Evolve HESI Fundamentals V1, V2 & V3 (2026
Edition) – Actual Verified Exams with Detailed
Rationales
1. A client is admitted with a diagnosis of Hyponatremia. Which assessment finding should
the nurse expect?
A. Muscle twitching and hyperreflexia
B. Tachycardia and flushed skin
C. Polyuria and thirst
D. Bounding peripheral pulses
Answer: A. Muscle twitching and hyperreflexia ✓
Rationale: Hyponatremia (low sodium) causes water to move into cells, leading to cerebral
edema and neurological symptoms such as muscle twitching, weakness, and hyperreflexia.
Tachycardia and flushed skin (B) are more common with hypernatremia. Polyuria and thirst (C)
are associated with hyperglycemia. Bounding pulses (D) are seen with fluid volume excess.
2. The nurse is preparing to administer a tuberculin (Mantoux) test. Which needle and angle
are correct for this intradermal injection?
A. 25-gauge, 1-inch needle at a 45-degree angle
B. 27-gauge, ½-inch needle at a 15-degree angle
C. 20-gauge, 1.5-inch needle at a 90-degree angle
D. 22-gauge, 1-inch needle at a 45-degree angle
Answer: B. 27-gauge, ½-inch needle at a 15-degree angle ✓
Rationale: Intradermal injections, like the Mantoux test, require a small, short needle (25-27
gauge, ½ inch) inserted at a 10-15 degree angle to deposit the medication just under the
epidermis. A 90-degree angle (C) is for intramuscular injections, and a 45-degree angle (A, D) is
typically for subcutaneous injections.
3. When providing perineal care for a female client, the nurse should wipe from:
A. Back to front.
B. Side to side.
C. The pubis to the rectum.
D. The rectum to the pubis.
Answer: C. The pubis to the rectum ✓
Rationale: Wiping from the pubis to the rectum (front to back) prevents transporting
,microorganisms from the anal area to the urethra, reducing the risk of a urinary tract infection.
Wiping back to front (A) or side to side (B) increases this risk.
4. A client has a new order for a full liquid diet. Which item should the nurse remove from the
client's tray?
A. Mashed potatoes
B. Vanilla ice cream
C. Strained cream soup
D. Plain yogurt
Answer: A. Mashed potatoes ✓
Rationale: A full liquid diet consists of foods that are liquid or become liquid at room
temperature. Mashed potatoes are a soft solid and are not allowed. Ice cream (B), strained
cream soup (C), and yogurt (D) are all acceptable on a full liquid diet.
5. The nurse is assessing a client's pulse and notes a rate of 120 beats/minute, with an
irregular rhythm. How should the nurse document this finding?
A. Tachycardia
B. Bradycardia
C. Pulse deficit
D. Dysrhythmia
Answer: A. Tachycardia ✓
Rationale: Tachycardia is defined as a heart rate greater than 100 beats per minute in an adult.
The irregular rhythm is a separate characteristic. Bradycardia (B) is a slow heart rate (<60 bpm).
Pulse deficit (C) is a difference between the apical and radial pulse rates. Dysrhythmia (D) is a
general term for an irregular rhythm but does not describe the fast rate.
6. A client is on strict bed rest. To best prevent the complication of atelectasis, the nurse
should encourage the client to:
A. Perform deep breathing and coughing exercises.
B. Drink 2-3 liters of fluid per day.
C. Flex and extend the knees and ankles.
D. Change position every two hours.
Answer: A. Perform deep breathing and coughing exercises. ✓
Rationale: Atelectasis is the collapse of alveoli. Deep breathing and coughing help to expand the
lungs and clear secretions, directly preventing atelectasis. Fluid intake (B) helps prevent
respiratory secretions from thickening but does not directly expand alveoli. Leg exercises (C)
prevent deep vein thrombosis. Repositioning (D) prevents pressure injuries.
,7. The nurse needs to assess a client's fluid balance most accurately. Which action should the
nurse take?
A. Check skin turgor over the sternum.
B. Monitor daily weight.
C. Measure intake and output.
D. Auscultate lung sounds.
Answer: B. Monitor daily weight. ✓
Rationale: Daily weight is the most sensitive indicator of fluid balance; a change of 1 kg (2.2 lb)
is equivalent to a gain or loss of 1 liter of fluid. Intake and output (C) is important but can be less
accurate due to unmeasured losses (insensible water loss). Skin turgor (A) and lung sounds (D)
are clinical assessments that can be influenced by other factors like age or cardiac status.
8. A client with heart failure has bilateral 2+ pitting edema in the lower extremities. The nurse
understands this edema is primarily caused by:
A. Decreased plasma oncotic pressure.
B. Increased capillary hydrostatic pressure.
C. Lymphatic obstruction.
D. Sodium depletion.
Answer: B. Increased capillary hydrostatic pressure. ✓
Rationale: In heart failure, the heart's pumping ability is compromised, leading to fluid backup
in the venous system. This increases the pressure within the capillaries (hydrostatic pressure),
forcing fluid out into the interstitial spaces and causing pitting edema. Decreased plasma
oncotic pressure (A) is seen in conditions like liver failure or malnutrition. Lymphatic obstruction
(C) causes non-pitting edema. Sodium depletion (D) would not cause edema.
9. When transferring a client from the bed to a chair, the nurse should first:
A. Apply a gait belt.
B. Dangle the client on the side of the bed.
C. Assess the client's strength.
D. Lock the wheels on the bed and chair.
Answer: D. Lock the wheels on the bed and chair. ✓
Rationale: Safety is the first priority. Locking the wheels prevents the bed or chair from moving
during the transfer, which could cause a fall. While applying a gait belt (A), dangling (B), and
assessing strength (C) are all important steps, they come after ensuring the equipment is secure.
10. The nurse is teaching a client about a low-sodium diet. Which food choice by the client
indicates a need for further teaching?
A. Fresh steamed broccoli
, B. A grilled chicken breast
C. A dill pickle spear
D. A baked potato with chives
Answer: C. A dill pickle spear ✓
Rationale: Pickled foods are extremely high in sodium. Fresh or frozen vegetables (A), plain
meats (B), and herbs like chives (D) are generally low-sodium choices.
11. A client has a nasogastric (NG) tube set to low intermittent suction. The primary purpose
of the suction is to:
A. Deliver medication to the stomach.
B. Decompress the stomach.
C. Provide enteral nutrition.
D. Lavage the stomach.
Answer: B. Decompress the stomach. ✓
Rationale: Low intermittent suction is used to remove gastric secretions and gas, preventing or
relieving abdominal distension (decompression). Delivering medication (A) and nutrition (C) are
functions of a different type of tube (e.g., Dobhoff). Lavage (D) is for irrigation, typically for
active bleeding or poisoning.
12. The nurse is preparing to administer an intramuscular (IM) injection using the Z-track
method. The primary reason for using this technique is to:
A. Reduce discomfort.
B. Prevent medication from leaking into subcutaneous tissue.
C. Ensure the medication reaches the muscle layer.
D. Aspirate for blood more effectively.
Answer: B. Prevent medication from leaking into subcutaneous tissue. ✓
Rationale: The Z-track technique involves pulling the skin to the side before injection. When
released, it creates a zigzag path that seals the medication deep within the muscle, preventing
irritating drugs from seeping back into the subcutaneous tissue and causing skin staining or
irritation.
13. During a bed bath, the client states, "I feel so useless having you bathe me." What is the
nurse's best response?
A. "It's no problem at all; it's part of my job."
B. "You can help by washing your face and hands."
C. "I understand this must be difficult. How are you feeling?"
D. "You'll be able to do it yourself again in a few days."
Edition) – Actual Verified Exams with Detailed
Rationales
1. A client is admitted with a diagnosis of Hyponatremia. Which assessment finding should
the nurse expect?
A. Muscle twitching and hyperreflexia
B. Tachycardia and flushed skin
C. Polyuria and thirst
D. Bounding peripheral pulses
Answer: A. Muscle twitching and hyperreflexia ✓
Rationale: Hyponatremia (low sodium) causes water to move into cells, leading to cerebral
edema and neurological symptoms such as muscle twitching, weakness, and hyperreflexia.
Tachycardia and flushed skin (B) are more common with hypernatremia. Polyuria and thirst (C)
are associated with hyperglycemia. Bounding pulses (D) are seen with fluid volume excess.
2. The nurse is preparing to administer a tuberculin (Mantoux) test. Which needle and angle
are correct for this intradermal injection?
A. 25-gauge, 1-inch needle at a 45-degree angle
B. 27-gauge, ½-inch needle at a 15-degree angle
C. 20-gauge, 1.5-inch needle at a 90-degree angle
D. 22-gauge, 1-inch needle at a 45-degree angle
Answer: B. 27-gauge, ½-inch needle at a 15-degree angle ✓
Rationale: Intradermal injections, like the Mantoux test, require a small, short needle (25-27
gauge, ½ inch) inserted at a 10-15 degree angle to deposit the medication just under the
epidermis. A 90-degree angle (C) is for intramuscular injections, and a 45-degree angle (A, D) is
typically for subcutaneous injections.
3. When providing perineal care for a female client, the nurse should wipe from:
A. Back to front.
B. Side to side.
C. The pubis to the rectum.
D. The rectum to the pubis.
Answer: C. The pubis to the rectum ✓
Rationale: Wiping from the pubis to the rectum (front to back) prevents transporting
,microorganisms from the anal area to the urethra, reducing the risk of a urinary tract infection.
Wiping back to front (A) or side to side (B) increases this risk.
4. A client has a new order for a full liquid diet. Which item should the nurse remove from the
client's tray?
A. Mashed potatoes
B. Vanilla ice cream
C. Strained cream soup
D. Plain yogurt
Answer: A. Mashed potatoes ✓
Rationale: A full liquid diet consists of foods that are liquid or become liquid at room
temperature. Mashed potatoes are a soft solid and are not allowed. Ice cream (B), strained
cream soup (C), and yogurt (D) are all acceptable on a full liquid diet.
5. The nurse is assessing a client's pulse and notes a rate of 120 beats/minute, with an
irregular rhythm. How should the nurse document this finding?
A. Tachycardia
B. Bradycardia
C. Pulse deficit
D. Dysrhythmia
Answer: A. Tachycardia ✓
Rationale: Tachycardia is defined as a heart rate greater than 100 beats per minute in an adult.
The irregular rhythm is a separate characteristic. Bradycardia (B) is a slow heart rate (<60 bpm).
Pulse deficit (C) is a difference between the apical and radial pulse rates. Dysrhythmia (D) is a
general term for an irregular rhythm but does not describe the fast rate.
6. A client is on strict bed rest. To best prevent the complication of atelectasis, the nurse
should encourage the client to:
A. Perform deep breathing and coughing exercises.
B. Drink 2-3 liters of fluid per day.
C. Flex and extend the knees and ankles.
D. Change position every two hours.
Answer: A. Perform deep breathing and coughing exercises. ✓
Rationale: Atelectasis is the collapse of alveoli. Deep breathing and coughing help to expand the
lungs and clear secretions, directly preventing atelectasis. Fluid intake (B) helps prevent
respiratory secretions from thickening but does not directly expand alveoli. Leg exercises (C)
prevent deep vein thrombosis. Repositioning (D) prevents pressure injuries.
,7. The nurse needs to assess a client's fluid balance most accurately. Which action should the
nurse take?
A. Check skin turgor over the sternum.
B. Monitor daily weight.
C. Measure intake and output.
D. Auscultate lung sounds.
Answer: B. Monitor daily weight. ✓
Rationale: Daily weight is the most sensitive indicator of fluid balance; a change of 1 kg (2.2 lb)
is equivalent to a gain or loss of 1 liter of fluid. Intake and output (C) is important but can be less
accurate due to unmeasured losses (insensible water loss). Skin turgor (A) and lung sounds (D)
are clinical assessments that can be influenced by other factors like age or cardiac status.
8. A client with heart failure has bilateral 2+ pitting edema in the lower extremities. The nurse
understands this edema is primarily caused by:
A. Decreased plasma oncotic pressure.
B. Increased capillary hydrostatic pressure.
C. Lymphatic obstruction.
D. Sodium depletion.
Answer: B. Increased capillary hydrostatic pressure. ✓
Rationale: In heart failure, the heart's pumping ability is compromised, leading to fluid backup
in the venous system. This increases the pressure within the capillaries (hydrostatic pressure),
forcing fluid out into the interstitial spaces and causing pitting edema. Decreased plasma
oncotic pressure (A) is seen in conditions like liver failure or malnutrition. Lymphatic obstruction
(C) causes non-pitting edema. Sodium depletion (D) would not cause edema.
9. When transferring a client from the bed to a chair, the nurse should first:
A. Apply a gait belt.
B. Dangle the client on the side of the bed.
C. Assess the client's strength.
D. Lock the wheels on the bed and chair.
Answer: D. Lock the wheels on the bed and chair. ✓
Rationale: Safety is the first priority. Locking the wheels prevents the bed or chair from moving
during the transfer, which could cause a fall. While applying a gait belt (A), dangling (B), and
assessing strength (C) are all important steps, they come after ensuring the equipment is secure.
10. The nurse is teaching a client about a low-sodium diet. Which food choice by the client
indicates a need for further teaching?
A. Fresh steamed broccoli
, B. A grilled chicken breast
C. A dill pickle spear
D. A baked potato with chives
Answer: C. A dill pickle spear ✓
Rationale: Pickled foods are extremely high in sodium. Fresh or frozen vegetables (A), plain
meats (B), and herbs like chives (D) are generally low-sodium choices.
11. A client has a nasogastric (NG) tube set to low intermittent suction. The primary purpose
of the suction is to:
A. Deliver medication to the stomach.
B. Decompress the stomach.
C. Provide enteral nutrition.
D. Lavage the stomach.
Answer: B. Decompress the stomach. ✓
Rationale: Low intermittent suction is used to remove gastric secretions and gas, preventing or
relieving abdominal distension (decompression). Delivering medication (A) and nutrition (C) are
functions of a different type of tube (e.g., Dobhoff). Lavage (D) is for irrigation, typically for
active bleeding or poisoning.
12. The nurse is preparing to administer an intramuscular (IM) injection using the Z-track
method. The primary reason for using this technique is to:
A. Reduce discomfort.
B. Prevent medication from leaking into subcutaneous tissue.
C. Ensure the medication reaches the muscle layer.
D. Aspirate for blood more effectively.
Answer: B. Prevent medication from leaking into subcutaneous tissue. ✓
Rationale: The Z-track technique involves pulling the skin to the side before injection. When
released, it creates a zigzag path that seals the medication deep within the muscle, preventing
irritating drugs from seeping back into the subcutaneous tissue and causing skin staining or
irritation.
13. During a bed bath, the client states, "I feel so useless having you bathe me." What is the
nurse's best response?
A. "It's no problem at all; it's part of my job."
B. "You can help by washing your face and hands."
C. "I understand this must be difficult. How are you feeling?"
D. "You'll be able to do it yourself again in a few days."
