BSN 225 HESI RN Specialty
Fundamentals of Nursing Exam V1
(Latest Update )
100+ Questions with Answers & Rationales
Question 1:
A nurse is caring for a client who is postoperative day 1 following abdominal surgery. The client's vital
signs are: BP 98/62 mmHg, HR 112 bpm, RR 22/min, temp 37.8°C (100.0°F). The client reports nausea
and the incision site appears slightly red and edematous. Which action should the nurse take FIRST?
A) Administer prescribed antiemetic medication
B) Notify the healthcare provider immediately
C) Assess the surgical incision for drainage
D) Apply a cool compress to the incision site
Answer: C) Assess the surgical incision for drainage
Rationale: The nurse should first assess the surgical incision for drainage, as signs of infection
(redness, edema, fever, tachycardia) may indicate a wound complication. Assessment must precede
intervention to gather complete data. While the healthcare provider should be notified, the nurse
must first complete a thorough assessment. Antiemetics may be needed but addressing potential
infection takes priority. Cool compresses could obscure assessment findings.
Question 2:
A client with chronic obstructive pulmonary disease (COPD) has an oxygen saturation of 88% on room
air. Which oxygen delivery device should the nurse use to provide the most precise oxygen
concentration?
A) Nasal cannula at 2 L/min
B) Simple face mask at 6 L/min
,C) Non-rebreather mask at 10 L/min
D) Venturi mask at 40%
Answer: D) Venturi mask at 40%
Rationale: The Venturi mask delivers the most precise oxygen concentration, making it the preferred
device for clients with COPD who require accurate FiO2 delivery. The Venturi mask uses a jet mixing
principle to deliver a specific percentage of oxygen regardless of the client's respiratory pattern. Nasal
cannulas and simple face masks provide less precise oxygen delivery. Non-rebreather masks deliver
high concentrations but are not as precise as Venturi masks.
Question 3:
A nurse is preparing to administer a subcutaneous injection of heparin to a client. Which technique is
most appropriate for this administration?
A) Use a 22-gauge, 1½-inch needle
B) Insert the needle at a 45-degree angle
C) Massage the site after injection
D) Aspirate for blood return before injection
Answer: B) Insert the needle at a 45-degree angle
Rationale: Heparin is administered subcutaneously and should be given at a 45 to 90-degree angle
depending on the amount of adipose tissue. A 22-gauge, 1½-inch needle is too large for subcutaneous
injections (25-27 gauge, ½ to ⅝ inch is appropriate). The site should not be massaged after heparin
administration as this can cause bruising and hematoma formation. Aspiration is not recommended
for subcutaneous heparin injections as it can cause tissue damage.
Question 4:
The nurse is assessing a client who is receiving IV fluids at 150 mL/hr. The client reports shortness of
breath and has crackles auscultated in the lung bases bilaterally. Which action should the nurse take
FIRST?
,A) Slow the IV infusion rate
B) Place the client in high-Fowler's position
C) Assess oxygen saturation
D) Notify the healthcare provider
Answer: C) Assess oxygen saturation
Rationale: The client is showing signs of fluid volume excess (pulmonary edema). The nurse should
first assess oxygen saturation to determine the severity of respiratory compromise. While slowing the
infusion, positioning the client, and notifying the provider are all important, assessing oxygen
saturation provides critical data about the client's current respiratory status and guides subsequent
interventions.
Question 5:
A client with diabetes mellitus is experiencing hypoglycemia. Which of the following is the priority
nursing intervention?
A) Administer 15g of rapid-acting carbohydrate
B) Check blood glucose level
C) Administer 1mg of glucagon IM
D) Call the healthcare provider
Answer: B) Check blood glucose level
Rationale: The priority action is to check the client's blood glucose level to confirm hypoglycemia
before administering treatment. While the "rule of 15" (administer 15g of carbohydrate) is an
appropriate intervention once hypoglycemia is confirmed, treatment should not be given without first
verifying the blood glucose level. Glucagon is used for severe hypoglycemia when the client cannot
take oral carbohydrates.
Question 6:
, A nurse is performing sterile wound irrigation for a client with a pressure injury. Which action
demonstrates correct sterile technique?
A) Use sterile gloves and clean technique supplies
B) Irrigate from the most contaminated area to the least contaminated area
C) Use a 60-mL syringe with an 18-gauge angiocatheter
D) Allow the irrigating solution to flow from the wound to the surrounding skin
Answer: C) Use a 60-mL syringe with an 18-gauge angiocatheter
Rationale: Sterile irrigation should be performed using a 35 to 60-mL syringe with an 18 or 19-gauge
angiocatheter or needle to create sufficient pressure (8-15 psi) for effective debridement without
damaging tissue. The wound should be irrigated from the least contaminated area to the most
contaminated area. Irrigation solution should flow from the cleanest area to the most contaminated
area to prevent introducing bacteria. Sterile technique requires sterile gloves, sterile solution, and
sterile supplies.
Question 7:
The nurse is caring for a client on fall precautions. Which intervention is most appropriate to prevent
falls?
A) Keep the bed in the lowest position with side rails up
B) Place the call light within easy reach of the client
C) Restrain the client to prevent unsupervised ambulation
D) Keep the room dark to promote rest
Answer: B) Place the call light within easy reach of the client
Rationale: Placing the call light within easy reach promotes client independence in calling for
assistance and reduces the risk of falls. Bed side rails should be used selectively; full side rails are
considered a restraint in many facilities and may increase fall risk. Physical restraints should not be
used as a first-line intervention and require a healthcare provider order. The room should be well-lit
to assist with visual cues and reduce fall risk.
Fundamentals of Nursing Exam V1
(Latest Update )
100+ Questions with Answers & Rationales
Question 1:
A nurse is caring for a client who is postoperative day 1 following abdominal surgery. The client's vital
signs are: BP 98/62 mmHg, HR 112 bpm, RR 22/min, temp 37.8°C (100.0°F). The client reports nausea
and the incision site appears slightly red and edematous. Which action should the nurse take FIRST?
A) Administer prescribed antiemetic medication
B) Notify the healthcare provider immediately
C) Assess the surgical incision for drainage
D) Apply a cool compress to the incision site
Answer: C) Assess the surgical incision for drainage
Rationale: The nurse should first assess the surgical incision for drainage, as signs of infection
(redness, edema, fever, tachycardia) may indicate a wound complication. Assessment must precede
intervention to gather complete data. While the healthcare provider should be notified, the nurse
must first complete a thorough assessment. Antiemetics may be needed but addressing potential
infection takes priority. Cool compresses could obscure assessment findings.
Question 2:
A client with chronic obstructive pulmonary disease (COPD) has an oxygen saturation of 88% on room
air. Which oxygen delivery device should the nurse use to provide the most precise oxygen
concentration?
A) Nasal cannula at 2 L/min
B) Simple face mask at 6 L/min
,C) Non-rebreather mask at 10 L/min
D) Venturi mask at 40%
Answer: D) Venturi mask at 40%
Rationale: The Venturi mask delivers the most precise oxygen concentration, making it the preferred
device for clients with COPD who require accurate FiO2 delivery. The Venturi mask uses a jet mixing
principle to deliver a specific percentage of oxygen regardless of the client's respiratory pattern. Nasal
cannulas and simple face masks provide less precise oxygen delivery. Non-rebreather masks deliver
high concentrations but are not as precise as Venturi masks.
Question 3:
A nurse is preparing to administer a subcutaneous injection of heparin to a client. Which technique is
most appropriate for this administration?
A) Use a 22-gauge, 1½-inch needle
B) Insert the needle at a 45-degree angle
C) Massage the site after injection
D) Aspirate for blood return before injection
Answer: B) Insert the needle at a 45-degree angle
Rationale: Heparin is administered subcutaneously and should be given at a 45 to 90-degree angle
depending on the amount of adipose tissue. A 22-gauge, 1½-inch needle is too large for subcutaneous
injections (25-27 gauge, ½ to ⅝ inch is appropriate). The site should not be massaged after heparin
administration as this can cause bruising and hematoma formation. Aspiration is not recommended
for subcutaneous heparin injections as it can cause tissue damage.
Question 4:
The nurse is assessing a client who is receiving IV fluids at 150 mL/hr. The client reports shortness of
breath and has crackles auscultated in the lung bases bilaterally. Which action should the nurse take
FIRST?
,A) Slow the IV infusion rate
B) Place the client in high-Fowler's position
C) Assess oxygen saturation
D) Notify the healthcare provider
Answer: C) Assess oxygen saturation
Rationale: The client is showing signs of fluid volume excess (pulmonary edema). The nurse should
first assess oxygen saturation to determine the severity of respiratory compromise. While slowing the
infusion, positioning the client, and notifying the provider are all important, assessing oxygen
saturation provides critical data about the client's current respiratory status and guides subsequent
interventions.
Question 5:
A client with diabetes mellitus is experiencing hypoglycemia. Which of the following is the priority
nursing intervention?
A) Administer 15g of rapid-acting carbohydrate
B) Check blood glucose level
C) Administer 1mg of glucagon IM
D) Call the healthcare provider
Answer: B) Check blood glucose level
Rationale: The priority action is to check the client's blood glucose level to confirm hypoglycemia
before administering treatment. While the "rule of 15" (administer 15g of carbohydrate) is an
appropriate intervention once hypoglycemia is confirmed, treatment should not be given without first
verifying the blood glucose level. Glucagon is used for severe hypoglycemia when the client cannot
take oral carbohydrates.
Question 6:
, A nurse is performing sterile wound irrigation for a client with a pressure injury. Which action
demonstrates correct sterile technique?
A) Use sterile gloves and clean technique supplies
B) Irrigate from the most contaminated area to the least contaminated area
C) Use a 60-mL syringe with an 18-gauge angiocatheter
D) Allow the irrigating solution to flow from the wound to the surrounding skin
Answer: C) Use a 60-mL syringe with an 18-gauge angiocatheter
Rationale: Sterile irrigation should be performed using a 35 to 60-mL syringe with an 18 or 19-gauge
angiocatheter or needle to create sufficient pressure (8-15 psi) for effective debridement without
damaging tissue. The wound should be irrigated from the least contaminated area to the most
contaminated area. Irrigation solution should flow from the cleanest area to the most contaminated
area to prevent introducing bacteria. Sterile technique requires sterile gloves, sterile solution, and
sterile supplies.
Question 7:
The nurse is caring for a client on fall precautions. Which intervention is most appropriate to prevent
falls?
A) Keep the bed in the lowest position with side rails up
B) Place the call light within easy reach of the client
C) Restrain the client to prevent unsupervised ambulation
D) Keep the room dark to promote rest
Answer: B) Place the call light within easy reach of the client
Rationale: Placing the call light within easy reach promotes client independence in calling for
assistance and reduces the risk of falls. Bed side rails should be used selectively; full side rails are
considered a restraint in many facilities and may increase fall risk. Physical restraints should not be
used as a first-line intervention and require a healthcare provider order. The room should be well-lit
to assist with visual cues and reduce fall risk.
