2026 Evolve HESI Fundamentals Exam (Version 3) | Complete
Questions and Answers with Rationales
1. A nurse is assessing a client’s respiratory status. Which
finding requires immediate intervention?
A. Respiratory rate of 18/min
B. Oxygen saturation of 96%
C. Use of accessory muscles
D. Clear bilateral breath sounds
Answer: C
Rationale: Accessory-muscle use indicates increased work of
breathing and possible respiratory compromise.
2. Which action is most appropriate when measuring a client’s
blood pressure?
A. Place the cuff over clothing
B. Use a cuff that is too small
C. Support the client’s arm at heart level
D. Have the client talk during measurement
Answer: C
Rationale: Supporting the arm at heart level promotes an
accurate blood-pressure measurement.
3. A client reports dizziness when standing. Which assessment
is most important?
A. Hearing acuity
B. Orthostatic blood pressure
C. Visual acuity
D. Pupillary response
,Answer: B
Rationale: Orthostatic measurements help identify a blood-
pressure drop associated with position changes.
4. Which intervention best reduces the risk of falls?
A. Keep the bed in the highest position
B. Keep the call light within reach
C. Keep the room dark
D. Encourage the client to walk without assistance
Answer: B
Rationale: Easy access to the call light allows the client to
request assistance before attempting to ambulate.
5. A nurse enters a client’s room and finds the client on the
floor. What should the nurse do first?
A. Complete an incident report
B. Move the client into bed
C. Assess the client for injury
D. Notify the family
Answer: C
Rationale: Immediate assessment determines whether the
client has sustained an injury requiring urgent intervention.
6. Which finding is most consistent with dehydration?
A. Moist mucous membranes
B. Bounding pulse
C. Concentrated urine
D. Peripheral edema
Answer: C
,Rationale: Dehydration commonly causes concentrated urine,
dry mucous membranes, thirst, and decreased urine output.
7. Which statement demonstrates therapeutic communication?
A. “You shouldn't feel that way.”
B. “Everything will be fine.”
C. “Tell me more about what concerns you.”
D. “I know exactly how you feel.”
Answer: C
Rationale: Open-ended questions encourage the client to
express concerns and feelings.
8. A client refuses a prescribed treatment. What should the
nurse do first?
A. Threaten to notify the provider
B. Explore the reason for refusal
C. Administer the treatment anyway
D. Ask a family member to convince the client
Answer: B
Rationale: The nurse should determine why the client is
refusing before planning further interventions.
9. Which action is appropriate when removing gloves after
client care?
A. Touch the outside of both gloves with bare hands
B. Remove the gloves and immediately perform hand hygiene
C. Wash the gloves before removing them
D. Reuse the gloves for another client
Answer: B
, Rationale: Gloves should be removed safely and followed by
hand hygiene.
10. Which client should the nurse assess first?
A. Client requesting a blanket
B. Client reporting new chest pressure
C. Client requesting discharge information
D. Client asking when lunch will arrive
Answer: B
Rationale: New chest pressure may indicate an acute
cardiovascular problem and requires immediate assessment.
11. Which position is generally most appropriate for a client
experiencing difficulty breathing?
A. Supine
B. High-Fowler’s
C. Prone
D. Trendelenburg
Answer: B
Rationale: Upright positioning improves lung expansion and
can decrease the work of breathing.
12. What is the nurse’s best action before administering
medication?
A. Ask another client to confirm the medication
B. Verify the medication against the prescription
C. Skip identification if the nurse knows the client
D. Administer it based solely on the package color
Answer: B
Questions and Answers with Rationales
1. A nurse is assessing a client’s respiratory status. Which
finding requires immediate intervention?
A. Respiratory rate of 18/min
B. Oxygen saturation of 96%
C. Use of accessory muscles
D. Clear bilateral breath sounds
Answer: C
Rationale: Accessory-muscle use indicates increased work of
breathing and possible respiratory compromise.
2. Which action is most appropriate when measuring a client’s
blood pressure?
A. Place the cuff over clothing
B. Use a cuff that is too small
C. Support the client’s arm at heart level
D. Have the client talk during measurement
Answer: C
Rationale: Supporting the arm at heart level promotes an
accurate blood-pressure measurement.
3. A client reports dizziness when standing. Which assessment
is most important?
A. Hearing acuity
B. Orthostatic blood pressure
C. Visual acuity
D. Pupillary response
,Answer: B
Rationale: Orthostatic measurements help identify a blood-
pressure drop associated with position changes.
4. Which intervention best reduces the risk of falls?
A. Keep the bed in the highest position
B. Keep the call light within reach
C. Keep the room dark
D. Encourage the client to walk without assistance
Answer: B
Rationale: Easy access to the call light allows the client to
request assistance before attempting to ambulate.
5. A nurse enters a client’s room and finds the client on the
floor. What should the nurse do first?
A. Complete an incident report
B. Move the client into bed
C. Assess the client for injury
D. Notify the family
Answer: C
Rationale: Immediate assessment determines whether the
client has sustained an injury requiring urgent intervention.
6. Which finding is most consistent with dehydration?
A. Moist mucous membranes
B. Bounding pulse
C. Concentrated urine
D. Peripheral edema
Answer: C
,Rationale: Dehydration commonly causes concentrated urine,
dry mucous membranes, thirst, and decreased urine output.
7. Which statement demonstrates therapeutic communication?
A. “You shouldn't feel that way.”
B. “Everything will be fine.”
C. “Tell me more about what concerns you.”
D. “I know exactly how you feel.”
Answer: C
Rationale: Open-ended questions encourage the client to
express concerns and feelings.
8. A client refuses a prescribed treatment. What should the
nurse do first?
A. Threaten to notify the provider
B. Explore the reason for refusal
C. Administer the treatment anyway
D. Ask a family member to convince the client
Answer: B
Rationale: The nurse should determine why the client is
refusing before planning further interventions.
9. Which action is appropriate when removing gloves after
client care?
A. Touch the outside of both gloves with bare hands
B. Remove the gloves and immediately perform hand hygiene
C. Wash the gloves before removing them
D. Reuse the gloves for another client
Answer: B
, Rationale: Gloves should be removed safely and followed by
hand hygiene.
10. Which client should the nurse assess first?
A. Client requesting a blanket
B. Client reporting new chest pressure
C. Client requesting discharge information
D. Client asking when lunch will arrive
Answer: B
Rationale: New chest pressure may indicate an acute
cardiovascular problem and requires immediate assessment.
11. Which position is generally most appropriate for a client
experiencing difficulty breathing?
A. Supine
B. High-Fowler’s
C. Prone
D. Trendelenburg
Answer: B
Rationale: Upright positioning improves lung expansion and
can decrease the work of breathing.
12. What is the nurse’s best action before administering
medication?
A. Ask another client to confirm the medication
B. Verify the medication against the prescription
C. Skip identification if the nurse knows the client
D. Administer it based solely on the package color
Answer: B
