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BSN 225 - HESI FUNDAMENTALS EXAM COMPREHENSIVE
2026 QUESTIONS EXAM LATEST VERSION SOLVED
QUESTIONS & ANSWERS VERIFIED 100 %
The nurse notes that a client who is receiving oxygen by nasal cannula
continues to remove the oxygen prongs from the nares. What action should
the nurse take?
a. tape the oxygen tubing to the client's nares
b. assess why the client removes the nasal cannula
c. increase the oxygen flow rate
d. change the nasal cannula to a mask
b. assess why the client removes the nasal cannula
Rationale:
Using the nursing process, the nurse would first assess why the client is removing
the nasal cannula from the nares. Nasal prongs can cause discomfort in the nose or
around the ears. If the client reports discomfort, the nurse can troubleshoot based on
their symptoms to ensure proper oxygen delivery (e.g., if nasal irritation is present,
the air can be humidified, etc.)
The nurse is concerned that a blood pressure reading is dangerously elevated
for an obese client. What should the nurse do first before contacting the health
care provider with the reading?
a. reassess the blood pressure using a larger cuff
b. reassess the blood pressure using a smaller cuff
c. reassess the blood pressure while the client is standing
d. reassess the blood pressure while the client is lying down
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a. reassess the blood pressure using a larger cuff
Rationale:
Blood pressure cuffs are sensitive and will provide either falsely high or falsely low
readings if an incorrect size is used. since the client is obese and the reading was
dangerously elevated, the nurse should first assure that the correct size of cuff was
used for the reading and then reassess the client's blood pressure. The nurse should
use a larger cuff to accurately assess this client's blood pressure.
BP - 136/80 mmHg
HR - 88 beats/min
RespR - 20 breaths/min
O2% sat - 92 % on 2L O2
Temp - 37 C (99.6 F) oral
A client with tracheostomy is admitted with pneumonia. The client has a
productive cough with thick yellow sputum, bilateral crackles on lung
auscultation, and vital sign as listed above. When creating this client's care
plan, which client outcome should be the nurse identify as a priority?
a. client will be able to effectively cough secretions via tracheostomy
b. client will have clear lungs sounds
c. client will be afebrile
d. client will have oxygen saturation greater than 90% during hospitalization
a. client will be able to effectively cough secretions via tracheostomy
Rationale:
A tracheostomy is an opening in the trachea that bypasses an obstructed upper
airway. There are multiple indications for and types of tracheostomies but regardless
of these variations, the nurse should focus care planning using the ABC (airway,
breathing, circulation) framework, combined with the nursing process. The first step
is assessment, during which the nurse has gathered data related to cough, lung
sounds, and vital signs. Next, the nurse should analyzed this data, noting abnormal
findings and looking for patterns. In this scenario, the nurse should notice that the
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client has many abnormal data points related to patent airway and compromised
respiratory system and will build the care plan from these abnormal data points.
An adult client is prescribed to receive 2.5 mL of medication through an IM
injection. The nurse should select which site to provide this medication?
a. dorsogluteal site
b. ventrogluteal site
c. deltoid site
d. abdomen
b. ventrogluteal site
Rationale:
The ventrogluteal site is the preferred site for IM injections because the injection
area is free of major nerves and blood vessels and has only a narrow layer of fat of
consistent thinness (which guarantees that the needle injects the drug into the
muscle instead of the subQ fat layer). The ventrogluteal site can hold large volumes
and is considered to be the sagest site for IM injections overall.
The nurse is assisting a client who has been on bedrest for several days to
move from sitting on the side of the bed to a standing position. As the client
begins to stand, the client complains of being dizzy and then loses
consciousness. What should the nurse do?
a. call for help while maintaining the client in a standing position.
b. assist the client to the floor
c. guide the client's body back into the bed
d. lift the client to the chair
c. guide the client's body back into the bed
Rationale:
Orthostatic hypotension is a common problem affecting the elderly population, esp.
after several days of bedrest. The resulting decrease in blood flow to the brain can
cause lightheadedness or even loss of consciousness. Since the client has lost
consciousness, the safest action would be for the nurse to guide the client's body
back into the bed.
BSN 225 - HESI FUNDAMENTALS EXAM COMPREHENSIVE
2026 QUESTIONS EXAM LATEST VERSION SOLVED
QUESTIONS & ANSWERS VERIFIED 100 %
The nurse notes that a client who is receiving oxygen by nasal cannula
continues to remove the oxygen prongs from the nares. What action should
the nurse take?
a. tape the oxygen tubing to the client's nares
b. assess why the client removes the nasal cannula
c. increase the oxygen flow rate
d. change the nasal cannula to a mask
b. assess why the client removes the nasal cannula
Rationale:
Using the nursing process, the nurse would first assess why the client is removing
the nasal cannula from the nares. Nasal prongs can cause discomfort in the nose or
around the ears. If the client reports discomfort, the nurse can troubleshoot based on
their symptoms to ensure proper oxygen delivery (e.g., if nasal irritation is present,
the air can be humidified, etc.)
The nurse is concerned that a blood pressure reading is dangerously elevated
for an obese client. What should the nurse do first before contacting the health
care provider with the reading?
a. reassess the blood pressure using a larger cuff
b. reassess the blood pressure using a smaller cuff
c. reassess the blood pressure while the client is standing
d. reassess the blood pressure while the client is lying down
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a. reassess the blood pressure using a larger cuff
Rationale:
Blood pressure cuffs are sensitive and will provide either falsely high or falsely low
readings if an incorrect size is used. since the client is obese and the reading was
dangerously elevated, the nurse should first assure that the correct size of cuff was
used for the reading and then reassess the client's blood pressure. The nurse should
use a larger cuff to accurately assess this client's blood pressure.
BP - 136/80 mmHg
HR - 88 beats/min
RespR - 20 breaths/min
O2% sat - 92 % on 2L O2
Temp - 37 C (99.6 F) oral
A client with tracheostomy is admitted with pneumonia. The client has a
productive cough with thick yellow sputum, bilateral crackles on lung
auscultation, and vital sign as listed above. When creating this client's care
plan, which client outcome should be the nurse identify as a priority?
a. client will be able to effectively cough secretions via tracheostomy
b. client will have clear lungs sounds
c. client will be afebrile
d. client will have oxygen saturation greater than 90% during hospitalization
a. client will be able to effectively cough secretions via tracheostomy
Rationale:
A tracheostomy is an opening in the trachea that bypasses an obstructed upper
airway. There are multiple indications for and types of tracheostomies but regardless
of these variations, the nurse should focus care planning using the ABC (airway,
breathing, circulation) framework, combined with the nursing process. The first step
is assessment, during which the nurse has gathered data related to cough, lung
sounds, and vital signs. Next, the nurse should analyzed this data, noting abnormal
findings and looking for patterns. In this scenario, the nurse should notice that the
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client has many abnormal data points related to patent airway and compromised
respiratory system and will build the care plan from these abnormal data points.
An adult client is prescribed to receive 2.5 mL of medication through an IM
injection. The nurse should select which site to provide this medication?
a. dorsogluteal site
b. ventrogluteal site
c. deltoid site
d. abdomen
b. ventrogluteal site
Rationale:
The ventrogluteal site is the preferred site for IM injections because the injection
area is free of major nerves and blood vessels and has only a narrow layer of fat of
consistent thinness (which guarantees that the needle injects the drug into the
muscle instead of the subQ fat layer). The ventrogluteal site can hold large volumes
and is considered to be the sagest site for IM injections overall.
The nurse is assisting a client who has been on bedrest for several days to
move from sitting on the side of the bed to a standing position. As the client
begins to stand, the client complains of being dizzy and then loses
consciousness. What should the nurse do?
a. call for help while maintaining the client in a standing position.
b. assist the client to the floor
c. guide the client's body back into the bed
d. lift the client to the chair
c. guide the client's body back into the bed
Rationale:
Orthostatic hypotension is a common problem affecting the elderly population, esp.
after several days of bedrest. The resulting decrease in blood flow to the brain can
cause lightheadedness or even loss of consciousness. Since the client has lost
consciousness, the safest action would be for the nurse to guide the client's body
back into the bed.
