EVOLVE HESI FUNDAMENTALS 140 ACTUAL QUESTIONS
AND CORRECT ANSWERS WITH RATIONALE NEW UPDATE
2026 ALREADY GRADED A+
1. A patient who is post-operative day one after abdominal surgery complains of
severe nausea and a feeling of abdominal fullness. The nurse notes that the patient
has not passed flatus or had a bowel movement since surgery. The nurse
auscultates the abdomen and hears no bowel sounds in any quadrant. What is the
priority nursing action?
A) Insert a rectal tube to stimulate peristalsis
B) Place the patient in a left side-lying position
C) Assess for signs of paralytic ileus and notify the healthcare provider
D) Encourage the patient to ambulate to stimulate bowel function
Answer: C
Rationale: Absent bowel sounds, nausea, and abdominal fullness after abdominal
surgery are classic signs of a paralytic ileus. The priority action is to assess the
patient thoroughly and notify the healthcare provider for further orders. Inserting a
rectal tube or encouraging ambulation may be appropriate interventions later, but
they are not the priority without an order.
2. A nurse is preparing to administer an enteral feeding via a nasogastric tube that
has been in place for 48 hours. Before initiating the feeding, what is the most
reliable method to verify tube placement?
A) Auscultate over the stomach while injecting air
B) Obtain an x-ray
C) Observe the color of the aspirated fluid
D) Measure the length of the exposed tube from the nares
Answer: B
Rationale: While an x-ray is the gold standard for initial placement verification, for
ongoing feeding, the most reliable bedside method is checking the pH of aspirated
fluid, which should be 5 or less. Auscultation is no longer considered reliable.
Observing color and measuring length are less accurate indicators.
3. A patient with a diagnosis of heart failure is prescribed a 2-gram sodium diet.
The nurse is educating the patient about food choices. Which food selection
indicates the patient understands the teaching?
A) Canned vegetable soup
,B) A turkey sandwich with pickles
C) Fresh apple slices with unsalted peanut butter
D) A ham and cheese omelet
Answer: C
Rationale: Fresh fruits and vegetables are naturally low in sodium. Processed
meats (ham), canned soups, and pickles are all high in sodium and should be
avoided on a 2-gram sodium restriction.
4. An older adult patient is at risk for falls. Which nursing intervention is most
effective in preventing falls in this population?
A) Keeping all four bed rails up at all times
B) Placing the call light within easy reach and ensuring the bed is in the lowest
position
C) Encouraging the patient to wear socks without grips to promote mobility
D) Restricting fluid intake in the evening to reduce nighttime bathroom trips
Answer: B
Rationale: Keeping the call light within reach empowers the patient to call for
assistance, and placing the bed in the lowest position reduces the distance and
injury if a fall occurs. Full bed rails are considered a restraint and can increase fall
risk. Socks without grips are slippery, and fluid restriction is not an appropriate
intervention.
5. A nurse is calculating the intake and output for a patient over an 8-hour shift.
The patient drank 240 mL of water, 120 mL of milk, and 180 mL of juice. The
patient also received 250 mL of intravenous fluids. The urinary output was 400
mL. What is the total intake for this patient?
A) 540 mL
B) 790 mL
C) 640 mL
D) 890 mL
Answer: B
Rationale: Total intake is the sum of all fluids consumed and intravenous fluids.
Intake = 240 + 120 + 180 + 250 = 790 mL. Output is 400 mL, but the question
only asks for intake.
6. A patient has an order for 500 mL of normal saline to infuse over 4 hours. The
drop factor is 15 gtt/mL. What is the infusion rate in drops per minute?
A) 21 gtt/min
B) 31 gtt/min
C) 41 gtt/min
,D) 51 gtt/min
Answer: B
Rationale: The formula is (Total volume in mL / Time in minutes) x Drop factor.
500 mL / 240 minutes = 2.08 mL/min. 2.08 x 15 = 31.25 gtt/min, rounded to 31
gtt/min.
7. A nurse is performing a sterile dressing change for a patient with a surgical
wound. After cleansing the wound, the nurse notices the sterile field has become
contaminated with a small amount of moisture from the patient's bed. What should
the nurse do?
A) Continue with the dressing change since the contamination is minor
B) Pat the area dry with a sterile gauze and continue
C) Discard the sterile field and start over with new supplies
D) Cover the contaminated area with a sterile towel
Answer: C
Rationale: Once a sterile field becomes contaminated, it must be discarded and a
new sterile field must be established to prevent infection. Patching the area or
continuing with the change compromises sterility.
8. A nurse is preparing to administer 2 mg of morphine sulfate intravenously to a
patient complaining of severe pain. The available vial contains 10 mg/mL. How
many mL will the nurse administer?
A) 0.1 mL
B) 0.2 mL
C) 0.5 mL
D) 1.0 mL
Answer: B
Rationale: Desired dose / Available dose = Volume to administer. 2 mg / 10 mg =
0.2 mL. Therefore, the nurse will administer 0.2 mL of the medication.
9. A patient with a nasogastric tube for gastric decompression has a prescription
for intermittent suction. The nurse notes the suction is set to continuous high
suction. The most appropriate action is to:
A) Leave the setting as ordered by the physician
B) Change the setting to intermittent low suction per the order
C) Increase the suction to high to ensure complete emptying
D) Clamp the tube for 15 minutes every hour to prevent irritation
Answer: B
, Rationale: The order specifies intermittent suction. Continuous high suction can
damage gastric mucosa and cause fluid and electrolyte imbalances. The nurse
should adjust the setting to match the prescription.
10. A patient is on strict bed rest and is at risk for developing a deep vein
thrombosis. Which nursing intervention is most effective in preventing this
complication?
A) Massaging the patient's calves twice daily
B) Applying sequential compression devices to the lower extremities
C) Encouraging the patient to do isometric exercises only
D) Keeping the knees flexed to improve venous return
Answer: B
Rationale: Sequential compression devices promote venous return by mimicking
the muscle pump action, reducing venous stasis. Massaging the calves can dislodge
a clot. Isometric exercises alone are insufficient, and flexed knees can impede
venous return.
11. A nurse is reviewing a patient's laboratory results and notes a potassium level
of 6.0 mEq/L. The patient's ECG shows peaked T waves. The nurse should
immediately:
A) Notify the healthcare provider
B) Administer a potassium supplement
C) Place the patient on a cardiac monitor
D) Encourage the patient to eat potassium-rich foods
Answer: A
Rationale: A potassium level of 6.0 mEq/L is critically high and life-threatening, as
evidenced by peaked T waves. The nurse must notify the healthcare provider
immediately for emergency interventions. Administering potassium would be
contraindicated.
12. A patient is receiving a blood transfusion of packed red blood cells. Fifteen
minutes after the infusion begins, the patient reports chills, lower back pain, and
feeling flushed. The nurse's priority action is:
A) Slow the infusion rate and assess the patient's vital signs
B) Stop the transfusion and keep the intravenous line open with normal saline
C) Administer an antihistamine as a pre-medication and continue the transfusion
D) Notify the provider and document the findings after the transfusion is complete
Answer: B
Rationale: The patient is showing signs of an acute hemolytic transfusion reaction,
which is a medical emergency. The nurse must stop the transfusion immediately
AND CORRECT ANSWERS WITH RATIONALE NEW UPDATE
2026 ALREADY GRADED A+
1. A patient who is post-operative day one after abdominal surgery complains of
severe nausea and a feeling of abdominal fullness. The nurse notes that the patient
has not passed flatus or had a bowel movement since surgery. The nurse
auscultates the abdomen and hears no bowel sounds in any quadrant. What is the
priority nursing action?
A) Insert a rectal tube to stimulate peristalsis
B) Place the patient in a left side-lying position
C) Assess for signs of paralytic ileus and notify the healthcare provider
D) Encourage the patient to ambulate to stimulate bowel function
Answer: C
Rationale: Absent bowel sounds, nausea, and abdominal fullness after abdominal
surgery are classic signs of a paralytic ileus. The priority action is to assess the
patient thoroughly and notify the healthcare provider for further orders. Inserting a
rectal tube or encouraging ambulation may be appropriate interventions later, but
they are not the priority without an order.
2. A nurse is preparing to administer an enteral feeding via a nasogastric tube that
has been in place for 48 hours. Before initiating the feeding, what is the most
reliable method to verify tube placement?
A) Auscultate over the stomach while injecting air
B) Obtain an x-ray
C) Observe the color of the aspirated fluid
D) Measure the length of the exposed tube from the nares
Answer: B
Rationale: While an x-ray is the gold standard for initial placement verification, for
ongoing feeding, the most reliable bedside method is checking the pH of aspirated
fluid, which should be 5 or less. Auscultation is no longer considered reliable.
Observing color and measuring length are less accurate indicators.
3. A patient with a diagnosis of heart failure is prescribed a 2-gram sodium diet.
The nurse is educating the patient about food choices. Which food selection
indicates the patient understands the teaching?
A) Canned vegetable soup
,B) A turkey sandwich with pickles
C) Fresh apple slices with unsalted peanut butter
D) A ham and cheese omelet
Answer: C
Rationale: Fresh fruits and vegetables are naturally low in sodium. Processed
meats (ham), canned soups, and pickles are all high in sodium and should be
avoided on a 2-gram sodium restriction.
4. An older adult patient is at risk for falls. Which nursing intervention is most
effective in preventing falls in this population?
A) Keeping all four bed rails up at all times
B) Placing the call light within easy reach and ensuring the bed is in the lowest
position
C) Encouraging the patient to wear socks without grips to promote mobility
D) Restricting fluid intake in the evening to reduce nighttime bathroom trips
Answer: B
Rationale: Keeping the call light within reach empowers the patient to call for
assistance, and placing the bed in the lowest position reduces the distance and
injury if a fall occurs. Full bed rails are considered a restraint and can increase fall
risk. Socks without grips are slippery, and fluid restriction is not an appropriate
intervention.
5. A nurse is calculating the intake and output for a patient over an 8-hour shift.
The patient drank 240 mL of water, 120 mL of milk, and 180 mL of juice. The
patient also received 250 mL of intravenous fluids. The urinary output was 400
mL. What is the total intake for this patient?
A) 540 mL
B) 790 mL
C) 640 mL
D) 890 mL
Answer: B
Rationale: Total intake is the sum of all fluids consumed and intravenous fluids.
Intake = 240 + 120 + 180 + 250 = 790 mL. Output is 400 mL, but the question
only asks for intake.
6. A patient has an order for 500 mL of normal saline to infuse over 4 hours. The
drop factor is 15 gtt/mL. What is the infusion rate in drops per minute?
A) 21 gtt/min
B) 31 gtt/min
C) 41 gtt/min
,D) 51 gtt/min
Answer: B
Rationale: The formula is (Total volume in mL / Time in minutes) x Drop factor.
500 mL / 240 minutes = 2.08 mL/min. 2.08 x 15 = 31.25 gtt/min, rounded to 31
gtt/min.
7. A nurse is performing a sterile dressing change for a patient with a surgical
wound. After cleansing the wound, the nurse notices the sterile field has become
contaminated with a small amount of moisture from the patient's bed. What should
the nurse do?
A) Continue with the dressing change since the contamination is minor
B) Pat the area dry with a sterile gauze and continue
C) Discard the sterile field and start over with new supplies
D) Cover the contaminated area with a sterile towel
Answer: C
Rationale: Once a sterile field becomes contaminated, it must be discarded and a
new sterile field must be established to prevent infection. Patching the area or
continuing with the change compromises sterility.
8. A nurse is preparing to administer 2 mg of morphine sulfate intravenously to a
patient complaining of severe pain. The available vial contains 10 mg/mL. How
many mL will the nurse administer?
A) 0.1 mL
B) 0.2 mL
C) 0.5 mL
D) 1.0 mL
Answer: B
Rationale: Desired dose / Available dose = Volume to administer. 2 mg / 10 mg =
0.2 mL. Therefore, the nurse will administer 0.2 mL of the medication.
9. A patient with a nasogastric tube for gastric decompression has a prescription
for intermittent suction. The nurse notes the suction is set to continuous high
suction. The most appropriate action is to:
A) Leave the setting as ordered by the physician
B) Change the setting to intermittent low suction per the order
C) Increase the suction to high to ensure complete emptying
D) Clamp the tube for 15 minutes every hour to prevent irritation
Answer: B
, Rationale: The order specifies intermittent suction. Continuous high suction can
damage gastric mucosa and cause fluid and electrolyte imbalances. The nurse
should adjust the setting to match the prescription.
10. A patient is on strict bed rest and is at risk for developing a deep vein
thrombosis. Which nursing intervention is most effective in preventing this
complication?
A) Massaging the patient's calves twice daily
B) Applying sequential compression devices to the lower extremities
C) Encouraging the patient to do isometric exercises only
D) Keeping the knees flexed to improve venous return
Answer: B
Rationale: Sequential compression devices promote venous return by mimicking
the muscle pump action, reducing venous stasis. Massaging the calves can dislodge
a clot. Isometric exercises alone are insufficient, and flexed knees can impede
venous return.
11. A nurse is reviewing a patient's laboratory results and notes a potassium level
of 6.0 mEq/L. The patient's ECG shows peaked T waves. The nurse should
immediately:
A) Notify the healthcare provider
B) Administer a potassium supplement
C) Place the patient on a cardiac monitor
D) Encourage the patient to eat potassium-rich foods
Answer: A
Rationale: A potassium level of 6.0 mEq/L is critically high and life-threatening, as
evidenced by peaked T waves. The nurse must notify the healthcare provider
immediately for emergency interventions. Administering potassium would be
contraindicated.
12. A patient is receiving a blood transfusion of packed red blood cells. Fifteen
minutes after the infusion begins, the patient reports chills, lower back pain, and
feeling flushed. The nurse's priority action is:
A) Slow the infusion rate and assess the patient's vital signs
B) Stop the transfusion and keep the intravenous line open with normal saline
C) Administer an antihistamine as a pre-medication and continue the transfusion
D) Notify the provider and document the findings after the transfusion is complete
Answer: B
Rationale: The patient is showing signs of an acute hemolytic transfusion reaction,
which is a medical emergency. The nurse must stop the transfusion immediately
