NIGHTINGALE COLLEGE BSN 225
HESI RN
Specialty
Fundamentals of
Nursing Exam V2
Comprehensive examination aligned with 2026-2027 HESI
Fundamentals standards, NCLEX-RN test plan, and
Nightingale College BSN curriculum competencies. One
hundred verified questions with evidence-based clinical
rationales covering all eight content domains.
Edition: Latest Update
Questions: 100 Multiple Choice
Standard: 100% Verified Correct | Grade A
N I G H T I N G A L E C O L L E G E | B S N P R O G R A M | H E S I P R E P A R AT I O N
,BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V2 (2026/2027) 100% Correct | Grade A - Nightingale
Section 1: Safe, Effective Care Environment (Management of Care, Safety &
Infection Control)
Q1: A nurse is preparing a client for a colonoscopy. The client signed the informed consent form earlier in
the day but now tells the nurse, 'I am not sure I understand what the doctor is going to do.' What is the
nurse's best action?
A. Proceed with the procedure since the consent form is already signed.
B. Explain the procedure to the client in detail and then continue with preparation.
C. Notify the provider that the client has questions about the procedure and needs further
explanation. [CORRECT]
D. Have the client sign a new consent form after reading it again.
Correct Answer: C
Rationale: The nurse's role in informed consent is to witness the signature and confirm understanding, not to explain the
procedure itself. The provider is responsible for explaining the procedure, risks, benefits, and alternatives. The nurse should
notify the provider that the client has unanswered questions so the provider can address them before the procedure proceeds.
Q2: A nurse receives a phone call from a person claiming to be a patient's family member requesting an
update on the patient's condition. Which of the following is the correct nursing action?
A. Provide the information since family members are always permitted to receive patient updates.
B. Verify the caller's identity and then provide a full report of the patient's condition.
C. Inform the caller that patient information cannot be disclosed without the patient's written
authorization. [CORRECT]
D. Transfer the caller directly to the patient's room so the patient can share the information.
Correct Answer: C
Rationale: HIPAA protects Protected Health Information (PHI) and only permits disclosures for Treatment, Payment, or
Healthcare Operations (TPO) without patient authorization. A family member's request does not fall under TPO unless the patient
has provided written authorization. The nurse must protect patient confidentiality regardless of the caller's claimed relationship.
Q3: A charge nurse on a medical-surgical unit is assigning tasks for the shift. Which of the following
tasks is most appropriate to delegate to an unlicensed assistive personnel (UAP)?
A. Assessing a postoperative client's incision site for signs of infection.
B. Administering oral medications to a stable client with hypertension.
C. Measuring and recording intake and output for a client with heart failure. [CORRECT]
D. Teaching a newly diagnosed diabetic client about insulin self-administration.
Correct Answer: C
Rationale: The UAP scope of practice includes ADLs, vital signs, ambulation, positioning, hygiene, and intake/output
measurement. Assessment, medication administration, and client education cannot be delegated to UAPs. Measuring and
recording intake and output is a standardized, non-judgment task within the UAP scope.
Q4: A nurse enters a client's room and finds the client unresponsive with no respirations. The nurse
cannot palpate a carotid pulse. Which of the following actions should the nurse take first?
A. Apply a cardiac monitor to determine the cardiac rhythm.
B. Begin chest compressions and activate the emergency response system. [CORRECT]
1
, BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V2 (2026/2027) 100% Correct | Grade A - Nightingale
C. Establish intravenous access and prepare to administer epinephrine.
D. Perform a focused assessment of the client's neurological status.
Correct Answer: B
Rationale: The ABCs (Airway, Breathing, Circulation) represent the highest priority assessment and intervention framework.
This client has no breathing and no pulse, indicating cardiac arrest. The immediate priority is to begin chest compressions
(Circulation) and activate the emergency response system. Defibrillation and ACLS medications follow after initial CPR is
initiated.
Q5: A competent adult client with terminal cancer tells the nurse, 'I do not want any more treatments. I
just want to be made comfortable.' Which of the following documents should the nurse ensure is in the
client's chart?
A. Informed consent form.
B. Do Not Resuscitate (DNR) order.
C. Living will. [CORRECT]
D. Physician's progress note.
Correct Answer: C
Rationale: A living will is a type of advance directive that documents a competent adult's wishes regarding medical treatment in
the event they become unable to communicate. The Patient Self-Determination Act requires healthcare facilities to inform patients
of their rights regarding advance directives. While a DNR order is also important, the living will is the broader document that
captures the client's treatment preferences.
Q6: A nurse is caring for a client who has wrist restraints applied. Which of the following nursing actions
is correct?
A. Remove the restraints every 4 hours to perform range-of-motion exercises.
B. Ensure a physician's order is obtained within 2 hours of restraint application.
C. Tie the restraint straps to the side rails for client safety.
D. Perform a face-to-face assessment of the client within 1 hour of restraint application.
[CORRECT]
Correct Answer: D
Rationale: Restraint protocols require a physician's order, a face-to-face evaluation within 1 hour of application, reassessment
every 4 hours for adults (every 2 hours for children), and release every 2 hours for range of motion, toileting, and nutrition.
Restraint straps must NEVER be tied to side rails because raising or lowering the rail could cause injury.
Q7: A fire is discovered in a trash can in the hallway of a medical-surgical unit. Which of the following
actions should the nurse take first, according to the RACE protocol?
A. Pull the fire alarm to alert all staff and visitors on the unit.
B. Extinguish the fire using the nearest fire extinguisher.
C. Rescue and evacuate all clients from the immediate area. [CORRECT]
D. Confine the fire by closing all doors and windows in the area.
Correct Answer: C
Rationale: The RACE protocol stands for Rescue, Alarm, Confine, Extinguish/Evacuate. The very first action is to Rescue clients
and individuals in immediate danger. Only after ensuring client safety should the nurse activate the Alarm, Confine the fire by
closing doors and windows, and then attempt to Extinguish the fire if it is safe to do so.
Q8: A nurse is caring for a client diagnosed with Clostridioides difficile (C. diff) infection. Which of the
following precautions should the nurse implement?
2
HESI RN
Specialty
Fundamentals of
Nursing Exam V2
Comprehensive examination aligned with 2026-2027 HESI
Fundamentals standards, NCLEX-RN test plan, and
Nightingale College BSN curriculum competencies. One
hundred verified questions with evidence-based clinical
rationales covering all eight content domains.
Edition: Latest Update
Questions: 100 Multiple Choice
Standard: 100% Verified Correct | Grade A
N I G H T I N G A L E C O L L E G E | B S N P R O G R A M | H E S I P R E P A R AT I O N
,BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V2 (2026/2027) 100% Correct | Grade A - Nightingale
Section 1: Safe, Effective Care Environment (Management of Care, Safety &
Infection Control)
Q1: A nurse is preparing a client for a colonoscopy. The client signed the informed consent form earlier in
the day but now tells the nurse, 'I am not sure I understand what the doctor is going to do.' What is the
nurse's best action?
A. Proceed with the procedure since the consent form is already signed.
B. Explain the procedure to the client in detail and then continue with preparation.
C. Notify the provider that the client has questions about the procedure and needs further
explanation. [CORRECT]
D. Have the client sign a new consent form after reading it again.
Correct Answer: C
Rationale: The nurse's role in informed consent is to witness the signature and confirm understanding, not to explain the
procedure itself. The provider is responsible for explaining the procedure, risks, benefits, and alternatives. The nurse should
notify the provider that the client has unanswered questions so the provider can address them before the procedure proceeds.
Q2: A nurse receives a phone call from a person claiming to be a patient's family member requesting an
update on the patient's condition. Which of the following is the correct nursing action?
A. Provide the information since family members are always permitted to receive patient updates.
B. Verify the caller's identity and then provide a full report of the patient's condition.
C. Inform the caller that patient information cannot be disclosed without the patient's written
authorization. [CORRECT]
D. Transfer the caller directly to the patient's room so the patient can share the information.
Correct Answer: C
Rationale: HIPAA protects Protected Health Information (PHI) and only permits disclosures for Treatment, Payment, or
Healthcare Operations (TPO) without patient authorization. A family member's request does not fall under TPO unless the patient
has provided written authorization. The nurse must protect patient confidentiality regardless of the caller's claimed relationship.
Q3: A charge nurse on a medical-surgical unit is assigning tasks for the shift. Which of the following
tasks is most appropriate to delegate to an unlicensed assistive personnel (UAP)?
A. Assessing a postoperative client's incision site for signs of infection.
B. Administering oral medications to a stable client with hypertension.
C. Measuring and recording intake and output for a client with heart failure. [CORRECT]
D. Teaching a newly diagnosed diabetic client about insulin self-administration.
Correct Answer: C
Rationale: The UAP scope of practice includes ADLs, vital signs, ambulation, positioning, hygiene, and intake/output
measurement. Assessment, medication administration, and client education cannot be delegated to UAPs. Measuring and
recording intake and output is a standardized, non-judgment task within the UAP scope.
Q4: A nurse enters a client's room and finds the client unresponsive with no respirations. The nurse
cannot palpate a carotid pulse. Which of the following actions should the nurse take first?
A. Apply a cardiac monitor to determine the cardiac rhythm.
B. Begin chest compressions and activate the emergency response system. [CORRECT]
1
, BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V2 (2026/2027) 100% Correct | Grade A - Nightingale
C. Establish intravenous access and prepare to administer epinephrine.
D. Perform a focused assessment of the client's neurological status.
Correct Answer: B
Rationale: The ABCs (Airway, Breathing, Circulation) represent the highest priority assessment and intervention framework.
This client has no breathing and no pulse, indicating cardiac arrest. The immediate priority is to begin chest compressions
(Circulation) and activate the emergency response system. Defibrillation and ACLS medications follow after initial CPR is
initiated.
Q5: A competent adult client with terminal cancer tells the nurse, 'I do not want any more treatments. I
just want to be made comfortable.' Which of the following documents should the nurse ensure is in the
client's chart?
A. Informed consent form.
B. Do Not Resuscitate (DNR) order.
C. Living will. [CORRECT]
D. Physician's progress note.
Correct Answer: C
Rationale: A living will is a type of advance directive that documents a competent adult's wishes regarding medical treatment in
the event they become unable to communicate. The Patient Self-Determination Act requires healthcare facilities to inform patients
of their rights regarding advance directives. While a DNR order is also important, the living will is the broader document that
captures the client's treatment preferences.
Q6: A nurse is caring for a client who has wrist restraints applied. Which of the following nursing actions
is correct?
A. Remove the restraints every 4 hours to perform range-of-motion exercises.
B. Ensure a physician's order is obtained within 2 hours of restraint application.
C. Tie the restraint straps to the side rails for client safety.
D. Perform a face-to-face assessment of the client within 1 hour of restraint application.
[CORRECT]
Correct Answer: D
Rationale: Restraint protocols require a physician's order, a face-to-face evaluation within 1 hour of application, reassessment
every 4 hours for adults (every 2 hours for children), and release every 2 hours for range of motion, toileting, and nutrition.
Restraint straps must NEVER be tied to side rails because raising or lowering the rail could cause injury.
Q7: A fire is discovered in a trash can in the hallway of a medical-surgical unit. Which of the following
actions should the nurse take first, according to the RACE protocol?
A. Pull the fire alarm to alert all staff and visitors on the unit.
B. Extinguish the fire using the nearest fire extinguisher.
C. Rescue and evacuate all clients from the immediate area. [CORRECT]
D. Confine the fire by closing all doors and windows in the area.
Correct Answer: C
Rationale: The RACE protocol stands for Rescue, Alarm, Confine, Extinguish/Evacuate. The very first action is to Rescue clients
and individuals in immediate danger. Only after ensuring client safety should the nurse activate the Alarm, Confine the fire by
closing doors and windows, and then attempt to Extinguish the fire if it is safe to do so.
Q8: A nurse is caring for a client diagnosed with Clostridioides difficile (C. diff) infection. Which of the
following precautions should the nurse implement?
2
