BSN 225 HESI RN Nursing FUNDAMENTALS
Comprehensive Resource To Help You Ace 2026-2027
Exams Includes Frequently Tested Questions With
ELABORATED 100% Correct COMPLETE SOLUTIONS
Guaranteed Pass First Attempt!! Current Update!!
1. On admission, a client presents a signed living will that includes a Do Not
Resuscitate (DNR) prescription. When the client stops breathing, the nurse
performs cardiopulmonary resuscitation (CPR) and successfully revives the
client. What legal issues could be brought against the nurse?
A) Assault.
B) Battery.
C) Malpractice.
D) False imprisonment. - Correct Answer: B) Battery
Civil laws protect individual rights and include intentional torts, such as assault (an
intentional threat to engage in harmful contact with another) or battery
(unwanted touching). Performing any procedure against the client's wishes can
potentially poise a legal issue, such as battery (B), even if the procedure is of
questionable benefit to the client. (A, C, and D) are not examples against the
client's request
2. During the daily nursing assessment, a client begins to cry and states that the
majority of family and friends have stopped calling and visiting. What action
should the nurse take?
,A) Listen and show interest as the client expresses these feelings.
B) Reinforce that this behavior means they were not true friends.
C) Ask the healthcare provider for a psychiatric consult.
D) Continue with the assessment and tell the client not to worry. - Correct
Answer: A) Listen and show interest as the client expresses these feelings
When a client begins to cry and express feelings, a therapeutic nursing
intervention is to listen and show interest as the client expresses feelings (A). (B) is
not therapeutic option and the nurse does not know the dynamics of their
relationships. (C) is not indicated at this time. (D) is non-therapeutic and offers
false hope
3. An elderly male client who is unresponsive following a cerebral vascular
accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube.
What is the best client position for administration of the bolus tube feedings?
A) Prone.
B) Fowler's.
C) Sims'.
D) Supine. - Correct Answer: B) Fowler's
The client should be positioned in a semi-sitting (Fowler's) (B) position during
feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a
PEG tube, due to placement by a percutaneous endoscopic gastrostomy
procedure, is inserted directly into the stomach through an incision in the
abdomen for long-term administration of nutrition and hydration in the
debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe
position for feeding. Placing the client in (D) increases the risk of aspiration
,4. Which nutritional assessment data should the nurse collect to best reflect
total muscle mass in an adolescent?
A) Height in inches or centimeters.
B) Weight in kilograms or pounds.
C) Triceps skin fold thickness.
D) Upper arm circumference. - Correct Answer: D) Upper arm circumference
Upper arm circumference (D) is an indirect measure of muscle mass. (A and B) do
not distinguish between fat (adipose) and muscularity. (C) is a measure of body
fat.
5. An older client who is a resident in a long term care facility has been
bedridden for a week. Which finding should the nurse identify as a client risk
factor for pressure ulcers?
A) Generalized dry skin.
B) Localized dry skin on lower extremities.
C) Red flush over entire skin surface.
D) Rashes in the axillary, groin, and skin fold regions - Correct Answer: D)
Rashes in the axillary, groin, and skin fold regions
Immobility, constant contact with bed clothing, and excessive heat and moisture
in areas where air flow is limited contributes to bacterial and fungal growth, which
increases the risk for rashes (D), skin breakdown, and the development of
pressure ulcers. (A, B, and C) do not address the concepts of inflammation and
tissue integrity
, 6. During a visit to the outpatient clinic, the nurse assesses a client with severe
osteoarthritis using a goniometer. Which finding should the nurse expect to
measure?
A) Adequate venous blood flow to the lower extremities.
B) Estimated amount of body fat by an underarm skinfold.
C) Degree of flexion and extension of the client's knee joint.
D) Change in the circumference of the joint in centimeters - Correct Answer:
C) Degree of flexion and extension of the client's knee joint
The goniometer is a two-piece ruler that is jointed in the middle with a protractor-
type measuring device that is placed over a joint as the individual extends or
flexes the joint to measure the degrees of flexion and extension on the protractor
(C). A doppler is used to measure blood flow (A). Calipers are used to measure
body fat (B). A tape measure is used to measure circumference of body parts (D).
7. The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units
of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound
infant by cesarean section. The tubing has been changed to a 20 gtt/ml
administration set. The nurse plans to set the flow rate at how many gtt/min?
A) 42 gtt/min.
B) 83 gtt/min.
C) 125 gtt/min.
D) 250 gtt/min - Correct Answer: B. 83 gtt/min
Comprehensive Resource To Help You Ace 2026-2027
Exams Includes Frequently Tested Questions With
ELABORATED 100% Correct COMPLETE SOLUTIONS
Guaranteed Pass First Attempt!! Current Update!!
1. On admission, a client presents a signed living will that includes a Do Not
Resuscitate (DNR) prescription. When the client stops breathing, the nurse
performs cardiopulmonary resuscitation (CPR) and successfully revives the
client. What legal issues could be brought against the nurse?
A) Assault.
B) Battery.
C) Malpractice.
D) False imprisonment. - Correct Answer: B) Battery
Civil laws protect individual rights and include intentional torts, such as assault (an
intentional threat to engage in harmful contact with another) or battery
(unwanted touching). Performing any procedure against the client's wishes can
potentially poise a legal issue, such as battery (B), even if the procedure is of
questionable benefit to the client. (A, C, and D) are not examples against the
client's request
2. During the daily nursing assessment, a client begins to cry and states that the
majority of family and friends have stopped calling and visiting. What action
should the nurse take?
,A) Listen and show interest as the client expresses these feelings.
B) Reinforce that this behavior means they were not true friends.
C) Ask the healthcare provider for a psychiatric consult.
D) Continue with the assessment and tell the client not to worry. - Correct
Answer: A) Listen and show interest as the client expresses these feelings
When a client begins to cry and express feelings, a therapeutic nursing
intervention is to listen and show interest as the client expresses feelings (A). (B) is
not therapeutic option and the nurse does not know the dynamics of their
relationships. (C) is not indicated at this time. (D) is non-therapeutic and offers
false hope
3. An elderly male client who is unresponsive following a cerebral vascular
accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube.
What is the best client position for administration of the bolus tube feedings?
A) Prone.
B) Fowler's.
C) Sims'.
D) Supine. - Correct Answer: B) Fowler's
The client should be positioned in a semi-sitting (Fowler's) (B) position during
feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a
PEG tube, due to placement by a percutaneous endoscopic gastrostomy
procedure, is inserted directly into the stomach through an incision in the
abdomen for long-term administration of nutrition and hydration in the
debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe
position for feeding. Placing the client in (D) increases the risk of aspiration
,4. Which nutritional assessment data should the nurse collect to best reflect
total muscle mass in an adolescent?
A) Height in inches or centimeters.
B) Weight in kilograms or pounds.
C) Triceps skin fold thickness.
D) Upper arm circumference. - Correct Answer: D) Upper arm circumference
Upper arm circumference (D) is an indirect measure of muscle mass. (A and B) do
not distinguish between fat (adipose) and muscularity. (C) is a measure of body
fat.
5. An older client who is a resident in a long term care facility has been
bedridden for a week. Which finding should the nurse identify as a client risk
factor for pressure ulcers?
A) Generalized dry skin.
B) Localized dry skin on lower extremities.
C) Red flush over entire skin surface.
D) Rashes in the axillary, groin, and skin fold regions - Correct Answer: D)
Rashes in the axillary, groin, and skin fold regions
Immobility, constant contact with bed clothing, and excessive heat and moisture
in areas where air flow is limited contributes to bacterial and fungal growth, which
increases the risk for rashes (D), skin breakdown, and the development of
pressure ulcers. (A, B, and C) do not address the concepts of inflammation and
tissue integrity
, 6. During a visit to the outpatient clinic, the nurse assesses a client with severe
osteoarthritis using a goniometer. Which finding should the nurse expect to
measure?
A) Adequate venous blood flow to the lower extremities.
B) Estimated amount of body fat by an underarm skinfold.
C) Degree of flexion and extension of the client's knee joint.
D) Change in the circumference of the joint in centimeters - Correct Answer:
C) Degree of flexion and extension of the client's knee joint
The goniometer is a two-piece ruler that is jointed in the middle with a protractor-
type measuring device that is placed over a joint as the individual extends or
flexes the joint to measure the degrees of flexion and extension on the protractor
(C). A doppler is used to measure blood flow (A). Calipers are used to measure
body fat (B). A tape measure is used to measure circumference of body parts (D).
7. The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units
of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound
infant by cesarean section. The tubing has been changed to a 20 gtt/ml
administration set. The nurse plans to set the flow rate at how many gtt/min?
A) 42 gtt/min.
B) 83 gtt/min.
C) 125 gtt/min.
D) 250 gtt/min - Correct Answer: B. 83 gtt/min
