C. Encourage the client to continue the routine until sleep is
need to be made (A). The routine practiced by the client is clearly
achieved.
unsuccessful, so encouragement alone is insufficient (C).
D. Ask the client to describe the routine that the client is currently
following.
, EVOLVE HESI FUNDAMENTAL ACTUAL EXAM QUESTIONS AND ANSWERS
WITH RATIONALES UPDATED 2025 |WELL STRUCTURED|100% VERIFIED|
A 65-year-old client who attends an adult daycare program and is Answer: B
wheelchair-mobile has redness in the sacral area. Which instruc- The most important teaching is to change positions frequently
tion is most important for the nurse to provide? (B) because pressure is the most significant factor related to the
A. Take a vitamin supplement tablet once a day. development of pressure ulcers. Increased vitamin and fluid intake
B. Change positions in the chair at least every hour. (A and C) may also be beneficial promote healing and reduce
C. Increase daily intake of water or other oral fluids. further risk. (D) is an intervention of last resort because this will
D. Purchase a newer model wheelchair. be very expensive for the client.
When turning an immobile bedridden client without assistance, Answer: B
which action by the nurse best ensures client safety? Because the nurse can only stand on one side of the bed, bed
A. Securely grasp the client's arm and leg. rails should be up on the opposite side to ensure that the client
B. Put bed rails up on the side of bed opposite from the nurse. does not fall out of bed (B). (A) can cause client injury to the skin
C. Correctly position and use a turn sheet. or joint. (C and D) are useful techniques while turning a client but
D. Lower the head of the client's bed slowly. have less priority in terms of safety than use of the bed rails.
A female client with frequent urinary tract infections (UTIs) asks
the nurse to explain her friend's advice about drinking a glass of
Answer: C
juice daily to prevent future UTIs. Which response is best for the
Cranberry juice (C) maintains urinary tract health by reducing the
nurse provide?
adherence of Escherichia coli bacteria to cells within the bladder.
A. Orange juice has vitamin C that deters bacterial growth.
(A, B, and D) have not been shown to be as effective as cranberry
B. Apple juice is the most useful in acidifying the urine.
juice (C) in preventing UTIs.
C. Cranberry juice stops pathogens' adherence to the bladder.
D. Grapefruit juice increases absorption of most antibiotics.
Answer: A
The nurse is aware that malnutrition is a common problem among
Long-term protein deficiency is required to cause significantly low-
clients served by a community health clinic for the homeless.
ered serum albumin levels (A). Albumin is made by the liver only
Which laboratory value is the most reliable indicator of chronic
when adequate amounts of amino acids (from protein breakdown)
protein malnutrition?
are available. Albumin has a long half-life, so acute protein loss
A. Low serum albumin level
does not significantly alter serum levels. (B) is a serum protein
B. Low serum transferrin level
with a half-life of only 8 to 10 days, so it will drop with an acute
C. High hemoglobin level
protein deficiency. Neither (C or D) are clinical measures of protein
D. High cholesterol level
malnutrition.
The nurse identifies a potential for infection in a patient with par- Answer: B
tial-thickness (second-degree) and full-thickness (third-degree) Careful hand washing technique (B) is the single most effective
burns. What intervention has the highest priority in decreasing the intervention for the prevention of contamination to all clients. (A)
client's risk of infection? reverses the hypovolemia that initially accompanies burn trauma
A. Administration of plasma expanders but is not related to decreasing the proliferation of infective or-
B. Use of careful hand washing technique ganisms. (C and D) are recommended by various burn centers as
C. Application of a topical antibacterial cream possible ways to reduce the chance of infection. (B) is a proven
D. Limiting visitors to the client with burns technique to prevent infection.
Which serum laboratory value should the nurse monitor carefully
for a client who has a nasogastric (NG) tube to suction for the past Answer: D
week? Monitoring serum sodium levels (D) for hyponatremia is indicat-
A. White blood cell count ed during prolonged NG suctioning because of loss of fluids.
B. Albumin Changes in levels of (A, B, or C) are not typically associated with
C. Calcium prolonged NG suctioning.
D. Sodium
In completing a client's preoperative routine, the nurse finds that
Answer: C
the operative permit is not signed. The client begins to ask more
The surgeon should be informed immediately that the permit is
questions about the surgical procedure. Which action should the
not signed (C). It is the surgeon's responsibility to explain the
nurse take next?
procedure to the cliesxnt and obtain the client's signature on the
A. Witness the client's signature to the permit.
permit. Although the nurse can witness an operative permit (A),
B. Answer the client's questions about the surgery.
the procedure must first be explained by the health care provider
C. Inform the surgeon that the operative permit is not signed and
or surgeon, including answering the client's questions (B). The
the client has questions about the surgery.
client's questions should be addressed before the permit is signed
D. Reassure the client that the surgeon will answer any questions (D).
before the anesthesia is administered.
The nurse is preparing an older client for discharge.Which method
Answer: D
is best for the nurse to use when evaluating the client's ability to
Observing the client directly (D) will allow the nurse to determine if
perform a dressing change at home?
mastery of the skill has been obtained and provide an opportunity
A. Determine how the client feels about changing the dressing.
to affirm the skill. (A) may be therapeutic but will not provide an
B. Ask the client to describe the procedure in writing.
WITH RATIONALES UPDATED 2025 |WELL STRUCTURED|100% VERIFIED|
Answer: C
Urinary catheterization is prescribed for a postoperative female
It is likely that the first catheter is in the vagina, rather than the
client who has been unable to void for 8 hours. The nurse inserts
bladder. Leaving the first catheter in place will help locate the
the catheter, but no urine is seen in the tubing. Which action will
meatus when attempting the second catheterization (C).The client
the nurse take next?
should have at least 240 mL of urine after 8 hours. (A) does not
A. Clamp the catheter and recheck it in 60 minutes.
B. resolve the problem. (B) will not change the location of the catheter
C. Pull the catheter back 3 inches and redirect upward. unless it is completely removed, in which case a new catheter must
Leave the catheter in place and reattempt with another catheter.
be used. There is no evidence of a urinary tract obstruction if the
D. Notify the health care provider of a possible obstruction.
catheter could be easily inserted (D).
The nurse is teaching an obese client, newly diagnosed with Answer: C
arteriosclerosis, about reducing the risk of a heart attack or stroke. A health promotion brochure about decreasing cholesterol (C) is
Which health promotion brochure is most important for the nurse most important to provide this client, because the most significant
to provide to this client? risk factor contributing to development of arteriosclerosis is excess
A. "Monitoring Your Blood Pressure at Home" dietary fat, particularly saturated fat and cholesterol. (A) does not
B. "Smoking Cessation as a Lifelong Commitment" address the underlying causes of arteriosclerosis. (B and D) are
C. "Decreasing Cholesterol Levels Through Diet" also important factors for reversing arteriosclerosis but are not as
D. "Stress Management for a Healthier You" important as lowering cholesterol (C).
Ten minutes after signing an operative permit for a fractured hip, Answer: B
This statement may indicate that the client is confused. Informed
an older client states, "The aliens will be coming to get me soon!"
consent must be provided by a mentally competent individual, so
and falls asleep. Which action should the nurse implement next?
the nurse should further assess the client's neurologic status (B)
A. Make the client comfortable and allow the client to sleep.
to be sure that the client understands and can legally provide
B. Assess the client's neurologic status.
consent for surgery. (A) does not provide sufficient follow-up. If the
C. Notify the surgeon about the comment.
nurse determines that the client is confused, the surgeon must be
D. Ask the client's family to co-sign the operative permit.
notified (C) and permission obtained from the next of kin (D).
The nurse-manager of a skilled nursing (chronic care) unit is
instructing UAPs on ways to prevent complications of immobility.
Answer: A
Which intervention should be included in this instruction?
Performing range-of-motion exercises (A) is beneficial in reducing
A. Perform range-of-motion exercises to prevent contractures.
contractures around joints. (B, C, and D) are all potentially harmful
B. Decrease the client's fluid intake to prevent diarrhea.
practices that place the immobile client at risk of complications.
C. Massage the client's legs to reduce embolism occurrence.
D. Turn the client from side to back every shift.
Answer: D
The nurse is assisting a client to the bathroom. When the client is
(D) is the most prudent intervention and is the priority nursing
5 feet from the bathroom door, he states, "I feel faint." Before the
action to prevent injury to the client and the nurse. Lowering the
nurse can get the client to a chair, the client starts to fall. Which is
client to the floor should be done when the client cannot support
the priority action for the nurse to take?
his own weight. The client should be placed in a bed or chair only
A. Check the client's carotid pulse.
when sufficient help is available to prevent injury. (A) is important
B. Encourage the client to get to the toilet.
but should be done after the client is in a safe position. Because
C. In a loud voice, call for help.
the client is not supporting himself, (B) is impractical. (C) is likely
D. Gently lower the client to the floor.
to cause chaos on the unit and might alarm the other clients.
A female nurse is assigned to care for a close friend, who says,
"I am worried that friends will find out about my diagnosis." The Answer: B
nurse tells her friend that legally she must protect a client's con- The State Nurse Practice Act (B) contains legal requirements
fidentiality. Which resource describes the nurse's legal responsi- for the protection of client confidentiality and the consequences
bilities? for breaches in confidentiality. (A) outlines ethical standards for
A. Code of Ethics for Nurses nursing care but does not include legal guidelines. (C and D)
B. State Nurse Practice Act describe expectations for nursing practice but do not address legal
C. Patient's Bill of Rights implications.
D. ANA Standards of Practice
The nurse is teaching a client how to perform progressive muscle
relaxation techniques to relieve insomnia. A week later the client
Answer: D
reports that he is still unable to sleep, despite following the same
The nurse should first evaluate whether the client has been ad-
routine every night. Which action should the nurse take first?
hering to the original instructions (D). A verbal report of the client's
A. Instruct the client to add regular exercise as a daily routine.
routine will provide more specific information than the client's
B. Determine if the client has been keeping a sleep diary.
written diary (B). The nurse can then determine which changes
C. Encourage the client to continue the routine until sleep is
need to be made (A). The routine practiced by the client is clearly
achieved.
unsuccessful, so encouragement alone is insufficient (C).
D. Ask the client to describe the routine that the client is currently
following.
, EVOLVE HESI FUNDAMENTAL ACTUAL EXAM QUESTIONS AND ANSWERS
WITH RATIONALES UPDATED 2025 |WELL STRUCTURED|100% VERIFIED|
A 65-year-old client who attends an adult daycare program and is Answer: B
wheelchair-mobile has redness in the sacral area. Which instruc- The most important teaching is to change positions frequently
tion is most important for the nurse to provide? (B) because pressure is the most significant factor related to the
A. Take a vitamin supplement tablet once a day. development of pressure ulcers. Increased vitamin and fluid intake
B. Change positions in the chair at least every hour. (A and C) may also be beneficial promote healing and reduce
C. Increase daily intake of water or other oral fluids. further risk. (D) is an intervention of last resort because this will
D. Purchase a newer model wheelchair. be very expensive for the client.
When turning an immobile bedridden client without assistance, Answer: B
which action by the nurse best ensures client safety? Because the nurse can only stand on one side of the bed, bed
A. Securely grasp the client's arm and leg. rails should be up on the opposite side to ensure that the client
B. Put bed rails up on the side of bed opposite from the nurse. does not fall out of bed (B). (A) can cause client injury to the skin
C. Correctly position and use a turn sheet. or joint. (C and D) are useful techniques while turning a client but
D. Lower the head of the client's bed slowly. have less priority in terms of safety than use of the bed rails.
A female client with frequent urinary tract infections (UTIs) asks
the nurse to explain her friend's advice about drinking a glass of
Answer: C
juice daily to prevent future UTIs. Which response is best for the
Cranberry juice (C) maintains urinary tract health by reducing the
nurse provide?
adherence of Escherichia coli bacteria to cells within the bladder.
A. Orange juice has vitamin C that deters bacterial growth.
(A, B, and D) have not been shown to be as effective as cranberry
B. Apple juice is the most useful in acidifying the urine.
juice (C) in preventing UTIs.
C. Cranberry juice stops pathogens' adherence to the bladder.
D. Grapefruit juice increases absorption of most antibiotics.
Answer: A
The nurse is aware that malnutrition is a common problem among
Long-term protein deficiency is required to cause significantly low-
clients served by a community health clinic for the homeless.
ered serum albumin levels (A). Albumin is made by the liver only
Which laboratory value is the most reliable indicator of chronic
when adequate amounts of amino acids (from protein breakdown)
protein malnutrition?
are available. Albumin has a long half-life, so acute protein loss
A. Low serum albumin level
does not significantly alter serum levels. (B) is a serum protein
B. Low serum transferrin level
with a half-life of only 8 to 10 days, so it will drop with an acute
C. High hemoglobin level
protein deficiency. Neither (C or D) are clinical measures of protein
D. High cholesterol level
malnutrition.
The nurse identifies a potential for infection in a patient with par- Answer: B
tial-thickness (second-degree) and full-thickness (third-degree) Careful hand washing technique (B) is the single most effective
burns. What intervention has the highest priority in decreasing the intervention for the prevention of contamination to all clients. (A)
client's risk of infection? reverses the hypovolemia that initially accompanies burn trauma
A. Administration of plasma expanders but is not related to decreasing the proliferation of infective or-
B. Use of careful hand washing technique ganisms. (C and D) are recommended by various burn centers as
C. Application of a topical antibacterial cream possible ways to reduce the chance of infection. (B) is a proven
D. Limiting visitors to the client with burns technique to prevent infection.
Which serum laboratory value should the nurse monitor carefully
for a client who has a nasogastric (NG) tube to suction for the past Answer: D
week? Monitoring serum sodium levels (D) for hyponatremia is indicat-
A. White blood cell count ed during prolonged NG suctioning because of loss of fluids.
B. Albumin Changes in levels of (A, B, or C) are not typically associated with
C. Calcium prolonged NG suctioning.
D. Sodium
In completing a client's preoperative routine, the nurse finds that
Answer: C
the operative permit is not signed. The client begins to ask more
The surgeon should be informed immediately that the permit is
questions about the surgical procedure. Which action should the
not signed (C). It is the surgeon's responsibility to explain the
nurse take next?
procedure to the cliesxnt and obtain the client's signature on the
A. Witness the client's signature to the permit.
permit. Although the nurse can witness an operative permit (A),
B. Answer the client's questions about the surgery.
the procedure must first be explained by the health care provider
C. Inform the surgeon that the operative permit is not signed and
or surgeon, including answering the client's questions (B). The
the client has questions about the surgery.
client's questions should be addressed before the permit is signed
D. Reassure the client that the surgeon will answer any questions (D).
before the anesthesia is administered.
The nurse is preparing an older client for discharge.Which method
Answer: D
is best for the nurse to use when evaluating the client's ability to
Observing the client directly (D) will allow the nurse to determine if
perform a dressing change at home?
mastery of the skill has been obtained and provide an opportunity
A. Determine how the client feels about changing the dressing.
to affirm the skill. (A) may be therapeutic but will not provide an
B. Ask the client to describe the procedure in writing.
