Page 1 of 139
QUESTIONS WITH DETAILED RATIONALES
**ALIGNED WITH THE LATEST ELSEVIER
EVOLVE HESI ADMISSION ASSESSMENT (A2)
BLUEPRINT | NCSBN CLINICAL JUDGMENT
TABLE OF CONTENTS
| **I** | **Fundamentals of Nursing** | Q1–Q30 |
| **II** | **Medical-Surgical Nursing** | Q31–Q60 |
| **III** | **Pharmacology & Medication Administration** | Q61–Q85 |
| **IV** | **Maternity & Obstetric Nursing** | Q86–Q105 |
| **V** | **Pediatric Nursing** | Q106–Q125 |
| **VI** | **Psychiatric / Mental Health Nursing** | Q126–Q145 |
| **VII** | **Anatomy & Physiology** | Q146–Q170 |
| **VIII** | **Biology** | Q171–Q185 |
| **IX** | **Chemistry** | Q186–Q200 |
| **X** | **Mathematics & Dosage Calculations** | Q201–Q215 |
| **XI** | **Reading Comprehension** | Q216–Q225 |
| **XII** | **Grammar & Vocabulary** | Q226–Q235 |
| **XIII** | **Critical Thinking & Clinical Reasoning** | Q236–Q250 |
| **XIV** | **Professional Issues & Nursing Readiness** | Q251–Q260 |
, Page 2 of 139
SECTION I: FUNDAMENTALS OF NURSING
### Questions 1–30
**Q1.** A patient is receiving a blood transfusion. Which sign indicates a potential transfusion
reaction that requires immediate action?
A) Mild itching at the IV site
B) Flushing and feeling warm
C) Chills, fever, and back pain
D) Slight increase in heart rate
** Correct Answer: C) Chills, fever, and back pain**
**Rationale:** Chills, fever, and back pain are classic signs of a hemolytic transfusion
reaction. The nurse should stop the transfusion immediately, maintain IV access with normal
saline, and notify the provider. Mild itching or flushing may occur but are less urgent.
---
**Q2.** A nurse is caring for a patient on fall precautions. Which intervention is most effective
in preventing falls?
A) Keeping the bed in the lowest position
B) Using bed alarms for all patients
C) Placing the call light within reach
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D) All of the above
** Correct Answer: D) All of the above**
**Rationale:** Fall prevention requires multiple interventions: bed in lowest position,
bed/chair alarms, call light within reach, non-slip footwear, and frequent rounding. A
multifactorial approach is most effective.
---
**Q3.** Which vital sign finding would the nurse report immediately in a postoperative patient?
A) Heart rate 88 bpm
B) Blood pressure 118/72 mmHg
C) Respiratory rate 28 breaths/min with crackles
D) Temperature 99.2°F (37.3°C)
** Correct Answer: C) Respiratory rate 28 breaths/min with crackles**
**Rationale:** Tachypnea (RR 28) with crackles suggests pulmonary edema or fluid
overload, a serious postoperative complication requiring immediate provider notification. The
other vital signs are within normal limits.
---
**Q4.** Which of the following is the correct sequence for donning personal protective
equipment (PPE)?
, Page 4 of 139
A) Gloves, gown, mask, eye protection
B) Gown, mask, eye protection, gloves
C) Mask, eye protection, gown, gloves
D) Eye protection, mask, gown, gloves
** Correct Answer: B) Gown, mask, eye protection, gloves**
**Rationale:** The correct sequence for donning PPE is gown first, then mask, eye
protection, and gloves last. This ensures the most contaminated items are applied last. Removal
sequence is gloves, eye protection, gown, mask.
---
**Q5.** A patient is on strict intake and output monitoring. The nurse should record which of
the following as output?
A) Oral fluids consumed
B) IV fluids infused
C) Urine, emesis, and wound drainage
D) Tube feeding volume
** Correct Answer: C) Urine, emesis, and wound drainage**
**Rationale:** Output includes urine, emesis, diarrhea, wound drainage, and chest tube
output. Oral fluids and IV fluids are input, not output. Accurate I&O is critical for fluid balance
assessment.
---
QUESTIONS WITH DETAILED RATIONALES
**ALIGNED WITH THE LATEST ELSEVIER
EVOLVE HESI ADMISSION ASSESSMENT (A2)
BLUEPRINT | NCSBN CLINICAL JUDGMENT
TABLE OF CONTENTS
| **I** | **Fundamentals of Nursing** | Q1–Q30 |
| **II** | **Medical-Surgical Nursing** | Q31–Q60 |
| **III** | **Pharmacology & Medication Administration** | Q61–Q85 |
| **IV** | **Maternity & Obstetric Nursing** | Q86–Q105 |
| **V** | **Pediatric Nursing** | Q106–Q125 |
| **VI** | **Psychiatric / Mental Health Nursing** | Q126–Q145 |
| **VII** | **Anatomy & Physiology** | Q146–Q170 |
| **VIII** | **Biology** | Q171–Q185 |
| **IX** | **Chemistry** | Q186–Q200 |
| **X** | **Mathematics & Dosage Calculations** | Q201–Q215 |
| **XI** | **Reading Comprehension** | Q216–Q225 |
| **XII** | **Grammar & Vocabulary** | Q226–Q235 |
| **XIII** | **Critical Thinking & Clinical Reasoning** | Q236–Q250 |
| **XIV** | **Professional Issues & Nursing Readiness** | Q251–Q260 |
, Page 2 of 139
SECTION I: FUNDAMENTALS OF NURSING
### Questions 1–30
**Q1.** A patient is receiving a blood transfusion. Which sign indicates a potential transfusion
reaction that requires immediate action?
A) Mild itching at the IV site
B) Flushing and feeling warm
C) Chills, fever, and back pain
D) Slight increase in heart rate
** Correct Answer: C) Chills, fever, and back pain**
**Rationale:** Chills, fever, and back pain are classic signs of a hemolytic transfusion
reaction. The nurse should stop the transfusion immediately, maintain IV access with normal
saline, and notify the provider. Mild itching or flushing may occur but are less urgent.
---
**Q2.** A nurse is caring for a patient on fall precautions. Which intervention is most effective
in preventing falls?
A) Keeping the bed in the lowest position
B) Using bed alarms for all patients
C) Placing the call light within reach
, Page 3 of 139
D) All of the above
** Correct Answer: D) All of the above**
**Rationale:** Fall prevention requires multiple interventions: bed in lowest position,
bed/chair alarms, call light within reach, non-slip footwear, and frequent rounding. A
multifactorial approach is most effective.
---
**Q3.** Which vital sign finding would the nurse report immediately in a postoperative patient?
A) Heart rate 88 bpm
B) Blood pressure 118/72 mmHg
C) Respiratory rate 28 breaths/min with crackles
D) Temperature 99.2°F (37.3°C)
** Correct Answer: C) Respiratory rate 28 breaths/min with crackles**
**Rationale:** Tachypnea (RR 28) with crackles suggests pulmonary edema or fluid
overload, a serious postoperative complication requiring immediate provider notification. The
other vital signs are within normal limits.
---
**Q4.** Which of the following is the correct sequence for donning personal protective
equipment (PPE)?
, Page 4 of 139
A) Gloves, gown, mask, eye protection
B) Gown, mask, eye protection, gloves
C) Mask, eye protection, gown, gloves
D) Eye protection, mask, gown, gloves
** Correct Answer: B) Gown, mask, eye protection, gloves**
**Rationale:** The correct sequence for donning PPE is gown first, then mask, eye
protection, and gloves last. This ensures the most contaminated items are applied last. Removal
sequence is gloves, eye protection, gown, mask.
---
**Q5.** A patient is on strict intake and output monitoring. The nurse should record which of
the following as output?
A) Oral fluids consumed
B) IV fluids infused
C) Urine, emesis, and wound drainage
D) Tube feeding volume
** Correct Answer: C) Urine, emesis, and wound drainage**
**Rationale:** Output includes urine, emesis, diarrhea, wound drainage, and chest tube
output. Oral fluids and IV fluids are input, not output. Accurate I&O is critical for fluid balance
assessment.
---
