BSN HESI 225 Fundamentals of Nursing Practice Exam
Actual 2025/2026 with Detailed Rationales | 100%
Verified | Pass Guaranteed – A+ Graded
SECTION 1: FOUNDATIONS OF NURSING PRACTICE (12 Questions)
Q1: A nurse is caring for a client who reports shortness of breath. The nurse
auscultates lung sounds, documents the findings, and contacts the provider. Which
step of the nursing process is the nurse performing when auscultating lung sounds?
A. Planning
B. Implementation
C. Assessment [CORRECT]
D. Evaluation
Correct Answer: C
Rationale: Correct because auscultating lung sounds is a data-gathering activity that
falls under the assessment phase of the nursing process, which involves collecting
subjective and objective data about the client.
Q2: During a clinical rotation, a nursing student recognizes that a postoperative client
is at risk for impaired skin integrity due to immobility. The student develops a plan to
reposition the client every 2 hours. This action best demonstrates which cognitive
skill?
A. Memorization
B. Critical thinking [CORRECT]
C. Rote learning
D. Trial and error
Correct Answer: B
Rationale: Correct because critical thinking involves analyzing client data,
recognizing potential complications, and developing appropriate interventions based
on clinical reasoning.
Q3: A nurse is applying the ethical principle of nonmaleficence when caring for a
client. Which action by the nurse best reflects this principle?
A. Ensuring the client understands the risks of a procedure before signing consent
,B. Administering the correct medication dose after verifying the order three times
[CORRECT]
C. Advocating for the client's right to refuse treatment
D. Distributing nursing resources equally among all clients on the unit
Correct Answer: B
Rationale: Correct because nonmaleficence means "do no harm," and verifying
medication dosage before administration is a direct action to prevent harm to the
client.
Q4: A client with diabetes mellitus asks the nurse why the provider ordered a
hemoglobin A1c test instead of a fasting blood glucose. The nurse explains that the
A1c reflects average blood glucose over which time period?
A. 24 hours
B. 1 week
C. 2 to 3 months [CORRECT]
D. 6 months
Correct Answer: C
Rationale: Correct because hemoglobin A1c measures the percentage of
hemoglobin coated with glucose, reflecting average blood glucose control over
approximately 2 to 3 months.
Q5: A nurse is prioritizing care for four clients at the beginning of the shift. Which
client should the nurse assess first?
A. A client scheduled for discharge in 2 hours
B. A client requesting a PRN analgesic for a headache rated 3/10
C. A client with a new onset of chest pain and oxygen saturation of 88% [CORRECT]
D. A client who needs assistance with ambulation to the bathroom
Correct Answer: C
Rationale: Correct because the client with chest pain and hypoxemia has potentially
life-threatening symptoms requiring immediate assessment and intervention using
airway, breathing, circulation (ABC) priorities.
Q6: A nursing student is reviewing the Nurse Practice Act for the state where they
are licensed. What is the primary purpose of this document?
A. To establish standardized nursing curricula for all schools
B. To define the legal scope of nursing practice and protect the public [CORRECT]
C. To determine salary ranges for registered nurses
D. To mandate specific nurse-to-client ratios for all healthcare facilities
Correct Answer: B
, Rationale: Correct because the Nurse Practice Act is state legislation that defines the
scope of nursing practice, establishes licensure requirements, and protects public
health and safety.
Q7: A nurse is caring for a client who refuses a blood transfusion based on religious
beliefs. The client's family insists the nurse administer the blood. What is the nurse's
most appropriate action?
A. Administer the blood because it is medically indicated
B. Obtain a court order to override the client's refusal
C. Respect the client's autonomous decision and notify the provider [CORRECT]
D. Ask the family to sign the informed consent instead
Correct Answer: C
Rationale: Correct because autonomy is the ethical principle that respects a
competent client's right to make informed decisions about their own healthcare, and
the nurse must advocate for this right.
Q8: During the evaluation phase of the nursing process, a nurse determines that a
client's goal has not been met. What is the nurse's next appropriate action?
A. Discontinue the nursing care plan entirely
B. Reassess the client and revise the care plan as needed [CORRECT]
C. Document the goal as met to maintain accurate records
D. Transfer the client to another unit for better outcomes
Correct Answer: B
Rationale: Correct because evaluation involves comparing actual outcomes with
expected outcomes, and if goals are not met, the nurse must reassess and modify
interventions to improve client outcomes.
Q9: A nurse is using clinical judgment when caring for a client with heart failure.
Which action demonstrates the "analyze cues" component of the Clinical Judgment
Measurement Model?
A. Collecting vital signs every 4 hours
B. Identifying that weight gain of 3 lb in 1 day indicates fluid retention [CORRECT]
C. Documenting intake and output on the flow sheet
D. Administering furosemide as prescribed
Correct Answer: B
Rationale: Correct because analyzing cues involves interpreting assessment data,
recognizing patterns, and identifying significant findings such as sudden weight gain
indicating fluid retention.
Actual 2025/2026 with Detailed Rationales | 100%
Verified | Pass Guaranteed – A+ Graded
SECTION 1: FOUNDATIONS OF NURSING PRACTICE (12 Questions)
Q1: A nurse is caring for a client who reports shortness of breath. The nurse
auscultates lung sounds, documents the findings, and contacts the provider. Which
step of the nursing process is the nurse performing when auscultating lung sounds?
A. Planning
B. Implementation
C. Assessment [CORRECT]
D. Evaluation
Correct Answer: C
Rationale: Correct because auscultating lung sounds is a data-gathering activity that
falls under the assessment phase of the nursing process, which involves collecting
subjective and objective data about the client.
Q2: During a clinical rotation, a nursing student recognizes that a postoperative client
is at risk for impaired skin integrity due to immobility. The student develops a plan to
reposition the client every 2 hours. This action best demonstrates which cognitive
skill?
A. Memorization
B. Critical thinking [CORRECT]
C. Rote learning
D. Trial and error
Correct Answer: B
Rationale: Correct because critical thinking involves analyzing client data,
recognizing potential complications, and developing appropriate interventions based
on clinical reasoning.
Q3: A nurse is applying the ethical principle of nonmaleficence when caring for a
client. Which action by the nurse best reflects this principle?
A. Ensuring the client understands the risks of a procedure before signing consent
,B. Administering the correct medication dose after verifying the order three times
[CORRECT]
C. Advocating for the client's right to refuse treatment
D. Distributing nursing resources equally among all clients on the unit
Correct Answer: B
Rationale: Correct because nonmaleficence means "do no harm," and verifying
medication dosage before administration is a direct action to prevent harm to the
client.
Q4: A client with diabetes mellitus asks the nurse why the provider ordered a
hemoglobin A1c test instead of a fasting blood glucose. The nurse explains that the
A1c reflects average blood glucose over which time period?
A. 24 hours
B. 1 week
C. 2 to 3 months [CORRECT]
D. 6 months
Correct Answer: C
Rationale: Correct because hemoglobin A1c measures the percentage of
hemoglobin coated with glucose, reflecting average blood glucose control over
approximately 2 to 3 months.
Q5: A nurse is prioritizing care for four clients at the beginning of the shift. Which
client should the nurse assess first?
A. A client scheduled for discharge in 2 hours
B. A client requesting a PRN analgesic for a headache rated 3/10
C. A client with a new onset of chest pain and oxygen saturation of 88% [CORRECT]
D. A client who needs assistance with ambulation to the bathroom
Correct Answer: C
Rationale: Correct because the client with chest pain and hypoxemia has potentially
life-threatening symptoms requiring immediate assessment and intervention using
airway, breathing, circulation (ABC) priorities.
Q6: A nursing student is reviewing the Nurse Practice Act for the state where they
are licensed. What is the primary purpose of this document?
A. To establish standardized nursing curricula for all schools
B. To define the legal scope of nursing practice and protect the public [CORRECT]
C. To determine salary ranges for registered nurses
D. To mandate specific nurse-to-client ratios for all healthcare facilities
Correct Answer: B
, Rationale: Correct because the Nurse Practice Act is state legislation that defines the
scope of nursing practice, establishes licensure requirements, and protects public
health and safety.
Q7: A nurse is caring for a client who refuses a blood transfusion based on religious
beliefs. The client's family insists the nurse administer the blood. What is the nurse's
most appropriate action?
A. Administer the blood because it is medically indicated
B. Obtain a court order to override the client's refusal
C. Respect the client's autonomous decision and notify the provider [CORRECT]
D. Ask the family to sign the informed consent instead
Correct Answer: C
Rationale: Correct because autonomy is the ethical principle that respects a
competent client's right to make informed decisions about their own healthcare, and
the nurse must advocate for this right.
Q8: During the evaluation phase of the nursing process, a nurse determines that a
client's goal has not been met. What is the nurse's next appropriate action?
A. Discontinue the nursing care plan entirely
B. Reassess the client and revise the care plan as needed [CORRECT]
C. Document the goal as met to maintain accurate records
D. Transfer the client to another unit for better outcomes
Correct Answer: B
Rationale: Correct because evaluation involves comparing actual outcomes with
expected outcomes, and if goals are not met, the nurse must reassess and modify
interventions to improve client outcomes.
Q9: A nurse is using clinical judgment when caring for a client with heart failure.
Which action demonstrates the "analyze cues" component of the Clinical Judgment
Measurement Model?
A. Collecting vital signs every 4 hours
B. Identifying that weight gain of 3 lb in 1 day indicates fluid retention [CORRECT]
C. Documenting intake and output on the flow sheet
D. Administering furosemide as prescribed
Correct Answer: B
Rationale: Correct because analyzing cues involves interpreting assessment data,
recognizing patterns, and identifying significant findings such as sudden weight gain
indicating fluid retention.
