,EVOLVE HESI Fundamentals V1, V2 & V3 |
Nursing Q & A | 2026 Edition (PDF)
**1. A client with congestive heart failure reports shortness of breath and increasing fatigue. The nurse
notes bilateral crackles and 2+ pitting edema. Which action should the nurse take first?**
A) Encourage the client to increase fluid intake
B) Administer the prescribed diuretic
C) Place the client in high-Fowler's position
D) Document the findings and reassess in 2 hours
Correct Answer: Place the client in high-Fowler's position
Rationale: High-Fowler's position improves ventilation and oxygenation immediately by using gravity to
pull the diaphragm downward, allowing for better lung expansion. While diuretics should be
administered, positioning is the priority to relieve respiratory distress.
**2. A client is scheduled for a colonoscopy. Which instruction should the nurse provide?**
A) "You may continue your aspirin daily."
B) "Drink clear liquids only the day before."
C) "You should not fast before the procedure."
D) "You can take your diabetic insulin as usual."
Correct Answer: "Drink clear liquids only the day before."
Rationale: Clear liquids help empty the bowel and reduce the risk of aspiration during the procedure.
Aspirin is typically stopped prior due to bleeding risk, and insulin is often adjusted or held.
**3. A client with pneumonia is receiving oxygen at 2 L/min via nasal cannula. The client becomes
confused and sleepy. What is the priority nursing action?**
A) Increase oxygen to 4 L/min
,B) Check oxygen saturation and respiratory rate
C) Administer a sedative to calm the client
D) Encourage the client to drink fluids
Correct Answer: Check oxygen saturation and respiratory rate
Rationale: Confusion and drowsiness may indicate hypoxia or carbon dioxide retention. Assessing
oxygenation and respiratory status is the priority before making any changes to the oxygen delivery or
administering medications.
**4. The nurse is assisting a client with ambulation. Which action ensures client safety?**
A) Allowing the client to walk barefoot
B) Using a gait belt
C) Keeping the bed in the highest position
D) Removing obstacles after ambulation
Correct Answer: Using a gait belt
Rationale: A gait belt provides secure support, reducing fall risk during ambulation. Removing obstacles
should be done before ambulation, not after. Clients should wear non-slip footwear.
**5. Which intervention prevents falls in an elderly client?**
A) Dim lighting in the room
B) Non-slip footwear
C) Cluttered pathways
D) No handrails in the bathroom
Correct Answer: Non-slip footwear
, Rationale: Non-slip footwear increases traction, reducing fall risk. Adequate lighting, clear pathways, and
handrails are also essential fall prevention measures.
**6. A client is at risk for falls. What should the nurse prioritize?**
A) Keep the call light out of reach
B) Raise all bed side rails
C) Assess fall risk using a tool
D) Encourage independent ambulation
Correct Answer: Assess fall risk using a tool
Rationale: Using a fall risk assessment tool (e.g., Morse Scale) identifies specific risks and guides
individualized interventions. Side rails should not be raised without proper assessment as they can
increase injury risk if the client climbs over them.
**7. A nurse is transferring a client to a wheelchair. What is the first step?**
A) Lock the wheelchair brakes
B) Lower the bed to the lowest position
C) Raise the wheelchair footrests
D) Assist the client to stand immediately
Correct Answer: Lock the wheelchair brakes
Rationale: Locking brakes prevents the wheelchair from moving during transfer, ensuring client safety.
The bed should be lowered after the wheelchair is secured.
**8. Which action ensures safe medication administration?**
A) Administering without checking allergies
B) Verifying client identity with two identifiers
C) Using a single identifier
Nursing Q & A | 2026 Edition (PDF)
**1. A client with congestive heart failure reports shortness of breath and increasing fatigue. The nurse
notes bilateral crackles and 2+ pitting edema. Which action should the nurse take first?**
A) Encourage the client to increase fluid intake
B) Administer the prescribed diuretic
C) Place the client in high-Fowler's position
D) Document the findings and reassess in 2 hours
Correct Answer: Place the client in high-Fowler's position
Rationale: High-Fowler's position improves ventilation and oxygenation immediately by using gravity to
pull the diaphragm downward, allowing for better lung expansion. While diuretics should be
administered, positioning is the priority to relieve respiratory distress.
**2. A client is scheduled for a colonoscopy. Which instruction should the nurse provide?**
A) "You may continue your aspirin daily."
B) "Drink clear liquids only the day before."
C) "You should not fast before the procedure."
D) "You can take your diabetic insulin as usual."
Correct Answer: "Drink clear liquids only the day before."
Rationale: Clear liquids help empty the bowel and reduce the risk of aspiration during the procedure.
Aspirin is typically stopped prior due to bleeding risk, and insulin is often adjusted or held.
**3. A client with pneumonia is receiving oxygen at 2 L/min via nasal cannula. The client becomes
confused and sleepy. What is the priority nursing action?**
A) Increase oxygen to 4 L/min
,B) Check oxygen saturation and respiratory rate
C) Administer a sedative to calm the client
D) Encourage the client to drink fluids
Correct Answer: Check oxygen saturation and respiratory rate
Rationale: Confusion and drowsiness may indicate hypoxia or carbon dioxide retention. Assessing
oxygenation and respiratory status is the priority before making any changes to the oxygen delivery or
administering medications.
**4. The nurse is assisting a client with ambulation. Which action ensures client safety?**
A) Allowing the client to walk barefoot
B) Using a gait belt
C) Keeping the bed in the highest position
D) Removing obstacles after ambulation
Correct Answer: Using a gait belt
Rationale: A gait belt provides secure support, reducing fall risk during ambulation. Removing obstacles
should be done before ambulation, not after. Clients should wear non-slip footwear.
**5. Which intervention prevents falls in an elderly client?**
A) Dim lighting in the room
B) Non-slip footwear
C) Cluttered pathways
D) No handrails in the bathroom
Correct Answer: Non-slip footwear
, Rationale: Non-slip footwear increases traction, reducing fall risk. Adequate lighting, clear pathways, and
handrails are also essential fall prevention measures.
**6. A client is at risk for falls. What should the nurse prioritize?**
A) Keep the call light out of reach
B) Raise all bed side rails
C) Assess fall risk using a tool
D) Encourage independent ambulation
Correct Answer: Assess fall risk using a tool
Rationale: Using a fall risk assessment tool (e.g., Morse Scale) identifies specific risks and guides
individualized interventions. Side rails should not be raised without proper assessment as they can
increase injury risk if the client climbs over them.
**7. A nurse is transferring a client to a wheelchair. What is the first step?**
A) Lock the wheelchair brakes
B) Lower the bed to the lowest position
C) Raise the wheelchair footrests
D) Assist the client to stand immediately
Correct Answer: Lock the wheelchair brakes
Rationale: Locking brakes prevents the wheelchair from moving during transfer, ensuring client safety.
The bed should be lowered after the wheelchair is secured.
**8. Which action ensures safe medication administration?**
A) Administering without checking allergies
B) Verifying client identity with two identifiers
C) Using a single identifier
