BSN 225 - HESI FUNDAMENTALS EXAM | BSN 225 - HESI
FUNDAMENTALS EXAM QUESTIONS WITH COMPLETE
SOLUTIONS| 2025-2026 LATEST UPDATED
A client is receiving humidified d. notify the respiratory therapy department to change the water
oxygen by nasal cannula at canister
4L per min. The nurse
notes that the water canister
is empty. Which action
should the nurse take?
a. temporary decrease the O2
to 2 L /min to prevent
drying of the nasal
mucosa
b. remove the water canister
and leave the O2 at
4L/min
c. discontinue the O2 while
awaiting water canister
replacement
d. notify the respiratory
therapy
department to change the
water canister
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,11/2/25, 11:51 PM BSN 225 - HESI FUNDAMENTALS EXAM | BSN 225 - HESI FUNDAMENTALS EXAM QUESTIONS WITH COMPLETE SOLUTIO…
The nurse is caring for a client b. offer to administer 5mg of morphine orally as prescribed for
on hospice breakthrough pain
who was started on a 25
mcg/hr Fentanyl
patch yesterday at 0800. The Rationale:
nurse
completes an assessment A fentanyl patch is effective for 72 hours before it needs to be
today at 2000 replaced. This
and reviews the following breakthrough pain is evidenced by a decline in pain rating
assessment data: followed by an elevated
pain rating during the time that the fentanyl patch should still be
effective.
Yesterday 0800
BP 98/60
HR 110
RR 24
O2SAT 94%
PAIN 6/10
INTERVENTIONS
Fentanyl patch 25mcg/hr
applied
Yesterday 2000
100/55
100
20
95%
2/10
Reposition, visiting with family
Today 0800
92/40
104
24
92%
4/10
Ice pack applied
Today 2000
100/65
110
24
94%
7/10
Which intervention is best for
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,11/2/25, 11:51 PM BSN 225 - HESI FUNDAMENTALS EXAM | BSN 225 - HESI FUNDAMENTALS EXAM QUESTIONS WITH COMPLETE SOLUTIO…
the nurse to
provide?
a. explain that the fentanyl
patch takes time
to become effective, and they
should
experience relief soon.
b. offer to administer 5mg of
morphine
orally as prescribed for
breakthrough pain
c. reposition the client and
offer to give a
back rub.
d. call the provider to provide
an update
on the client's condition
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, 11/2/25, 11:51 PM BSN 225 - HESI FUNDAMENTALS EXAM | BSN 225 - HESI FUNDAMENTALS EXAM QUESTIONS WITH COMPLETE SOLUTIO…
When changing a client's a. Notify the healthcare provider.
post-op wound dressing, the
nurse notes yellow purulent Rationale:
drainage. What action Yellow purulent drainage is an indication of an infection.
should the nurse take? This finding should be reported to the healthcare
provider for assessment and intervention.
a. Notifythe healthcare
provider. Choices B, C, and D are all incorrect because the priority
b. Cover the wound with action is to notify the healthcare provider of the status
clean gauze and secure. of the wound. Further wound management
c. Irrigate the wound with (cultures, irrigation, or no irrigation, packing or no
sterile water and leave packing, antibiotics, etc.) should be determined after
open to air. assessment of the site by the surgical team. Irrigating
d. Irrigate the wound with the wound before assessment has been completed may
normal saline and pack interfere with medical decision-making and hsould be
with gauze. avoided.
2670 mL
Rationale:
The healthcare provider
66mL/hour x 20 hours = 1320 mL
prescribes enteral feeds of
Jevity 1.2 cal at 66mL/hour Then it is necessary to calculate the amount of fluid
over 20 hours, and free
water flushes of 225 mL q 4 from the free water flushes. Free water flushes every
hours x 24 hr via
nasogastric tube. How 4 hours for 24 hours = 6 flushes
many mL of total fluid will
the client receive in 24 225 mL x 65 flushes = 1350 mL
hours? (Enter numerical
value only. If rounding is Finally, add the two sums together:
required, round to one 1320 mL + 1350 mL = 2670 mL in 24 hours
decimal place.)
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