EVOLVE HESI FUNDAMENTALS V3 LATEST
UPDATED 2026-2027 ACTUAL FINAL PRACTICE
EXAM PREP WITH ALL POSSIBLE TESTED
COMPREHENSIVE QUESTIONS AND 100% CORRECT
VERIFIED ANSWERS WITH DETAILED RATIONALES
PLUS CERTIFIED ANSWER KEY RATED A+ GRADE
FREE PDF ACCESS
1. A nurse is preparing to provide care for a client. Which action is the most
important for preventing the spread of infection?
A. Wearing gloves for all client contact
B. Performing hand hygiene before and after client contact
C. Placing the client in a private room
D. Wearing a mask when within 3 feet of the client
B. Performing hand hygiene before and after client contact
Rationale: Hand hygiene is the single most effective method for preventing
infection transmission. Gloves, private rooms, and masks are used based on
specific precautions but do not replace hand hygiene.
2. A nurse is caring for an older adult client at risk for falls. Which intervention
should the nurse implement first?
A. Apply a bed alarm
B. Keep the bed in the lowest position
C. Place the client in a restraint
D. Administer a sedative at bedtime
B. Keep the bed in the lowest position
Rationale: Keeping the bed in the lowest position reduces the risk of injury if the
client falls. Bed alarms and other measures may be added, but environmental
safety is a first-line intervention.
3. A client reports dizziness when standing up. Which instruction should the nurse
provide?
A. “Cross your legs before standing.”
B. “Stand up quickly to adjust your blood pressure.”
,C. “Change positions slowly and dangle your legs before standing.”
D. “Avoid drinking fluids before getting out of bed.”
C. “Change positions slowly and dangle your legs before standing.”
Rationale: Slow position changes help prevent orthostatic hypotension. Dangling
the legs allows the body to adjust before standing.
4. A nurse is planning care for a client who is immobile. Which intervention best
prevents pressure injuries?
A. Massage reddened bony prominences
B. Reposition the client at least every 2 hours
C. Keep the head of the bed elevated 90 degrees
D. Apply tight-fitting sheets to prevent wrinkles
B. Reposition the client at least every 2 hours
Rationale: Repositioning relieves pressure over bony prominences and is a key
prevention strategy. Massaging reddened areas can cause further tissue damage.
5. Which tool should the nurse use to assess a client’s risk for developing pressure
injuries?
A. Glasgow Coma Scale
B. Braden Scale
C. Morse Fall Scale
D. Pain Assessment in Advanced Dementia
B. Braden Scale
Rationale: The Braden Scale evaluates sensory perception, moisture, activity,
mobility, nutrition, and friction/shear to determine pressure injury risk.
6. A nurse is assessing an adult client’s oral temperature. Which finding is within
the expected reference range?
A. 35.0°C (95.0°F)
B. 36.8°C (98.2°F)
C. 38.0°C (100.4°F)
D. 39.0°C (102.2°F)
B. 36.8°C (98.2°F)
Rationale: Normal oral temperature is approximately 36.5°C to 37.5°C (97.7°F
to 99.5°F). Values above 38°C indicate fever.
7. A nurse obtains a pulse oximetry reading of 89% on a client. Which action
should the nurse take first?
A. Document the finding as normal
, B. Assess the client’s respiratory status and apply oxygen if prescribed
C. Ask the client to ambulate
D. Recheck the pulse oximetry in 4 hours
B. Assess the client’s respiratory status and apply oxygen if prescribed
Rationale: A pulse oximetry reading below 90% indicates hypoxemia. The nurse
should assess the client and intervene immediately.
8. Which adult heart rate should the nurse document as within the expected
reference range?
A. 42 beats/min
B. 58 beats/min
C. 72 beats/min
D. 110 beats/min
C. 72 beats/min
Rationale: The expected adult heart rate is 60 to 100 beats/min. Values below 60
indicate bradycardia, and values above 100 indicate tachycardia.
9. A nurse is assessing an adult client’s respiratory rate. Which finding is within
the expected reference range?
A. 8 breaths/min
B. 16 breaths/min
C. 24 breaths/min
D. 30 breaths/min
B. 16 breaths/min
Rationale: The expected adult respiratory rate is 12 to 20 breaths/min. Rates
outside this range require further assessment.
10. A nurse is preparing to measure a client’s blood pressure. Which action is
correct?
A. Use a cuff that is too small for the arm
B. Place the cuff over the client’s clothing
C. Position the cuff 2.5 cm (1 inch) above the antecubital space
D. Inflate the cuff rapidly after placing the stethoscope over the brachial artery
C. Position the cuff 2.5 cm (1 inch) above the antecubital space
Rationale: The cuff should be placed 2.5 cm above the antecubital space over
bare skin. A cuff that is too small can produce a falsely high reading.
11. A nurse is assessing a client’s pain. Which mnemonic helps guide a
comprehensive pain assessment?
UPDATED 2026-2027 ACTUAL FINAL PRACTICE
EXAM PREP WITH ALL POSSIBLE TESTED
COMPREHENSIVE QUESTIONS AND 100% CORRECT
VERIFIED ANSWERS WITH DETAILED RATIONALES
PLUS CERTIFIED ANSWER KEY RATED A+ GRADE
FREE PDF ACCESS
1. A nurse is preparing to provide care for a client. Which action is the most
important for preventing the spread of infection?
A. Wearing gloves for all client contact
B. Performing hand hygiene before and after client contact
C. Placing the client in a private room
D. Wearing a mask when within 3 feet of the client
B. Performing hand hygiene before and after client contact
Rationale: Hand hygiene is the single most effective method for preventing
infection transmission. Gloves, private rooms, and masks are used based on
specific precautions but do not replace hand hygiene.
2. A nurse is caring for an older adult client at risk for falls. Which intervention
should the nurse implement first?
A. Apply a bed alarm
B. Keep the bed in the lowest position
C. Place the client in a restraint
D. Administer a sedative at bedtime
B. Keep the bed in the lowest position
Rationale: Keeping the bed in the lowest position reduces the risk of injury if the
client falls. Bed alarms and other measures may be added, but environmental
safety is a first-line intervention.
3. A client reports dizziness when standing up. Which instruction should the nurse
provide?
A. “Cross your legs before standing.”
B. “Stand up quickly to adjust your blood pressure.”
,C. “Change positions slowly and dangle your legs before standing.”
D. “Avoid drinking fluids before getting out of bed.”
C. “Change positions slowly and dangle your legs before standing.”
Rationale: Slow position changes help prevent orthostatic hypotension. Dangling
the legs allows the body to adjust before standing.
4. A nurse is planning care for a client who is immobile. Which intervention best
prevents pressure injuries?
A. Massage reddened bony prominences
B. Reposition the client at least every 2 hours
C. Keep the head of the bed elevated 90 degrees
D. Apply tight-fitting sheets to prevent wrinkles
B. Reposition the client at least every 2 hours
Rationale: Repositioning relieves pressure over bony prominences and is a key
prevention strategy. Massaging reddened areas can cause further tissue damage.
5. Which tool should the nurse use to assess a client’s risk for developing pressure
injuries?
A. Glasgow Coma Scale
B. Braden Scale
C. Morse Fall Scale
D. Pain Assessment in Advanced Dementia
B. Braden Scale
Rationale: The Braden Scale evaluates sensory perception, moisture, activity,
mobility, nutrition, and friction/shear to determine pressure injury risk.
6. A nurse is assessing an adult client’s oral temperature. Which finding is within
the expected reference range?
A. 35.0°C (95.0°F)
B. 36.8°C (98.2°F)
C. 38.0°C (100.4°F)
D. 39.0°C (102.2°F)
B. 36.8°C (98.2°F)
Rationale: Normal oral temperature is approximately 36.5°C to 37.5°C (97.7°F
to 99.5°F). Values above 38°C indicate fever.
7. A nurse obtains a pulse oximetry reading of 89% on a client. Which action
should the nurse take first?
A. Document the finding as normal
, B. Assess the client’s respiratory status and apply oxygen if prescribed
C. Ask the client to ambulate
D. Recheck the pulse oximetry in 4 hours
B. Assess the client’s respiratory status and apply oxygen if prescribed
Rationale: A pulse oximetry reading below 90% indicates hypoxemia. The nurse
should assess the client and intervene immediately.
8. Which adult heart rate should the nurse document as within the expected
reference range?
A. 42 beats/min
B. 58 beats/min
C. 72 beats/min
D. 110 beats/min
C. 72 beats/min
Rationale: The expected adult heart rate is 60 to 100 beats/min. Values below 60
indicate bradycardia, and values above 100 indicate tachycardia.
9. A nurse is assessing an adult client’s respiratory rate. Which finding is within
the expected reference range?
A. 8 breaths/min
B. 16 breaths/min
C. 24 breaths/min
D. 30 breaths/min
B. 16 breaths/min
Rationale: The expected adult respiratory rate is 12 to 20 breaths/min. Rates
outside this range require further assessment.
10. A nurse is preparing to measure a client’s blood pressure. Which action is
correct?
A. Use a cuff that is too small for the arm
B. Place the cuff over the client’s clothing
C. Position the cuff 2.5 cm (1 inch) above the antecubital space
D. Inflate the cuff rapidly after placing the stethoscope over the brachial artery
C. Position the cuff 2.5 cm (1 inch) above the antecubital space
Rationale: The cuff should be placed 2.5 cm above the antecubital space over
bare skin. A cuff that is too small can produce a falsely high reading.
11. A nurse is assessing a client’s pain. Which mnemonic helps guide a
comprehensive pain assessment?
