Fundamentals of Nursing Evolve HESI Real
Exams Questions Bank: 340 Questions with
Detailed Answers and Rationales
Section 1: Basic Nursing Care and Safety (Questions 1-85)
Question 1: A nurse is preparing to insert a nasogastric tube. Which position is most appropriate for this
procedure?
A) Supine position with head flat
B) High-Fowler's position with head tilted forward
C) Left side-lying position
D) Trendelenburg position
Answer: B) High-Fowler's position with head tilted forward
Rationale: High-Fowler's position with the head tilted forward allows the NG tube to follow the natural
curvature of the nasopharynx and facilitates swallowing, which helps guide the tube into the esophagus.
This position also reduces the risk of aspiration. Supine position may cause the tube to enter the trachea,
and Trendelenburg is not appropriate for this procedure.
Question 2: A client is admitted with a diagnosis of pneumonia. Which finding requires immediate
nursing intervention?
A) Temperature of 101.2°F (38.4°C)
B) Productive cough with green sputum
C) Oxygen saturation of 88% on room air
D) Respiratory rate of 22 breaths per minute
Answer: C) Oxygen saturation of 88% on room air
Rationale: An oxygen saturation of 88% indicates significant hypoxemia and requires immediate
intervention, including oxygen administration and further assessment. This is below the normal range of
95-100% and indicates inadequate oxygenation. While fever, productive cough, and tachypnea are
concerning, they do not require the same level of immediate intervention as hypoxia.
Question 3: A nurse is administering a cleansing enema. The client reports abdominal cramping. What
should the nurse do?
A) Continue the enema and instruct the client to take deep breaths
B) Stop the enema and remove the tubing
C) Slow the rate of infusion and lower the enema bag
D) Administer pain medication before continuing
Answer: C) Slow the rate of infusion and lower the enema bag
Rationale: Abdominal cramping during an enema is common and is often caused by too rapid infusion or
solution that is too cold. The nurse should slow the infusion rate and lower the enema bag to decrease
,the pressure and flow. If cramping continues, the nurse may stop the enema temporarily. Removing the
tubing and administering pain medication are not appropriate first responses.
Question 4: A client has an order for furosemide (Lasix) 40 mg IV push. Which assessment finding should
the nurse report to the healthcare provider before administering the medication?
A) Blood pressure of 138/86 mmHg
B) Serum potassium of 3.2 mEq/L
C) Urine output of 30 mL/hour
D) Heart rate of 72 beats per minute
Answer: B) Serum potassium of 3.2 mEq/L
Rationale: Furosemide is a loop diuretic that can cause hypokalemia. A serum potassium of 3.2 mEq/L is
below normal (3.5-5.0 mEq/L) and indicates the client may need potassium supplementation before the
medication is administered. The nurse should report this finding to the healthcare provider. The other
findings are within acceptable ranges.
Question 5: A nurse is providing tracheostomy care. When suctioning the tracheostomy tube, which
action is correct?
A) Apply suction during insertion of the catheter
B) Apply suction for 15 seconds while withdrawing the catheter
C) Suction for 10-15 seconds with a rotating motion
D) Use clean technique for tracheostomy suctioning
Answer: C) Suction for 10-15 seconds with a rotating motion
Rationale: The correct technique for tracheostomy suctioning is to apply suction intermittently while
withdrawing the catheter using a rotating motion for 10-15 seconds. Suction should not be applied
during insertion, and the duration should not exceed 15 seconds to prevent hypoxia. Sterile technique
should be used for tracheostomy suctioning.
Question 6: A client with a history of falls is admitted to the hospital. Which nursing intervention is most
appropriate to prevent falls?
A) Keep the bed in the lowest position with the side rails up
B) Keep the room darkened to promote rest
C) Restrict the client to bed rest
D) Keep the bed in the highest position for easy access
Answer: A) Keep the bed in the lowest position with the side rails up
Rationale: Keeping the bed in the lowest position with side rails up is an appropriate fall prevention
intervention. The room should have adequate lighting, and the client should be encouraged to call for
assistance. Bed rest should be avoided if possible, and the bed should not be in the highest position as
this would increase fall risk.
Question 7: A nurse is caring for a client with a wound that is healing by secondary intention. Which
finding indicates that the wound is healing properly?
A) The wound edges are approximated
B) The wound bed is pink and granular
,C) The wound has purulent drainage
D) The wound is covered with dry eschar
Answer: B) The wound bed is pink and granular
Rationale: A pink, granular wound bed indicates healthy granulation tissue and proper healing by
secondary intention. Wounds healing by secondary intention have edges that are not approximated
(they are open) and heal from the bottom up. Purulent drainage indicates infection, and dry eschar is a
barrier to healing that may need debridement.
Question 8: A client is receiving a blood transfusion. The nurse notes that the client has developed chills,
fever, and back pain. Which action should the nurse take first?
A) Stop the transfusion
B) Administer diphenhydramine
C) Notify the healthcare provider
D) Decrease the transfusion rate
Answer: A) Stop the transfusion
Rationale: Chills, fever, and back pain are signs of a potential transfusion reaction. The nurse should
immediately stop the transfusion, maintain IV access with normal saline, and then notify the healthcare
provider. Continuing the transfusion or decreasing the rate could worsen the reaction. Administering
medications may be necessary but should occur after stopping the transfusion.
Question 9: A client with a nasogastric tube is reporting nausea and abdominal distention. What is the
nurse's priority action?
A) Irrigate the nasogastric tube
B) Check the placement of the nasogastric tube
C) Administer an antiemetic
D) Increase the suction setting
Answer: B) Check the placement of the nasogastric tube
Rationale: Nausea and abdominal distention may indicate that the nasogastric tube is not in the proper
position or is obstructed. The nurse should first check the tube placement and patency. Irrigating the
tube may be necessary, but verifying placement is the priority. Increasing suction or administering
medication without assessing the tube could be ineffective or unsafe.
Question 10: A nurse is assessing a client's peripheral IV site. Which finding indicates phlebitis?
A) Edema and coolness around the insertion site
B) Redness, warmth, and tenderness along the vein
C) Pallor and numbness in the extremity
D) Serous drainage at the insertion site
Answer: B) Redness, warmth, and tenderness along the vein
Rationale: Phlebitis is characterized by inflammation of the vein, presenting with redness, warmth,
tenderness, and often a palpable cord along the vein. Edema and coolness suggest infiltration, pallor and
numbness suggest arterial insufficiency, and serous drainage may indicate infection but is not specific to
phlebitis.
, Question 11: A client is receiving IV fluids at 125 mL/hour. The nurse notes that the IV site is swollen and
cool to the touch. Which condition is most likely?
A) Phlebitis
B) Infiltration
C) Infection
D) Thrombophlebitis
Answer: B) Infiltration
Rationale: Infiltration occurs when IV fluid leaks into the surrounding tissue, causing swelling, coolness,
and a slowed infusion rate. Phlebitis presents with redness, warmth, and tenderness. Infection would
show signs of redness, warmth, and possibly purulent drainage. Thrombophlebitis combines
inflammation with clot formation.
Question 12: A nurse is providing teaching to a client who is prescribed a low-sodium diet. Which food
selection by the client indicates understanding of the teaching?
A) A slice of cheese pizza
B) A turkey sandwich with lettuce and tomato
C) A can of tomato soup with crackers
D) A hot dog with ketchup
Answer: B) A turkey sandwich with lettuce and tomato
Rationale: A turkey sandwich with lettuce and tomato is the lowest sodium choice among the options.
Cheese pizza, canned tomato soup, and hot dogs with ketchup are all high in sodium. A low-sodium diet
should emphasize fresh, unprocessed foods and avoid processed meats, canned soups, and condiments.
Question 13: A client is receiving oxygen via nasal cannula at 2 L/min. Which finding indicates the client
is receiving adequate oxygenation?
A) Respiratory rate of 24 breaths per minute
B) Pulse oximetry reading of 92%
C) Client reports feeling short of breath
D) Heart rate of 110 beats per minute
Answer: B) Pulse oximetry reading of 92%
Rationale: A pulse oximetry reading of 92% indicates adequate oxygenation, though the target may vary
depending on the client's condition. A reading of 95% or higher is ideal. Tachypnea, shortness of breath,
and tachycardia suggest inadequate oxygenation and require further assessment and intervention.
Question 14: A nurse is performing a sterile dressing change. Which action demonstrates proper sterile
technique?
A) Opening the sterile package toward the body
B) Cleaning the wound from the outer edge toward the center
C) Holding sterile items above waist level
D) Using sterile gloves that have been opened but not touched
Answer: C) Holding sterile items above waist level
Rationale: Sterile items should be kept above waist level to prevent contamination. Opening sterile
Exams Questions Bank: 340 Questions with
Detailed Answers and Rationales
Section 1: Basic Nursing Care and Safety (Questions 1-85)
Question 1: A nurse is preparing to insert a nasogastric tube. Which position is most appropriate for this
procedure?
A) Supine position with head flat
B) High-Fowler's position with head tilted forward
C) Left side-lying position
D) Trendelenburg position
Answer: B) High-Fowler's position with head tilted forward
Rationale: High-Fowler's position with the head tilted forward allows the NG tube to follow the natural
curvature of the nasopharynx and facilitates swallowing, which helps guide the tube into the esophagus.
This position also reduces the risk of aspiration. Supine position may cause the tube to enter the trachea,
and Trendelenburg is not appropriate for this procedure.
Question 2: A client is admitted with a diagnosis of pneumonia. Which finding requires immediate
nursing intervention?
A) Temperature of 101.2°F (38.4°C)
B) Productive cough with green sputum
C) Oxygen saturation of 88% on room air
D) Respiratory rate of 22 breaths per minute
Answer: C) Oxygen saturation of 88% on room air
Rationale: An oxygen saturation of 88% indicates significant hypoxemia and requires immediate
intervention, including oxygen administration and further assessment. This is below the normal range of
95-100% and indicates inadequate oxygenation. While fever, productive cough, and tachypnea are
concerning, they do not require the same level of immediate intervention as hypoxia.
Question 3: A nurse is administering a cleansing enema. The client reports abdominal cramping. What
should the nurse do?
A) Continue the enema and instruct the client to take deep breaths
B) Stop the enema and remove the tubing
C) Slow the rate of infusion and lower the enema bag
D) Administer pain medication before continuing
Answer: C) Slow the rate of infusion and lower the enema bag
Rationale: Abdominal cramping during an enema is common and is often caused by too rapid infusion or
solution that is too cold. The nurse should slow the infusion rate and lower the enema bag to decrease
,the pressure and flow. If cramping continues, the nurse may stop the enema temporarily. Removing the
tubing and administering pain medication are not appropriate first responses.
Question 4: A client has an order for furosemide (Lasix) 40 mg IV push. Which assessment finding should
the nurse report to the healthcare provider before administering the medication?
A) Blood pressure of 138/86 mmHg
B) Serum potassium of 3.2 mEq/L
C) Urine output of 30 mL/hour
D) Heart rate of 72 beats per minute
Answer: B) Serum potassium of 3.2 mEq/L
Rationale: Furosemide is a loop diuretic that can cause hypokalemia. A serum potassium of 3.2 mEq/L is
below normal (3.5-5.0 mEq/L) and indicates the client may need potassium supplementation before the
medication is administered. The nurse should report this finding to the healthcare provider. The other
findings are within acceptable ranges.
Question 5: A nurse is providing tracheostomy care. When suctioning the tracheostomy tube, which
action is correct?
A) Apply suction during insertion of the catheter
B) Apply suction for 15 seconds while withdrawing the catheter
C) Suction for 10-15 seconds with a rotating motion
D) Use clean technique for tracheostomy suctioning
Answer: C) Suction for 10-15 seconds with a rotating motion
Rationale: The correct technique for tracheostomy suctioning is to apply suction intermittently while
withdrawing the catheter using a rotating motion for 10-15 seconds. Suction should not be applied
during insertion, and the duration should not exceed 15 seconds to prevent hypoxia. Sterile technique
should be used for tracheostomy suctioning.
Question 6: A client with a history of falls is admitted to the hospital. Which nursing intervention is most
appropriate to prevent falls?
A) Keep the bed in the lowest position with the side rails up
B) Keep the room darkened to promote rest
C) Restrict the client to bed rest
D) Keep the bed in the highest position for easy access
Answer: A) Keep the bed in the lowest position with the side rails up
Rationale: Keeping the bed in the lowest position with side rails up is an appropriate fall prevention
intervention. The room should have adequate lighting, and the client should be encouraged to call for
assistance. Bed rest should be avoided if possible, and the bed should not be in the highest position as
this would increase fall risk.
Question 7: A nurse is caring for a client with a wound that is healing by secondary intention. Which
finding indicates that the wound is healing properly?
A) The wound edges are approximated
B) The wound bed is pink and granular
,C) The wound has purulent drainage
D) The wound is covered with dry eschar
Answer: B) The wound bed is pink and granular
Rationale: A pink, granular wound bed indicates healthy granulation tissue and proper healing by
secondary intention. Wounds healing by secondary intention have edges that are not approximated
(they are open) and heal from the bottom up. Purulent drainage indicates infection, and dry eschar is a
barrier to healing that may need debridement.
Question 8: A client is receiving a blood transfusion. The nurse notes that the client has developed chills,
fever, and back pain. Which action should the nurse take first?
A) Stop the transfusion
B) Administer diphenhydramine
C) Notify the healthcare provider
D) Decrease the transfusion rate
Answer: A) Stop the transfusion
Rationale: Chills, fever, and back pain are signs of a potential transfusion reaction. The nurse should
immediately stop the transfusion, maintain IV access with normal saline, and then notify the healthcare
provider. Continuing the transfusion or decreasing the rate could worsen the reaction. Administering
medications may be necessary but should occur after stopping the transfusion.
Question 9: A client with a nasogastric tube is reporting nausea and abdominal distention. What is the
nurse's priority action?
A) Irrigate the nasogastric tube
B) Check the placement of the nasogastric tube
C) Administer an antiemetic
D) Increase the suction setting
Answer: B) Check the placement of the nasogastric tube
Rationale: Nausea and abdominal distention may indicate that the nasogastric tube is not in the proper
position or is obstructed. The nurse should first check the tube placement and patency. Irrigating the
tube may be necessary, but verifying placement is the priority. Increasing suction or administering
medication without assessing the tube could be ineffective or unsafe.
Question 10: A nurse is assessing a client's peripheral IV site. Which finding indicates phlebitis?
A) Edema and coolness around the insertion site
B) Redness, warmth, and tenderness along the vein
C) Pallor and numbness in the extremity
D) Serous drainage at the insertion site
Answer: B) Redness, warmth, and tenderness along the vein
Rationale: Phlebitis is characterized by inflammation of the vein, presenting with redness, warmth,
tenderness, and often a palpable cord along the vein. Edema and coolness suggest infiltration, pallor and
numbness suggest arterial insufficiency, and serous drainage may indicate infection but is not specific to
phlebitis.
, Question 11: A client is receiving IV fluids at 125 mL/hour. The nurse notes that the IV site is swollen and
cool to the touch. Which condition is most likely?
A) Phlebitis
B) Infiltration
C) Infection
D) Thrombophlebitis
Answer: B) Infiltration
Rationale: Infiltration occurs when IV fluid leaks into the surrounding tissue, causing swelling, coolness,
and a slowed infusion rate. Phlebitis presents with redness, warmth, and tenderness. Infection would
show signs of redness, warmth, and possibly purulent drainage. Thrombophlebitis combines
inflammation with clot formation.
Question 12: A nurse is providing teaching to a client who is prescribed a low-sodium diet. Which food
selection by the client indicates understanding of the teaching?
A) A slice of cheese pizza
B) A turkey sandwich with lettuce and tomato
C) A can of tomato soup with crackers
D) A hot dog with ketchup
Answer: B) A turkey sandwich with lettuce and tomato
Rationale: A turkey sandwich with lettuce and tomato is the lowest sodium choice among the options.
Cheese pizza, canned tomato soup, and hot dogs with ketchup are all high in sodium. A low-sodium diet
should emphasize fresh, unprocessed foods and avoid processed meats, canned soups, and condiments.
Question 13: A client is receiving oxygen via nasal cannula at 2 L/min. Which finding indicates the client
is receiving adequate oxygenation?
A) Respiratory rate of 24 breaths per minute
B) Pulse oximetry reading of 92%
C) Client reports feeling short of breath
D) Heart rate of 110 beats per minute
Answer: B) Pulse oximetry reading of 92%
Rationale: A pulse oximetry reading of 92% indicates adequate oxygenation, though the target may vary
depending on the client's condition. A reading of 95% or higher is ideal. Tachypnea, shortness of breath,
and tachycardia suggest inadequate oxygenation and require further assessment and intervention.
Question 14: A nurse is performing a sterile dressing change. Which action demonstrates proper sterile
technique?
A) Opening the sterile package toward the body
B) Cleaning the wound from the outer edge toward the center
C) Holding sterile items above waist level
D) Using sterile gloves that have been opened but not touched
Answer: C) Holding sterile items above waist level
Rationale: Sterile items should be kept above waist level to prevent contamination. Opening sterile
