BSN 225 HESI APPROVED PRACTICE QUESTIONS AND CORRECT ANSWERS WITH RATIONALE EXAM 2026

BSN 225 BSN 225 BSN 225 HESI APPROVED PRACTICE QUESTIONS AND CORRECT ANSWERS WITH RATIONALE EXAM 2026 A nurse is preparing to give medications through a nasogastric feeding tube. Which nursing action should prevent complications during administration? a.)Mix each medication individually. b.)Use sterile gloves for the procedure. c.)Monitor vital signs before giving medications. d.)Mix all medications together to facilitate administration. - Correct Answer-a.) Mix each medication individually. Rationale: When administering medications through a nasogastric feeding tube, the medications should be mixed separately to prevent clumping. The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? a.) A college-age track runner with a sprained ankle. b.) A lactating woman nursing her 3-day-old infant. c.) A school-aged child with Type 2 diabetes. d.) An elderly man being treated for a peptic ulcer. - Correct Answer-B.) A lactating woman nursing her 3-day-old infant. Rationale: A lactating woman has the greatest need for additional protein intake. Orthopedic injuries, type 2 diabetes, and peptic ulcers are all conditions that require protein, but do not have the increased metabolic protein demands of lactation. A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. Which action should the nurse take first? A.) Irrigate the nasogastric tube with sterile normal saline. B.) Reposition the client on her side. C.) Advance the nasogastric tube an additional five centimeters. D.) Administer an intravenous antiemetic prescribed for PRN use. - Correct Answer-b.) Reposition the client on her side. BSN 225 BSN 225 Rationale: The nurse has identified two things suggesting the the nasogastric tube is not functioning properly; the client is nauseated and no drainage from the tube in 2 hours. The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention should be attempted first. This includes repositioning the client to her side. The tube may need to be irrigated or advanced but these actions should follow repositioning the client. The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A.) The belief is held that the "evil eye" enters the child if anything cold is ingested. B.) After surgery the child probably has refused all foods except broth. C.) Eating broth strengthens the child's innate energy called "chi." D.) "Hot" remedies restore balance after surgery, which is considered a "cold" condition. - Correct Answer-d.) "Hot" remedies restore balance after surgery, which is considered a "cold" condition. Rationale: Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body. The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? a.) Encourage the client to cough to help loosen secretions. b.) Advise the client to increase the intake of oral fluids. c.) Rotate the suction catheter to obtain any remaining secretions. d.) Re-oxygenate the client before attempting to suction again. - Correct Answer-d.) Re oxygenate the client before attempting to suction again. Rationale: Nasotracheal suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time. Additional suctioning may continue after the client has received oxygen. The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? BSN 225 BSN 225 A.) The client voluntarily signed the form. B.) The client fully understands the procedure. C.) The client agrees with the procedure to be done. D.) The client authorizes continued treatment. - Correct Answer-a.) The client voluntarily signed the form. Rationale: The nurse signs the consent form to witness that the client voluntarily signs the consent, that the client's signature is authentic, and that the client is otherwise competent to give consent. It is the healthcare provider's responsibility to ensure that the client fully understands the procedure. The nurse's signature does not indicate that the client agrees to or authorizes treatment. At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. Which is the best response to this client's silence? A.) "It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel." B.) "Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery." C.) "It is OK if you don't want to talk about your surgery. I will be available when you are ready." D.) "I will ask a woman who has had a mastectomy to come by and share her experiences with you." - Correct Answer-C.) "It is OK if you don't want to talk about your surgery. I will be available when you are ready." Rationale: When a client is reluctant to look at a surgical wound or refuses to talk about the surgery, the nurse should reflect that these feelings are OK and that the nurse is available when the client is ready. Such a response displays sensitivity and understanding without judging the client. On the other hand, telling a client how she should feel is judgmental and insensitive. A client who has a sinus infection is receiving a prescription for amoxicillin/clavulanate potassium (Augmentin) 500 mg PO q8 hours. The available form is 250 mg amoxicillin/125mg clavulanate tablets. How many tablets should the nurse administer for each dose? (Enter numeric value only.) - Correct Answer-2 Rationale: Using Desired/Available Formula— 500mg/250mg x 1 tablet = 2 On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs BSN 225 BSN 225 cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? A.) Assault. B.) Battery. C.) Malpractice. D.) False imprisonment. - Correct Answer-B.) Battery Rationale: Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching).Performing any procedure against the client's wishes can potentially create a legal issue, such as battery, even if the procedure is of questionable benefit to the client. An older client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A.) Massage any reddened areas for at least five minutes. B.) Encourage active range of motion exercises on extremities. C.) Position the client laterally, prone, and dorsally in sequence. D.) Gently lift the client when moving into a desired position. - Correct Answer-d.) Gently lift the client when moving into a desired position. Rationale: To avoid shearing forces when repositioning, the client should be lifted gently across a surface. Reddened areas should not be massaged since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion may be limited on the affected leg. A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A.) Record the coughing incident. No further action is required at this time. B.) Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C.) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D.) Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. - Correct Answer-c.) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. Rationale: Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing BSN 225 BSN 225 the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action. The auscultating method has been found to be unreliable for small-bore feeding tubes. A Sub-Saharan African widowed immigrant woman lives with her deceased husband's brother and his family, which includes the brother-in-law's children and the widow's adult children. Each family member speaks fluent English. Surgery is recommended for this client. What is the best plan to obtain consent for surgery for this client? A.) Obtain an interpreter to explain the procedure to the client. B.) Encourage the client to make her own decision regarding surgery. C.) Ask the family members to provide a clarification of the surgeon's explanation to the client. D.) Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow. - Correct Answer-d.) Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow. Rationale: Customary law in some rural sub-Saharan countries encompasses wife inheritance and polygamy; the widow becomes the inherited wife of the her husband's brother. In those rural areas women live in a patriarchal family where decisions are made by men. Most likely, the brother-in-law will make the decision for his inherited wife, so it is important to provide the surgeon with culturally sensitive information. Since all family members speak fluent English, there is no need for a translator. It is culturally insensitive to encourage the woman to go against her wishes to follow her cultural worldview. When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action should the nurse implement first? A.) Establish a new nursing diagnosis. B.) Note which actions were not implemented. C.) Add additional nursing orders to the plan. D.) Collaborate with the healthcare provider to make changes. - Correct Answer-b.) Note which actions were not implemented. Rationale: First, the nurse should review which actions in the original plan were not implemented in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome, or identifying a new nursing diagnosis.