BSN 225 HESI RN Fundamentals | Nightingale College | 2026-2027
BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V3
Nightingale College | Latest 2026/2027 Update | 100 Questions with Verified Answers | Grade A
Section 1: Nursing Process and Critical Thinking (Assessment, Diagnosis, Planning, Implementation,
Evaluation, Prioritization, Clinical Judgment)
Q1: A nursing student is reviewing the five-step nursing process in preparation for the HESI exam. Which of the
following sequences correctly lists the nursing process steps in order?
A. Assessment, Diagnosis, Planning, Implementation, Evaluation **[CORRECT]**
B. Assessment, Planning, Diagnosis, Implementation, Evaluation
C. Diagnosis, Assessment, Planning, Implementation, Evaluation
D. Assessment, Diagnosis, Implementation, Planning, Evaluation
Correct Answer: A
The correct order of the nursing process is ADPIE: Assessment, Diagnosis, Planning, Implementation, and Evaluation. Assessment must
come first because it provides the data needed to formulate a diagnosis; planning and implementation follow diagnosis; and evaluation
determines whether goals were met. HESI frequently tests the sequence — options B, C, and D all swap Planning and Diagnosis or
Implementation and Planning, which are common student errors.
Q2: A nurse on a medical-surgical unit is caring for four newly admitted patients. The charge nurse reminds the staff
that comprehensive data collection must be completed before any interventions are planned. Which statement best
explains why assessment is considered the first and most critical step of the nursing process?
A. It allows the nurse to delegate tasks to unlicensed personnel immediately.
B. It is required by facility policy before medications can be administered.
C. It provides the foundation of data needed to identify patient problems and guide all subsequent steps.
**[CORRECT]**
D. It eliminates the need for ongoing reassessment throughout the shift.
Correct Answer: C
Assessment is the first and most critical step because it gathers the subjective and objective data upon which every subsequent step of the
nursing process depends. Without accurate assessment data, the nurse cannot correctly identify diagnoses, set appropriate goals, or select
effective interventions. Options A and B are incorrect because assessment's importance is clinical, not administrative; option D is
incorrect because assessment is continuous, not a one-time event.
Q3: A nursing instructor is teaching students how to differentiate types of nursing diagnoses. Which of the following
statements correctly distinguishes an actual nursing diagnosis from a risk diagnosis?
A. An actual diagnosis describes a problem the patient is currently experiencing, while a risk diagnosis indicates the
patient is vulnerable to developing a problem. **[CORRECT]**
B. A risk diagnosis requires interventions, whereas an actual diagnosis requires only monitoring.
C. An actual diagnosis is based on objective data only, while a risk diagnosis is based on subjective data.
D. A risk diagnosis must be changed to an actual diagnosis within 24 hours of admission.
Correct Answer: A
An actual nursing diagnosis describes a human response to a health condition that is already present (e.g., 'Ineffective Airway Clearance'),
whereas a risk diagnosis identifies increased susceptibility (e.g., 'Risk for Impaired Skin Integrity'). Both types of diagnoses require
interventions — risk diagnoses require preventive actions, and actual diagnoses require both treatment and monitoring. Both use
subjective and objective data, and there is no time limit for changing a risk to an actual diagnosis.
Page 1
, BSN 225 HESI RN Fundamentals | Nightingale College | 2026-2027
Q4: A nurse is setting goals for a patient's plan of care during the planning phase of the nursing process. Which of the
following best describes the SMART framework used to write effective patient goals?
A. Safe, Measurable, Accurate, Reliable, Thorough
B. Standard, Manageable, Attainable, Reviewed, Tested
C. Specific, Measurable, Action-oriented, Relevant, Therapeutic
D. Specific, Measurable, Attainable, Realistic, Timely **[CORRECT]**
Correct Answer: D
SMART stands for Specific, Measurable, Attainable, Realistic, and Timely. This framework ensures that patient goals are clearly defined,
can be evaluated objectively, are within the patient's capabilities, are clinically appropriate, and have a target time frame. HESI distractors
often substitute similar-sounding words (e.g., 'Safe' for 'Specific' or 'Thorough' for 'Timely') to test whether students know the exact
acronym.
Q5: A nurse has been caring for a patient with a nursing diagnosis of 'Impaired Physical Mobility.' The patient's goal
was to ambulate 50 feet with a walker by the end of day 3. On day 3, the nurse observes the patient ambulate 30 feet
before becoming fatigued and needing to sit. Which step of the nursing process should the nurse perform next?
A. Reassess the patient's current functional status and revise the plan of care. **[CORRECT]**
B. Discontinue the nursing diagnosis because partial progress was made.
C. Implement new interventions without reassessing the patient.
D. Document the outcome as fully met and close the care plan.
Correct Answer: A
The nurse is performing the Evaluation step, which measures patient outcomes against the established goals. Since the patient ambulated
only 30 feet (goal was 50), the outcome is not met, and the nurse must reassess the situation and modify the plan — such as adjusting the
distance goal, changing interventions, or extending the timeline. The nursing process is cyclic; unmet goals trigger returning to earlier
steps rather than simply closing the care plan or implementing unexamined changes.
Q6: A nurse receives a change-of-shift report on four patients. Which patient should the nurse assess first using the ABC
(Airway, Breathing, Circulation) priority framework?
A. A patient who reports postoperative pain of 6/10 requesting pain medication.
B. A patient with a blood pressure of 90/60 mmHg who is scheduled for a scheduled blood transfusion in 2 hours.
C. A patient with new-onset stridor and a respiratory rate of 32 breaths/min after a tonsillectomy. **[CORRECT]**
D. A patient who is tearful and anxious after receiving a new cancer diagnosis.
Correct Answer: C
Using the ABC framework, the nurse must prioritize the patient with a compromised airway. New-onset stridor and tachypnea following
tonsillectomy suggest airway obstruction, which is a life-threatening emergency. Pain (option A), hypotension that is stable and planned
for transfusion (option B), and emotional distress (option D) are important but do not supersede an airway threat. HESI commonly tests
ABC prioritization with airway-compromised patients as the correct answer.
Q7: A nurse working on a telemetry unit has the following four patients. Using the ABC/Maslow prioritization
framework, which patient should the nurse assess first?
A. A patient with atrial fibrillation who has a controlled heart rate of 88 bpm on digoxin.
B. A patient with type 2 diabetes who has a blood glucose of 180 mg/dL awaiting breakfast trays.
C. A patient with chronic obstructive pulmonary disease (COPD) who has oxygen saturations dropping from 94% to
82% and increasing work of breathing. **[CORRECT]**
D. A patient with a urinary tract infection who reports dysuria and has a temperature of 100.4°F (38°C).
Correct Answer: C
The COPD patient with a falling oxygen saturation (82%) and increased work of breathing has an immediately compromised airway and
breathing status, making this the highest priority. Using Maslow's hierarchy, physiological needs — especially oxygenation — take
precedence over all other needs. The atrial fibrillation patient is stable on medication (option A), the glucose of 180 is elevated but not
critical (option B), and the UTI with low-grade fever can be addressed after the life-threatening oxygenation problem (option D).
Page 2
, BSN 225 HESI RN Fundamentals | Nightingale College | 2026-2027
Q8: A nursing student is documenting findings from a patient assessment. Which of the following represents subjective
data?
A. The patient's blood pressure is 142/88 mmHg.
B. The patient states, 'I feel a sharp pain in my chest when I take a deep breath.' **[CORRECT]**
C. The patient has 2+ pitting edema in both lower extremities.
D. The patient's respiratory rate is 24 breaths/min and shallow.
Correct Answer: B
Subjective data is information that can only be felt or reported by the patient, such as pain, nausea, or dizziness — often called
'symptoms.' The patient's statement about chest pain is subjective because it cannot be measured or directly observed by another person.
Blood pressure (option A), edema (option C), and respiratory rate (option D) are all objective data — measurable or observable findings
that the nurse can verify independently.
Q9: A postoperative patient who had abdominal surgery yesterday was alert and oriented in the morning. By afternoon,
the nurse notes the patient is increasingly restless, confused, and complaining of abdominal distension despite having had
a Foley catheter with only 10 mL of urine output in the last 4 hours. The nurse reviews the morning laboratory results
and notes a blood urea nitrogen (BUN) of 38 mg/dL and a creatinine of 2.1 mg/dL. Which conclusion best reflects the
nurse's use of critical thinking and clinical judgment?
A. The patient's restlessness, altered mental status, oliguria, and elevated BUN/creatinine suggest acute kidney
injury or fluid imbalance, requiring immediate provider notification. **[CORRECT]**
B. The patient's confusion is likely due to lack of sleep and will resolve with rest.
C. The abdominal distension is expected after surgery and does not require further assessment.
D. The patient's condition is stable because the vital signs have not changed since morning.
Correct Answer: A
Critical thinking involves synthesizing multiple pieces of assessment data to recognize a pattern indicating a clinical change. Here, the
nurse connects restlessness, confusion (altered mental status), oliguria (10 mL/4 hr), abdominal distension, and elevated renal labs (BUN
38, creatinine 2.1) — all pointing to possible acute kidney injury or fluid overload. Option B dismisses concerning symptoms; option C
fails to recognize abnormal findings; option D relies on incomplete data by only considering vital signs. HESI tests the ability to integrate
data rather than isolate findings.
Q10: A nurse is completing documentation for a patient who experienced a fall during the shift. Which of the following is
the most accurate and legally appropriate documentation practice?
A. Document that the patient was 'clumsy' and 'not paying attention' when the fall occurred.
B. Delay documentation until the end of the shift to ensure all details are complete.
C. Ask a coworker to document the event on the nurse's behalf from memory.
D. Document the objective facts of the fall, including time, location, patient's position when found, injuries
observed, vital signs after the fall, and interventions performed. **[CORRECT]**
Correct Answer: D
Legal and professional documentation standards require entries to be accurate, timely, objective, and complete. Option D describes
correct practice: recording factual, observable data without subjective interpretations. Labeling a patient as 'clumsy' (option A) is
subjective and unprofessional; delaying documentation (option B) increases the risk of inaccuracy and legal vulnerability; and having
another person document from memory (option C) compromises accuracy and accountability. The medical record is a legal document,
and HESI consistently tests proper documentation principles.
Page 3
, BSN 225 HESI RN Fundamentals | Nightingale College | 2026-2027
Q11: A nursing faculty member is presenting the six QSEN competencies that prepare nurses to improve quality and
safety in patient care. Which of the following lists all six QSEN competencies?
A. Safety, Evidence-Based Practice, Patient-Centered Care, Teamwork and Collaboration, Quality Improvement,
Informatics **[CORRECT]**
B. Safety, Communication, Leadership, Patient-Centered Care, Quality Improvement, Informatics
C. Safety, Evidence-Based Practice, Patient-Centered Care, Delegation, Quality Improvement, Informatics
D. Safety, Evidence-Based Practice, Patient Education, Teamwork and Collaboration, Quality Improvement, Informatics
Correct Answer: A
The six QSEN (Quality and Safety Education for Nurses) competencies are: Safety, Evidence-Based Practice (EBP), Patient-Centered
Care, Teamwork and Collaboration, Quality Improvement (QI), and Informatics. HESI distractors replace one or more competencies with
plausible-sounding but incorrect terms — 'Communication' or 'Leadership' (option B), 'Delegation' (option C), or 'Patient Education'
(option D) — testing the student's precise recall of the six core competencies.
Q12: A nurse assesses a patient who is 3 days postoperative following abdominal surgery. The patient has not passed
flatus, the abdomen is firm and distended, bowel sounds are hypoactive in all quadrants, and the patient reports nausea.
Which nursing diagnosis is most appropriate based on this assessment data?
A. Risk for Bleeding related to surgical incision.
B. Impaired Gas Exchange related to abdominal distension.
C. Constipation related to decreased peristalsis secondary to surgery and immobility. **[CORRECT]**
D. Acute Pain related to surgical incision.
Correct Answer: C
The assessment data — absence of flatus, abdominal distension, hypoactive bowel sounds, and nausea — all point to decreased
gastrointestinal motility, making 'Constipation related to decreased peristalsis secondary to surgery and immobility' the most appropriate
nursing diagnosis. Risk for Bleeding (option A) is not supported by the data presented; Impaired Gas Exchange (option B) is unrelated to
the GI assessment findings; Acute Pain (option D) is not the primary problem evidenced by the data. HESI tests the ability to cluster data
and match it to the correct diagnosis.
Q13: A nurse is developing a care plan for a patient newly diagnosed with heart failure. During the planning step, the
nurse writes the following goal: 'The patient will demonstrate an understanding of a low-sodium diet within 2 days.'
Which characteristic of this goal indicates that it is well-written?
A. It includes an intervention the nurse will perform.
B. It identifies a measurable patient behavior with a specific time frame. **[CORRECT]**
C. It includes a medical diagnosis as the focus of the goal.
D. It describes the nursing actions needed to achieve the goal.
Correct Answer: B
During the Planning step, the nurse develops expected outcomes that are patient-centered, measurable, and time-bound. This goal
specifies the patient's behavior ('demonstrate an understanding of a low-sodium diet') and a time frame ('within 2 days'), making it
measurable and evaluable. Nursing goals focus on patient responses, not nursing actions (options A and D), and should not use medical
diagnoses (option C) as the goal focus. HESI tests understanding that outcomes belong to the patient.
Page 4
BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V3
Nightingale College | Latest 2026/2027 Update | 100 Questions with Verified Answers | Grade A
Section 1: Nursing Process and Critical Thinking (Assessment, Diagnosis, Planning, Implementation,
Evaluation, Prioritization, Clinical Judgment)
Q1: A nursing student is reviewing the five-step nursing process in preparation for the HESI exam. Which of the
following sequences correctly lists the nursing process steps in order?
A. Assessment, Diagnosis, Planning, Implementation, Evaluation **[CORRECT]**
B. Assessment, Planning, Diagnosis, Implementation, Evaluation
C. Diagnosis, Assessment, Planning, Implementation, Evaluation
D. Assessment, Diagnosis, Implementation, Planning, Evaluation
Correct Answer: A
The correct order of the nursing process is ADPIE: Assessment, Diagnosis, Planning, Implementation, and Evaluation. Assessment must
come first because it provides the data needed to formulate a diagnosis; planning and implementation follow diagnosis; and evaluation
determines whether goals were met. HESI frequently tests the sequence — options B, C, and D all swap Planning and Diagnosis or
Implementation and Planning, which are common student errors.
Q2: A nurse on a medical-surgical unit is caring for four newly admitted patients. The charge nurse reminds the staff
that comprehensive data collection must be completed before any interventions are planned. Which statement best
explains why assessment is considered the first and most critical step of the nursing process?
A. It allows the nurse to delegate tasks to unlicensed personnel immediately.
B. It is required by facility policy before medications can be administered.
C. It provides the foundation of data needed to identify patient problems and guide all subsequent steps.
**[CORRECT]**
D. It eliminates the need for ongoing reassessment throughout the shift.
Correct Answer: C
Assessment is the first and most critical step because it gathers the subjective and objective data upon which every subsequent step of the
nursing process depends. Without accurate assessment data, the nurse cannot correctly identify diagnoses, set appropriate goals, or select
effective interventions. Options A and B are incorrect because assessment's importance is clinical, not administrative; option D is
incorrect because assessment is continuous, not a one-time event.
Q3: A nursing instructor is teaching students how to differentiate types of nursing diagnoses. Which of the following
statements correctly distinguishes an actual nursing diagnosis from a risk diagnosis?
A. An actual diagnosis describes a problem the patient is currently experiencing, while a risk diagnosis indicates the
patient is vulnerable to developing a problem. **[CORRECT]**
B. A risk diagnosis requires interventions, whereas an actual diagnosis requires only monitoring.
C. An actual diagnosis is based on objective data only, while a risk diagnosis is based on subjective data.
D. A risk diagnosis must be changed to an actual diagnosis within 24 hours of admission.
Correct Answer: A
An actual nursing diagnosis describes a human response to a health condition that is already present (e.g., 'Ineffective Airway Clearance'),
whereas a risk diagnosis identifies increased susceptibility (e.g., 'Risk for Impaired Skin Integrity'). Both types of diagnoses require
interventions — risk diagnoses require preventive actions, and actual diagnoses require both treatment and monitoring. Both use
subjective and objective data, and there is no time limit for changing a risk to an actual diagnosis.
Page 1
, BSN 225 HESI RN Fundamentals | Nightingale College | 2026-2027
Q4: A nurse is setting goals for a patient's plan of care during the planning phase of the nursing process. Which of the
following best describes the SMART framework used to write effective patient goals?
A. Safe, Measurable, Accurate, Reliable, Thorough
B. Standard, Manageable, Attainable, Reviewed, Tested
C. Specific, Measurable, Action-oriented, Relevant, Therapeutic
D. Specific, Measurable, Attainable, Realistic, Timely **[CORRECT]**
Correct Answer: D
SMART stands for Specific, Measurable, Attainable, Realistic, and Timely. This framework ensures that patient goals are clearly defined,
can be evaluated objectively, are within the patient's capabilities, are clinically appropriate, and have a target time frame. HESI distractors
often substitute similar-sounding words (e.g., 'Safe' for 'Specific' or 'Thorough' for 'Timely') to test whether students know the exact
acronym.
Q5: A nurse has been caring for a patient with a nursing diagnosis of 'Impaired Physical Mobility.' The patient's goal
was to ambulate 50 feet with a walker by the end of day 3. On day 3, the nurse observes the patient ambulate 30 feet
before becoming fatigued and needing to sit. Which step of the nursing process should the nurse perform next?
A. Reassess the patient's current functional status and revise the plan of care. **[CORRECT]**
B. Discontinue the nursing diagnosis because partial progress was made.
C. Implement new interventions without reassessing the patient.
D. Document the outcome as fully met and close the care plan.
Correct Answer: A
The nurse is performing the Evaluation step, which measures patient outcomes against the established goals. Since the patient ambulated
only 30 feet (goal was 50), the outcome is not met, and the nurse must reassess the situation and modify the plan — such as adjusting the
distance goal, changing interventions, or extending the timeline. The nursing process is cyclic; unmet goals trigger returning to earlier
steps rather than simply closing the care plan or implementing unexamined changes.
Q6: A nurse receives a change-of-shift report on four patients. Which patient should the nurse assess first using the ABC
(Airway, Breathing, Circulation) priority framework?
A. A patient who reports postoperative pain of 6/10 requesting pain medication.
B. A patient with a blood pressure of 90/60 mmHg who is scheduled for a scheduled blood transfusion in 2 hours.
C. A patient with new-onset stridor and a respiratory rate of 32 breaths/min after a tonsillectomy. **[CORRECT]**
D. A patient who is tearful and anxious after receiving a new cancer diagnosis.
Correct Answer: C
Using the ABC framework, the nurse must prioritize the patient with a compromised airway. New-onset stridor and tachypnea following
tonsillectomy suggest airway obstruction, which is a life-threatening emergency. Pain (option A), hypotension that is stable and planned
for transfusion (option B), and emotional distress (option D) are important but do not supersede an airway threat. HESI commonly tests
ABC prioritization with airway-compromised patients as the correct answer.
Q7: A nurse working on a telemetry unit has the following four patients. Using the ABC/Maslow prioritization
framework, which patient should the nurse assess first?
A. A patient with atrial fibrillation who has a controlled heart rate of 88 bpm on digoxin.
B. A patient with type 2 diabetes who has a blood glucose of 180 mg/dL awaiting breakfast trays.
C. A patient with chronic obstructive pulmonary disease (COPD) who has oxygen saturations dropping from 94% to
82% and increasing work of breathing. **[CORRECT]**
D. A patient with a urinary tract infection who reports dysuria and has a temperature of 100.4°F (38°C).
Correct Answer: C
The COPD patient with a falling oxygen saturation (82%) and increased work of breathing has an immediately compromised airway and
breathing status, making this the highest priority. Using Maslow's hierarchy, physiological needs — especially oxygenation — take
precedence over all other needs. The atrial fibrillation patient is stable on medication (option A), the glucose of 180 is elevated but not
critical (option B), and the UTI with low-grade fever can be addressed after the life-threatening oxygenation problem (option D).
Page 2
, BSN 225 HESI RN Fundamentals | Nightingale College | 2026-2027
Q8: A nursing student is documenting findings from a patient assessment. Which of the following represents subjective
data?
A. The patient's blood pressure is 142/88 mmHg.
B. The patient states, 'I feel a sharp pain in my chest when I take a deep breath.' **[CORRECT]**
C. The patient has 2+ pitting edema in both lower extremities.
D. The patient's respiratory rate is 24 breaths/min and shallow.
Correct Answer: B
Subjective data is information that can only be felt or reported by the patient, such as pain, nausea, or dizziness — often called
'symptoms.' The patient's statement about chest pain is subjective because it cannot be measured or directly observed by another person.
Blood pressure (option A), edema (option C), and respiratory rate (option D) are all objective data — measurable or observable findings
that the nurse can verify independently.
Q9: A postoperative patient who had abdominal surgery yesterday was alert and oriented in the morning. By afternoon,
the nurse notes the patient is increasingly restless, confused, and complaining of abdominal distension despite having had
a Foley catheter with only 10 mL of urine output in the last 4 hours. The nurse reviews the morning laboratory results
and notes a blood urea nitrogen (BUN) of 38 mg/dL and a creatinine of 2.1 mg/dL. Which conclusion best reflects the
nurse's use of critical thinking and clinical judgment?
A. The patient's restlessness, altered mental status, oliguria, and elevated BUN/creatinine suggest acute kidney
injury or fluid imbalance, requiring immediate provider notification. **[CORRECT]**
B. The patient's confusion is likely due to lack of sleep and will resolve with rest.
C. The abdominal distension is expected after surgery and does not require further assessment.
D. The patient's condition is stable because the vital signs have not changed since morning.
Correct Answer: A
Critical thinking involves synthesizing multiple pieces of assessment data to recognize a pattern indicating a clinical change. Here, the
nurse connects restlessness, confusion (altered mental status), oliguria (10 mL/4 hr), abdominal distension, and elevated renal labs (BUN
38, creatinine 2.1) — all pointing to possible acute kidney injury or fluid overload. Option B dismisses concerning symptoms; option C
fails to recognize abnormal findings; option D relies on incomplete data by only considering vital signs. HESI tests the ability to integrate
data rather than isolate findings.
Q10: A nurse is completing documentation for a patient who experienced a fall during the shift. Which of the following is
the most accurate and legally appropriate documentation practice?
A. Document that the patient was 'clumsy' and 'not paying attention' when the fall occurred.
B. Delay documentation until the end of the shift to ensure all details are complete.
C. Ask a coworker to document the event on the nurse's behalf from memory.
D. Document the objective facts of the fall, including time, location, patient's position when found, injuries
observed, vital signs after the fall, and interventions performed. **[CORRECT]**
Correct Answer: D
Legal and professional documentation standards require entries to be accurate, timely, objective, and complete. Option D describes
correct practice: recording factual, observable data without subjective interpretations. Labeling a patient as 'clumsy' (option A) is
subjective and unprofessional; delaying documentation (option B) increases the risk of inaccuracy and legal vulnerability; and having
another person document from memory (option C) compromises accuracy and accountability. The medical record is a legal document,
and HESI consistently tests proper documentation principles.
Page 3
, BSN 225 HESI RN Fundamentals | Nightingale College | 2026-2027
Q11: A nursing faculty member is presenting the six QSEN competencies that prepare nurses to improve quality and
safety in patient care. Which of the following lists all six QSEN competencies?
A. Safety, Evidence-Based Practice, Patient-Centered Care, Teamwork and Collaboration, Quality Improvement,
Informatics **[CORRECT]**
B. Safety, Communication, Leadership, Patient-Centered Care, Quality Improvement, Informatics
C. Safety, Evidence-Based Practice, Patient-Centered Care, Delegation, Quality Improvement, Informatics
D. Safety, Evidence-Based Practice, Patient Education, Teamwork and Collaboration, Quality Improvement, Informatics
Correct Answer: A
The six QSEN (Quality and Safety Education for Nurses) competencies are: Safety, Evidence-Based Practice (EBP), Patient-Centered
Care, Teamwork and Collaboration, Quality Improvement (QI), and Informatics. HESI distractors replace one or more competencies with
plausible-sounding but incorrect terms — 'Communication' or 'Leadership' (option B), 'Delegation' (option C), or 'Patient Education'
(option D) — testing the student's precise recall of the six core competencies.
Q12: A nurse assesses a patient who is 3 days postoperative following abdominal surgery. The patient has not passed
flatus, the abdomen is firm and distended, bowel sounds are hypoactive in all quadrants, and the patient reports nausea.
Which nursing diagnosis is most appropriate based on this assessment data?
A. Risk for Bleeding related to surgical incision.
B. Impaired Gas Exchange related to abdominal distension.
C. Constipation related to decreased peristalsis secondary to surgery and immobility. **[CORRECT]**
D. Acute Pain related to surgical incision.
Correct Answer: C
The assessment data — absence of flatus, abdominal distension, hypoactive bowel sounds, and nausea — all point to decreased
gastrointestinal motility, making 'Constipation related to decreased peristalsis secondary to surgery and immobility' the most appropriate
nursing diagnosis. Risk for Bleeding (option A) is not supported by the data presented; Impaired Gas Exchange (option B) is unrelated to
the GI assessment findings; Acute Pain (option D) is not the primary problem evidenced by the data. HESI tests the ability to cluster data
and match it to the correct diagnosis.
Q13: A nurse is developing a care plan for a patient newly diagnosed with heart failure. During the planning step, the
nurse writes the following goal: 'The patient will demonstrate an understanding of a low-sodium diet within 2 days.'
Which characteristic of this goal indicates that it is well-written?
A. It includes an intervention the nurse will perform.
B. It identifies a measurable patient behavior with a specific time frame. **[CORRECT]**
C. It includes a medical diagnosis as the focus of the goal.
D. It describes the nursing actions needed to achieve the goal.
Correct Answer: B
During the Planning step, the nurse develops expected outcomes that are patient-centered, measurable, and time-bound. This goal
specifies the patient's behavior ('demonstrate an understanding of a low-sodium diet') and a time frame ('within 2 days'), making it
measurable and evaluable. Nursing goals focus on patient responses, not nursing actions (options A and D), and should not use medical
diagnoses (option C) as the goal focus. HESI tests understanding that outcomes belong to the patient.
Page 4
