HESI RN FUNDAMENTALS BSN 225 SPECIALTY
EXAM QUESTIONS AND VERIFIED RATIONALES |
GRADE A STUDY GUIDE BUNDLE
This comprehensive exam preparation package features 200 high-yield,
proctored-style practice questions with detailed answers and rationales
specifically tailored for nursing students. It thoroughly evaluates
foundational concepts including clinical safety, infection control, dosage
calculations, patient prioritization, and legal/ethical nursing practices.
Mastering these realistic scenarios will significantly enhance critical
thinking, maximize test-day performance, and ensure a passing grade on
the first attempt.
Q1. A nurse is planning care for a client who is at
risk for developing pressure ulcers. Which
intervention should the nurse include in the plan
of care?
A. Massage bony prominences daily.
B. Use a synthetic sheepskin pad.
C. Keep the head of the bed elevated at 45 degrees.
D. Turn and position the client at least every 2
hours.
Answer: D
Rationale: Turning and positioning a client at
least every 2 hours relieves mechanical pressure
on bony prominences, preventing tissue
ischemia. Massaging reddened areas can cause
deeper tissue damage, a 45-degree elevation
,increases shear risk, and sheepskin pads do not
adequately relieve pressure.
Q2. A nurse is preparing to administer an
intramuscular injection to an 8-month-old infant.
Which site should the nurse select?
A. Deltoid
B. Dorsogluteal
C. Vastus lateralis
D. Ventrogluteal
Answer: C
Rationale: The vastus lateralis muscle is the
preferred and safest injection site for infants
under 12 months because it is the most
developed muscle mass at this stage of growth.
Q3. A nurse is caring for a client who is 1 day
postoperative. The client reports a pain level of 7
on a scale of 0 to 10. Which action should the
nurse take first?
A. Check the client’s vital signs.
B. Administer the prescribed analgesic.
C. Assess the surgical incision site.
D. Provide a nonpharmacological pain relief
measure.
Answer: B
,Rationale: A pain level of 7 indicates severe pain.
The nurse's immediate priority is to alleviate the
client's pain by administering the prescribed
pharmacological intervention.
Q4. A nurse is documenting care in a client's
medical record. Which entry represents the most
objective documentation?
A. "Client is uncooperative and refuses to take
morning medications."
B. "Client appears depressed and cried during the
morning assessment."
C. "Client reports pain as 4 on a 0-10 scale; noted
grimacing during movement."
D. "Client had a good day and ambulated well in the
hallway."
Answer: C
Rationale: Objective documentation must be
factual, measurable, and free of personal bias or
judgment. Recording the client's exact pain
scale rating and specific physical signs like
grimacing is completely objective.
Q5. A nurse is performing a sterile wound
dressing change. Which action breaks sterile
technique?
, A. Opening the sterile pack away from the body first.
B. Maintaining a 1-inch border around the sterile
field.
C. Keeping sterile gloved hands above the waist
level.
D. Reaching across the sterile field to pick up a
dressing tool.
Answer: D
Rationale: Reaching over a sterile field
introduces micro-organisms from the nurse's
sleeves or arms, which contaminates the field.
Sterile items must always be approached from
the sides or front without crossing over them.
Q6. A client refuses a scheduled dose of
antihypertensive medication. Which action
should the nurse take first?
A. Inform the provider of the refusal.
B. Document the refusal in the chart.
C. Explore the client’s reasons for refusing.
D. Explain the risks of skipping the medication.
Answer: C
Rationale: Under the nursing process,
assessment always comes first. The nurse must
first explore why the client is refusing the
medication to address any misunderstandings,
EXAM QUESTIONS AND VERIFIED RATIONALES |
GRADE A STUDY GUIDE BUNDLE
This comprehensive exam preparation package features 200 high-yield,
proctored-style practice questions with detailed answers and rationales
specifically tailored for nursing students. It thoroughly evaluates
foundational concepts including clinical safety, infection control, dosage
calculations, patient prioritization, and legal/ethical nursing practices.
Mastering these realistic scenarios will significantly enhance critical
thinking, maximize test-day performance, and ensure a passing grade on
the first attempt.
Q1. A nurse is planning care for a client who is at
risk for developing pressure ulcers. Which
intervention should the nurse include in the plan
of care?
A. Massage bony prominences daily.
B. Use a synthetic sheepskin pad.
C. Keep the head of the bed elevated at 45 degrees.
D. Turn and position the client at least every 2
hours.
Answer: D
Rationale: Turning and positioning a client at
least every 2 hours relieves mechanical pressure
on bony prominences, preventing tissue
ischemia. Massaging reddened areas can cause
deeper tissue damage, a 45-degree elevation
,increases shear risk, and sheepskin pads do not
adequately relieve pressure.
Q2. A nurse is preparing to administer an
intramuscular injection to an 8-month-old infant.
Which site should the nurse select?
A. Deltoid
B. Dorsogluteal
C. Vastus lateralis
D. Ventrogluteal
Answer: C
Rationale: The vastus lateralis muscle is the
preferred and safest injection site for infants
under 12 months because it is the most
developed muscle mass at this stage of growth.
Q3. A nurse is caring for a client who is 1 day
postoperative. The client reports a pain level of 7
on a scale of 0 to 10. Which action should the
nurse take first?
A. Check the client’s vital signs.
B. Administer the prescribed analgesic.
C. Assess the surgical incision site.
D. Provide a nonpharmacological pain relief
measure.
Answer: B
,Rationale: A pain level of 7 indicates severe pain.
The nurse's immediate priority is to alleviate the
client's pain by administering the prescribed
pharmacological intervention.
Q4. A nurse is documenting care in a client's
medical record. Which entry represents the most
objective documentation?
A. "Client is uncooperative and refuses to take
morning medications."
B. "Client appears depressed and cried during the
morning assessment."
C. "Client reports pain as 4 on a 0-10 scale; noted
grimacing during movement."
D. "Client had a good day and ambulated well in the
hallway."
Answer: C
Rationale: Objective documentation must be
factual, measurable, and free of personal bias or
judgment. Recording the client's exact pain
scale rating and specific physical signs like
grimacing is completely objective.
Q5. A nurse is performing a sterile wound
dressing change. Which action breaks sterile
technique?
, A. Opening the sterile pack away from the body first.
B. Maintaining a 1-inch border around the sterile
field.
C. Keeping sterile gloved hands above the waist
level.
D. Reaching across the sterile field to pick up a
dressing tool.
Answer: D
Rationale: Reaching over a sterile field
introduces micro-organisms from the nurse's
sleeves or arms, which contaminates the field.
Sterile items must always be approached from
the sides or front without crossing over them.
Q6. A client refuses a scheduled dose of
antihypertensive medication. Which action
should the nurse take first?
A. Inform the provider of the refusal.
B. Document the refusal in the chart.
C. Explore the client’s reasons for refusing.
D. Explain the risks of skipping the medication.
Answer: C
Rationale: Under the nursing process,
assessment always comes first. The nurse must
first explore why the client is refusing the
medication to address any misunderstandings,
