BSN HESI 215 – Mock Final Exam Review Questions and
Answers with Rationales 2026/2027 Update -
Nightingale College
Assessment, Fundamentals & Patient Safety
1. A client suddenly reports severe shortness of breath. What
should the nurse assess first?
A. Pain level
B. Airway and breathing
C. Nutritional status
D. Psychosocial history
Answer: B
Rationale: Airway and breathing are immediate priorities
because impaired oxygenation can rapidly become life-
threatening.
2. Which finding requires immediate intervention?
A. Temperature 37.1°C (98.8°F)
B. Respiratory rate 7/min
C. Pulse 82/min
D. BP 124/78 mmHg
Answer: B
Rationale: A respiratory rate of 7/min indicates significant
respiratory depression and requires prompt assessment.
3. Which intervention is most effective for preventing
healthcare-associated infections?
,A. Wearing gloves continuously
B. Appropriate hand hygiene
C. Wearing a mask for every interaction
D. Using sterile technique for every procedure
Answer: B
Rationale: Proper hand hygiene is one of the most effective
methods for preventing transmission of microorganisms.
4. Which client is at greatest risk for falling?
A. Young adult with no mobility problems
B. Older adult receiving a sedating medication
C. Adult with normal gait
D. Client independently ambulating
Answer: B
Rationale: Older age combined with sedation increases the risk
of impaired balance and falls.
5. Which intervention is appropriate for a client at high risk for
falls?
A. Keep the call light within reach
B. Keep the bed elevated
C. Encourage independent ambulation
D. Keep the room completely dark
Answer: A
Rationale: Easy access to the call light allows the client to
request assistance.
,6. Which client should the nurse assess first?
A. Client requesting discharge paperwork
B. Client with new chest pressure and diaphoresis
C. Client requesting a blanket
D. Client with chronic back pain
Answer: B
Rationale: Chest pressure with diaphoresis may indicate acute
coronary syndrome and requires immediate assessment.
7. Which documentation is most appropriate?
A. "Client seems fine."
B. "Client had a bad day."
C. "Client reports pain decreased from 8/10 to 3/10 30 minutes
after medication."
D. "Client doing better."
Answer: C
Rationale: Objective, measurable documentation
communicates the client's status clearly.
8. Which position generally promotes lung expansion in a
dyspneic client?
A. Supine
B. High-Fowler's
C. Trendelenburg
D. Flat prone
, Answer: B
Rationale: Upright positioning facilitates diaphragmatic
expansion and ventilation.
9. A client becomes unresponsive. What should the nurse do
first?
A. Call the family
B. Assess responsiveness and breathing
C. Obtain a complete history
D. Document the event
Answer: B
Rationale: Immediate assessment determines whether
emergency intervention is necessary.
10. Which finding may be an early indication of hypoxia?
A. Restlessness
B. Cardiac arrest
C. Severe cyanosis
D. Profound hypotension
Answer: A
Rationale: Restlessness and anxiety can occur early with
inadequate oxygenation.
11. Which finding is most concerning in a postoperative client?
A. Mild incisional pain
B. Oxygen saturation of 87%
C. Mild nausea
D. Reduced appetite
Answers with Rationales 2026/2027 Update -
Nightingale College
Assessment, Fundamentals & Patient Safety
1. A client suddenly reports severe shortness of breath. What
should the nurse assess first?
A. Pain level
B. Airway and breathing
C. Nutritional status
D. Psychosocial history
Answer: B
Rationale: Airway and breathing are immediate priorities
because impaired oxygenation can rapidly become life-
threatening.
2. Which finding requires immediate intervention?
A. Temperature 37.1°C (98.8°F)
B. Respiratory rate 7/min
C. Pulse 82/min
D. BP 124/78 mmHg
Answer: B
Rationale: A respiratory rate of 7/min indicates significant
respiratory depression and requires prompt assessment.
3. Which intervention is most effective for preventing
healthcare-associated infections?
,A. Wearing gloves continuously
B. Appropriate hand hygiene
C. Wearing a mask for every interaction
D. Using sterile technique for every procedure
Answer: B
Rationale: Proper hand hygiene is one of the most effective
methods for preventing transmission of microorganisms.
4. Which client is at greatest risk for falling?
A. Young adult with no mobility problems
B. Older adult receiving a sedating medication
C. Adult with normal gait
D. Client independently ambulating
Answer: B
Rationale: Older age combined with sedation increases the risk
of impaired balance and falls.
5. Which intervention is appropriate for a client at high risk for
falls?
A. Keep the call light within reach
B. Keep the bed elevated
C. Encourage independent ambulation
D. Keep the room completely dark
Answer: A
Rationale: Easy access to the call light allows the client to
request assistance.
,6. Which client should the nurse assess first?
A. Client requesting discharge paperwork
B. Client with new chest pressure and diaphoresis
C. Client requesting a blanket
D. Client with chronic back pain
Answer: B
Rationale: Chest pressure with diaphoresis may indicate acute
coronary syndrome and requires immediate assessment.
7. Which documentation is most appropriate?
A. "Client seems fine."
B. "Client had a bad day."
C. "Client reports pain decreased from 8/10 to 3/10 30 minutes
after medication."
D. "Client doing better."
Answer: C
Rationale: Objective, measurable documentation
communicates the client's status clearly.
8. Which position generally promotes lung expansion in a
dyspneic client?
A. Supine
B. High-Fowler's
C. Trendelenburg
D. Flat prone
, Answer: B
Rationale: Upright positioning facilitates diaphragmatic
expansion and ventilation.
9. A client becomes unresponsive. What should the nurse do
first?
A. Call the family
B. Assess responsiveness and breathing
C. Obtain a complete history
D. Document the event
Answer: B
Rationale: Immediate assessment determines whether
emergency intervention is necessary.
10. Which finding may be an early indication of hypoxia?
A. Restlessness
B. Cardiac arrest
C. Severe cyanosis
D. Profound hypotension
Answer: A
Rationale: Restlessness and anxiety can occur early with
inadequate oxygenation.
11. Which finding is most concerning in a postoperative client?
A. Mild incisional pain
B. Oxygen saturation of 87%
C. Mild nausea
D. Reduced appetite
