BSN 225 HESI RN Specialty Fundamentals of Nursing
Exam V1 (Latest Update 2026/2027) Questions &
Answers | 100% Correct | Grade A+ - Nightingale
Section 1: Nursing Process and Clinical Judgment
(Questions 1–40)
Question 1: Which phase of the nursing process involves
collecting comprehensive data about the patient's health status?
A. Planning
B. Implementation
C. Assessment
D. Evaluation
Answer: C
Rationale: Assessment is the foundational first step of the nursing process where the
nurse collects comprehensive data about the patient's health status through interview,
physical examination, and review of records. This data is necessary before any planning
or intervention can occur .
Question 2: A nurse is developing a care plan for a client. In which
phase of the nursing process does the nurse establish goals and
expected outcomes?
A. Assessment
B. Diagnosis
,C. Planning
D. Implementation
Answer: C
Rationale: The planning phase of the nursing process is when the nurse establishes
goals and expected outcomes for the client. These goals should be measurable, realistic,
and client-centered .
Question 3: A client's care plan includes the goal: "The client will
ambulate 50 feet with a walker within 3 days." This goal is:
A. Measurable
B. Time-limited
C. Realistic
D. All of the above
Answer: D
Rationale: This goal is measurable (50 feet with a walker), time-limited (within 3 days),
and realistic for a client who is being prepared for discharge. Goals should be SMART:
Specific, Measurable, Achievable, Realistic, and Time-bound .
Question 4: A nurse is evaluating the effectiveness of a nursing
intervention. Which action is most appropriate?
A. Assess the client's response to the intervention
B. Review the nursing care plan
C. Ask the physician for feedback
D. Document the intervention performed
Answer: A
,Rationale: Evaluation involves assessing the client's response to nursing interventions.
This determines whether the goals and expected outcomes have been achieved. The
nursing care plan should then be revised based on the evaluation .
Question 5: The nurse is using the SBAR communication tool
when calling the healthcare provider. What does SBAR stand for?
A. Situation, Background, Assessment, Recommendation
B. Status, Behavior, Action, Response
C. Summary, Background, Analysis, Review
D. Situation, Briefing, Action, Result
Answer: A
Rationale: SBAR is a standardized communication tool that stands for Situation,
Background, Assessment, and Recommendation. It improves patient safety by ensuring
clear, concise, and structured communication during handoffs .
Question 6: Which of the following is a component of the nursing
diagnosis statement?
A. Problem (diagnostic label)
B. Etiology (related factors)
C. Defining characteristics
D. All of the above
Answer: D
Rationale: A nursing diagnosis statement includes the problem (diagnostic label), the
etiology (related factors), and the defining characteristics (signs and symptoms). The
structure is: Problem (NANDA-I label) related to etiology as evidenced by defining
characteristics .
, Question 7: A nurse is prioritizing care for multiple clients. Which
client should the nurse assess first?
A. A client with a new onset of confusion
B. A client requesting pain medication
C. A client who needs assistance with ambulation
D. A client who is ready for discharge
Answer: A
Rationale: A client with a new onset of confusion is a priority because it could indicate a
life-threatening condition such as hypoglycemia, hypoxia, or a neurological event. The
nurse should use Maslow's hierarchy of needs and the ABCs (airway, breathing,
circulation) to prioritize care .
Question 8: The nurse is documenting in the client's medical
record. Which of the following is correct?
A. Record entries objectively and timely
B. Leave blank spaces between entries
C. Use white-out to fix mistakes
D. Sign for a colleague who forgot to document
Answer: A
Rationale: Documentation should be factual, accurate, and completed as soon as
possible after care is provided. Objective recording prevents personal bias from entering
the legal medical record. Blank spaces should not be left, white-out should not be used,
and nurses should never sign for a colleague .
Question 9: Which documentation entry is the most objective and
accurate?
Exam V1 (Latest Update 2026/2027) Questions &
Answers | 100% Correct | Grade A+ - Nightingale
Section 1: Nursing Process and Clinical Judgment
(Questions 1–40)
Question 1: Which phase of the nursing process involves
collecting comprehensive data about the patient's health status?
A. Planning
B. Implementation
C. Assessment
D. Evaluation
Answer: C
Rationale: Assessment is the foundational first step of the nursing process where the
nurse collects comprehensive data about the patient's health status through interview,
physical examination, and review of records. This data is necessary before any planning
or intervention can occur .
Question 2: A nurse is developing a care plan for a client. In which
phase of the nursing process does the nurse establish goals and
expected outcomes?
A. Assessment
B. Diagnosis
,C. Planning
D. Implementation
Answer: C
Rationale: The planning phase of the nursing process is when the nurse establishes
goals and expected outcomes for the client. These goals should be measurable, realistic,
and client-centered .
Question 3: A client's care plan includes the goal: "The client will
ambulate 50 feet with a walker within 3 days." This goal is:
A. Measurable
B. Time-limited
C. Realistic
D. All of the above
Answer: D
Rationale: This goal is measurable (50 feet with a walker), time-limited (within 3 days),
and realistic for a client who is being prepared for discharge. Goals should be SMART:
Specific, Measurable, Achievable, Realistic, and Time-bound .
Question 4: A nurse is evaluating the effectiveness of a nursing
intervention. Which action is most appropriate?
A. Assess the client's response to the intervention
B. Review the nursing care plan
C. Ask the physician for feedback
D. Document the intervention performed
Answer: A
,Rationale: Evaluation involves assessing the client's response to nursing interventions.
This determines whether the goals and expected outcomes have been achieved. The
nursing care plan should then be revised based on the evaluation .
Question 5: The nurse is using the SBAR communication tool
when calling the healthcare provider. What does SBAR stand for?
A. Situation, Background, Assessment, Recommendation
B. Status, Behavior, Action, Response
C. Summary, Background, Analysis, Review
D. Situation, Briefing, Action, Result
Answer: A
Rationale: SBAR is a standardized communication tool that stands for Situation,
Background, Assessment, and Recommendation. It improves patient safety by ensuring
clear, concise, and structured communication during handoffs .
Question 6: Which of the following is a component of the nursing
diagnosis statement?
A. Problem (diagnostic label)
B. Etiology (related factors)
C. Defining characteristics
D. All of the above
Answer: D
Rationale: A nursing diagnosis statement includes the problem (diagnostic label), the
etiology (related factors), and the defining characteristics (signs and symptoms). The
structure is: Problem (NANDA-I label) related to etiology as evidenced by defining
characteristics .
, Question 7: A nurse is prioritizing care for multiple clients. Which
client should the nurse assess first?
A. A client with a new onset of confusion
B. A client requesting pain medication
C. A client who needs assistance with ambulation
D. A client who is ready for discharge
Answer: A
Rationale: A client with a new onset of confusion is a priority because it could indicate a
life-threatening condition such as hypoglycemia, hypoxia, or a neurological event. The
nurse should use Maslow's hierarchy of needs and the ABCs (airway, breathing,
circulation) to prioritize care .
Question 8: The nurse is documenting in the client's medical
record. Which of the following is correct?
A. Record entries objectively and timely
B. Leave blank spaces between entries
C. Use white-out to fix mistakes
D. Sign for a colleague who forgot to document
Answer: A
Rationale: Documentation should be factual, accurate, and completed as soon as
possible after care is provided. Objective recording prevents personal bias from entering
the legal medical record. Blank spaces should not be left, white-out should not be used,
and nurses should never sign for a colleague .
Question 9: Which documentation entry is the most objective and
accurate?
