2026 EVOLVE HESI FUNDAMENTALS VERSION 1,2& 3 ACTUAL EXAM EACH VERSION CONTAINS 400
QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES|ALREADY GRADED A+ (BRAND
NEW!!)
1. A nurse is teaching a patient about preventing constipation. Which instruction is most
appropriate?
A. "Limit your fluid intake to prevent bloating."
B. "Increase dietary fiber such as fruits and vegetables."
C. "Avoid all physical activity after meals."
D. "Take a laxative every night."
Answer: B
Rationale: High-fiber diets promote bowel motility. Limiting fluids or routine laxative use is
harmful, and activity should be encouraged.
2. Which is the best position for a patient with difficulty breathing?
A. Supine
B. Fowler’s
C. Prone
D. Sims’
Answer: B
Rationale: Fowler’s (semi to high) promotes lung expansion by using gravity. Supine and prone
impair chest expansion.
3. The nurse prepares to insert a Foley catheter in a female patient. The priority nursing action is:
A. Explain the procedure to the patient.
B. Position the patient in Fowler’s.
C. Use sterile technique.
D. Inflate the balloon before insertion.
Answer: C
Rationale: Sterile technique prevents infection. Explanation is important but not the priority for
safety.
4. A nurse notes a pressure injury on a patient’s sacrum with partial skin loss involving the
epidermis. Which stage is this?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
Answer: B
Rationale: Stage II involves partial-thickness loss of skin (epidermis/dermis). Stage I is non-
blanchable erythema, Stage III involves full-thickness tissue, and Stage IV includes bone/muscle.
5. A patient is at risk for aspiration. The safest nursing action during meals is:
A. Encourage the patient to lie supine.
B. Place the patient in a high Fowler’s position.
C. Provide thin liquids.
D. Feed the patient quickly to reduce fatigue.
,Answer: B
Rationale: Upright positioning reduces aspiration risk. Thin liquids increase aspiration; feeding
should be slow.
6. Which finding requires immediate nursing intervention?
A. BP 128/78 mmHg
B. HR 88 bpm
C. Oxygen saturation 82%
D. Temperature 37.5°C (99.5°F)
Answer: C
Rationale: An O₂ sat <90% indicates hypoxemia, which is a priority.
7. The nurse checks a patient’s IV site and notes redness and swelling. What should the nurse do
first?
A. Slow the infusion rate.
B. Apply warm compresses.
C. Remove the IV catheter.
D. Elevate the extremity.
Answer: C
Rationale: Redness and swelling suggest infiltration or phlebitis; removing the IV prevents further
damage.
8. A nurse is reinforcing teaching about the use of a cane. Which statement shows correct
understanding?
A. "I should hold the cane on my weak side."
B. "I should advance the cane and my strong leg together."
C. "I should move the cane forward first, then my weak leg."
D. "I should place the cane 2 feet ahead of me."
Answer: C
Rationale: Proper cane use: cane moves first, then weak leg, then strong leg. The cane is held on
the strong side.
9. A patient receiving oxygen via nasal cannula at 2 L/min complains of dry nasal passages. The
nurse should:
A. Increase oxygen to 6 L/min.
B. Humidify the oxygen.
C. Switch to a non-rebreather mask.
D. Stop the oxygen.
Answer: B
Rationale: Humidification prevents mucosal dryness. Increasing flow without reason is unsafe.
10. A nurse notes that a postoperative patient’s urinary output has been <30 mL/hr for the past 2
hours. The best action is:
A. Continue monitoring for 2 more hours.
B. Administer a diuretic.
C. Notify the healthcare provider.
,D. Restrict oral fluids.
Answer: C
Rationale: Urine output <30 mL/hr may indicate renal compromise and must be reported.
11. Which nursing action prevents venous thromboembolism in a bedbound patient?
A. Limit fluids
B. Apply sequential compression devices
C. Keep the legs crossed
D. Place pillows under knees
Answer: B
Rationale: SCDs promote venous return. Crossing legs and pressure behind knees impede
circulation.
12. A nurse uses the teach-back method to evaluate patient understanding. This technique is used
to:
A. Test memory skills.
B. Assess literacy level.
C. Ensure patient comprehension.
D. Shorten teaching time.
Answer: C
Rationale: Teach-back ensures the patient understands instructions correctly.
13. The nurse prepares to administer an IM injection. Which site is safest for an adult?
A. Dorsogluteal
B. Deltoid
C. Vastus lateralis
D. Ventrogluteal
Answer: D
Rationale: Ventrogluteal is the preferred adult IM site due to fewer major nerves/vessels.
14. A patient is in restraints. The nurse should:
A. Tie restraints to side rails.
B. Remove restraints every 2 hours.
C. Apply restraints for staff convenience.
D. Skip skin assessments if the patient is calm.
Answer: B
Rationale: Restraints must be removed regularly for circulation, skin checks, and ROM. They should
never be tied to side rails.
15. A patient with a new colostomy expresses embarrassment about odor. The best nursing
response is:
A. "You should avoid social situations."
B. "Empty the pouch when it is one-third full."
C. "You should irrigate the colostomy daily."
D. "There is nothing that can be done."
, Answer: B
Rationale: Emptying early reduces odor and leakage, promoting dignity and participation in
activities.
16. When performing hand hygiene, which action is correct?
A. Wash for at least 10 seconds.
B. Turn off faucet with bare hands.
C. Use warm water and friction.
D. Apply alcohol gel if hands are visibly soiled.
Answer: C
Rationale: Soap, water, and friction are essential; 20 seconds is recommended. Alcohol gel is not
effective on visibly soiled hands.
17. A patient reports pain rated 8/10. The nurse administers prescribed analgesia. What should the
nurse do next?
A. Document the medication.
B. Reassess pain in 30–60 minutes.
C. Ask the patient to rest.
D. Wait for the provider to visit.
Answer: B
Rationale: Reassessment ensures effectiveness of intervention. Documentation follows.
18. Which patient is at greatest risk for developing hypokalemia?
A. Patient taking furosemide
B. Patient with renal failure
C. Patient receiving potassium supplements
D. Patient on spironolactone
Answer: A
Rationale: Loop diuretics like furosemide cause potassium loss. Renal failure and spironolactone
cause hyperkalemia.
19. A patient states, “I’m afraid of surgery.” The nurse’s best response is:
A. "There’s no reason to be afraid."
B. "Why are you afraid?"
C. "Tell me more about your feelings."
D. "You’ll be fine after anesthesia."
Answer: C
Rationale: Open-ended therapeutic communication encourages expression of feelings.
20. The nurse prepares to transfer a patient from bed to chair. Which action is correct?
A. Position the chair on the patient’s weak side.
B. Keep feet apart and knees bent.
C. Bend at the waist.
D. Place the chair far from the bed.
Answer: B
Rationale: Wide base of support and bending knees protect both nurse and patient.
QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES|ALREADY GRADED A+ (BRAND
NEW!!)
1. A nurse is teaching a patient about preventing constipation. Which instruction is most
appropriate?
A. "Limit your fluid intake to prevent bloating."
B. "Increase dietary fiber such as fruits and vegetables."
C. "Avoid all physical activity after meals."
D. "Take a laxative every night."
Answer: B
Rationale: High-fiber diets promote bowel motility. Limiting fluids or routine laxative use is
harmful, and activity should be encouraged.
2. Which is the best position for a patient with difficulty breathing?
A. Supine
B. Fowler’s
C. Prone
D. Sims’
Answer: B
Rationale: Fowler’s (semi to high) promotes lung expansion by using gravity. Supine and prone
impair chest expansion.
3. The nurse prepares to insert a Foley catheter in a female patient. The priority nursing action is:
A. Explain the procedure to the patient.
B. Position the patient in Fowler’s.
C. Use sterile technique.
D. Inflate the balloon before insertion.
Answer: C
Rationale: Sterile technique prevents infection. Explanation is important but not the priority for
safety.
4. A nurse notes a pressure injury on a patient’s sacrum with partial skin loss involving the
epidermis. Which stage is this?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
Answer: B
Rationale: Stage II involves partial-thickness loss of skin (epidermis/dermis). Stage I is non-
blanchable erythema, Stage III involves full-thickness tissue, and Stage IV includes bone/muscle.
5. A patient is at risk for aspiration. The safest nursing action during meals is:
A. Encourage the patient to lie supine.
B. Place the patient in a high Fowler’s position.
C. Provide thin liquids.
D. Feed the patient quickly to reduce fatigue.
,Answer: B
Rationale: Upright positioning reduces aspiration risk. Thin liquids increase aspiration; feeding
should be slow.
6. Which finding requires immediate nursing intervention?
A. BP 128/78 mmHg
B. HR 88 bpm
C. Oxygen saturation 82%
D. Temperature 37.5°C (99.5°F)
Answer: C
Rationale: An O₂ sat <90% indicates hypoxemia, which is a priority.
7. The nurse checks a patient’s IV site and notes redness and swelling. What should the nurse do
first?
A. Slow the infusion rate.
B. Apply warm compresses.
C. Remove the IV catheter.
D. Elevate the extremity.
Answer: C
Rationale: Redness and swelling suggest infiltration or phlebitis; removing the IV prevents further
damage.
8. A nurse is reinforcing teaching about the use of a cane. Which statement shows correct
understanding?
A. "I should hold the cane on my weak side."
B. "I should advance the cane and my strong leg together."
C. "I should move the cane forward first, then my weak leg."
D. "I should place the cane 2 feet ahead of me."
Answer: C
Rationale: Proper cane use: cane moves first, then weak leg, then strong leg. The cane is held on
the strong side.
9. A patient receiving oxygen via nasal cannula at 2 L/min complains of dry nasal passages. The
nurse should:
A. Increase oxygen to 6 L/min.
B. Humidify the oxygen.
C. Switch to a non-rebreather mask.
D. Stop the oxygen.
Answer: B
Rationale: Humidification prevents mucosal dryness. Increasing flow without reason is unsafe.
10. A nurse notes that a postoperative patient’s urinary output has been <30 mL/hr for the past 2
hours. The best action is:
A. Continue monitoring for 2 more hours.
B. Administer a diuretic.
C. Notify the healthcare provider.
,D. Restrict oral fluids.
Answer: C
Rationale: Urine output <30 mL/hr may indicate renal compromise and must be reported.
11. Which nursing action prevents venous thromboembolism in a bedbound patient?
A. Limit fluids
B. Apply sequential compression devices
C. Keep the legs crossed
D. Place pillows under knees
Answer: B
Rationale: SCDs promote venous return. Crossing legs and pressure behind knees impede
circulation.
12. A nurse uses the teach-back method to evaluate patient understanding. This technique is used
to:
A. Test memory skills.
B. Assess literacy level.
C. Ensure patient comprehension.
D. Shorten teaching time.
Answer: C
Rationale: Teach-back ensures the patient understands instructions correctly.
13. The nurse prepares to administer an IM injection. Which site is safest for an adult?
A. Dorsogluteal
B. Deltoid
C. Vastus lateralis
D. Ventrogluteal
Answer: D
Rationale: Ventrogluteal is the preferred adult IM site due to fewer major nerves/vessels.
14. A patient is in restraints. The nurse should:
A. Tie restraints to side rails.
B. Remove restraints every 2 hours.
C. Apply restraints for staff convenience.
D. Skip skin assessments if the patient is calm.
Answer: B
Rationale: Restraints must be removed regularly for circulation, skin checks, and ROM. They should
never be tied to side rails.
15. A patient with a new colostomy expresses embarrassment about odor. The best nursing
response is:
A. "You should avoid social situations."
B. "Empty the pouch when it is one-third full."
C. "You should irrigate the colostomy daily."
D. "There is nothing that can be done."
, Answer: B
Rationale: Emptying early reduces odor and leakage, promoting dignity and participation in
activities.
16. When performing hand hygiene, which action is correct?
A. Wash for at least 10 seconds.
B. Turn off faucet with bare hands.
C. Use warm water and friction.
D. Apply alcohol gel if hands are visibly soiled.
Answer: C
Rationale: Soap, water, and friction are essential; 20 seconds is recommended. Alcohol gel is not
effective on visibly soiled hands.
17. A patient reports pain rated 8/10. The nurse administers prescribed analgesia. What should the
nurse do next?
A. Document the medication.
B. Reassess pain in 30–60 minutes.
C. Ask the patient to rest.
D. Wait for the provider to visit.
Answer: B
Rationale: Reassessment ensures effectiveness of intervention. Documentation follows.
18. Which patient is at greatest risk for developing hypokalemia?
A. Patient taking furosemide
B. Patient with renal failure
C. Patient receiving potassium supplements
D. Patient on spironolactone
Answer: A
Rationale: Loop diuretics like furosemide cause potassium loss. Renal failure and spironolactone
cause hyperkalemia.
19. A patient states, “I’m afraid of surgery.” The nurse’s best response is:
A. "There’s no reason to be afraid."
B. "Why are you afraid?"
C. "Tell me more about your feelings."
D. "You’ll be fine after anesthesia."
Answer: C
Rationale: Open-ended therapeutic communication encourages expression of feelings.
20. The nurse prepares to transfer a patient from bed to chair. Which action is correct?
A. Position the chair on the patient’s weak side.
B. Keep feet apart and knees bent.
C. Bend at the waist.
D. Place the chair far from the bed.
Answer: B
Rationale: Wide base of support and bending knees protect both nurse and patient.
