BSN 225 HESI RN Specialty Fundamentals of Nursing
Exam V1 (Latest Update Questions & Answers | 100%
Correct | Grade A - Nightingale
Q1
A nurse is preparing to administer an intramuscular injection to an adult client. Which
action is the most critical to perform immediately prior to piercing the client’s skin?
A. aspirating for blood return to ensure proper needle placement.
B. verifying the client's identity using two unique identifiers.
C. documenting the medication administration on the electronic chart.
D. changing the needle to a larger gauge to ensure rapid medication flow.
Correct Answer: B
Rationale: Patient safety is always the highest priority on HESI exams. Verifying the
client's identity using two unique identifiers (e.g., full name and date of birth) against the
medication administration record (MAR) prevents medication errors. Documentation is
done after administration, and aspiration is no longer routinely recommended for most
IM sites. [1, 2]
, Q2
An assistive personnel (AP) is assigned to care for a client who is under airborne
precautions for suspected tuberculosis (TB). Which action by the AP requires immediate
intervention by the nurse? [1]
A. Entering the client's room while wearing a standard surgical mask.
B. Washing hands with soap and water after removing examination gloves.
C. Keeping the door to the client's negative-pressure isolation room closed.
D. Placing a surgical mask on the client during transport to radiology.
Correct Answer: A
Rationale: Airborne precautions (such as for TB, measles, or varicella) require
healthcare workers to wear a fit-tested N95 respirator or higher when entering the room.
A standard surgical mask does not filter out microscopic airborne droplet nuclei. The
other choices are correct care components.
Clinical Nursing Interventions & Documentation
Q3
A nurse is caring for a client who has a prescription for sequential compression devices
(SCDs). Which statement by the nurse best explains the underlying physiological
rationale for this therapy?
A. "SCDs reduce localized dependent edema by pulling fluid into the lymphatic spaces."
B. "SCDs promote venous return by mimicking the muscle pump action of the
legs."
C. "SCDs actively dilate the deep veins of the lower extremities to drop blood pressure."
D. "SCDs prevent arterial plaque formation through rhythmic surface compression."
Correct Answer: B
Rationale: SCDs are used for deep vein thrombosis (DVT) prophylaxis in immobile
clients. The rhythmic inflation and deflation compress the calves, mimicking the natural
skeletal muscle pump that pushes venous blood back toward the heart, preventing
venous stasis and clot formation.
Q4
A nurse documents the following entry in a client’s medical record: "Client reports
severe abdominal pain rating 8/10. Administered morphine 2 mg IV push as prescribed.
Client states pain is now 2/10 and appears resting quietly." Which critical phase of the
nursing process did the nurse demonstrate by recording the pain score of 2/10?
, A. Planning
B. Implementation
C. Diagnosis
D. Evaluation
Correct Answer: D
Rationale: Evaluation involves assessing the client's response to an intervention to
determine if the therapeutic goal (pain reduction) was achieved. Assessment is
gathering baseline data, planning is choosing goals, and implementation is giving the
medication. [1, 2]
Basic Care, Comfort, and Patient Legal Issues
Q5
An older adult client who is alert and oriented states, "I do not want to take that
medication today because it makes me feel dizzy." The nurse administers the
medication anyway while the client is distracted. What legal tort has the nurse
committed?
A. Assault
B. Malpractice
C. Battery
D. Negligence
Correct Answer: C
Rationale: Battery is the intentional, unconsented, and offensive touching or physical
contact of a person. Because the alert and oriented client exercised their legal right to
refuse a medication, giving it anyway constitutes battery. Assault is a threat of harm that
causes fear, while negligence and malpractice imply a failure to meet standards of care
resulting in unintentional injury.
Q6
A nurse is preparing to transfer an older adult client from the bed to a chair. The client
has a history of orthostatic hypotension and has been on prolonged bed rest. Which
action should the nurse take first?
A. Apply a transfer belt snugly around the client's waist.
B. Place non-skid footwear on the client's feet.
C. Dangle the client's legs over the edge of the bed for 1 to 2 minutes.
D. Position the chair at a 45-degree angle to the bed.
Exam V1 (Latest Update Questions & Answers | 100%
Correct | Grade A - Nightingale
Q1
A nurse is preparing to administer an intramuscular injection to an adult client. Which
action is the most critical to perform immediately prior to piercing the client’s skin?
A. aspirating for blood return to ensure proper needle placement.
B. verifying the client's identity using two unique identifiers.
C. documenting the medication administration on the electronic chart.
D. changing the needle to a larger gauge to ensure rapid medication flow.
Correct Answer: B
Rationale: Patient safety is always the highest priority on HESI exams. Verifying the
client's identity using two unique identifiers (e.g., full name and date of birth) against the
medication administration record (MAR) prevents medication errors. Documentation is
done after administration, and aspiration is no longer routinely recommended for most
IM sites. [1, 2]
, Q2
An assistive personnel (AP) is assigned to care for a client who is under airborne
precautions for suspected tuberculosis (TB). Which action by the AP requires immediate
intervention by the nurse? [1]
A. Entering the client's room while wearing a standard surgical mask.
B. Washing hands with soap and water after removing examination gloves.
C. Keeping the door to the client's negative-pressure isolation room closed.
D. Placing a surgical mask on the client during transport to radiology.
Correct Answer: A
Rationale: Airborne precautions (such as for TB, measles, or varicella) require
healthcare workers to wear a fit-tested N95 respirator or higher when entering the room.
A standard surgical mask does not filter out microscopic airborne droplet nuclei. The
other choices are correct care components.
Clinical Nursing Interventions & Documentation
Q3
A nurse is caring for a client who has a prescription for sequential compression devices
(SCDs). Which statement by the nurse best explains the underlying physiological
rationale for this therapy?
A. "SCDs reduce localized dependent edema by pulling fluid into the lymphatic spaces."
B. "SCDs promote venous return by mimicking the muscle pump action of the
legs."
C. "SCDs actively dilate the deep veins of the lower extremities to drop blood pressure."
D. "SCDs prevent arterial plaque formation through rhythmic surface compression."
Correct Answer: B
Rationale: SCDs are used for deep vein thrombosis (DVT) prophylaxis in immobile
clients. The rhythmic inflation and deflation compress the calves, mimicking the natural
skeletal muscle pump that pushes venous blood back toward the heart, preventing
venous stasis and clot formation.
Q4
A nurse documents the following entry in a client’s medical record: "Client reports
severe abdominal pain rating 8/10. Administered morphine 2 mg IV push as prescribed.
Client states pain is now 2/10 and appears resting quietly." Which critical phase of the
nursing process did the nurse demonstrate by recording the pain score of 2/10?
, A. Planning
B. Implementation
C. Diagnosis
D. Evaluation
Correct Answer: D
Rationale: Evaluation involves assessing the client's response to an intervention to
determine if the therapeutic goal (pain reduction) was achieved. Assessment is
gathering baseline data, planning is choosing goals, and implementation is giving the
medication. [1, 2]
Basic Care, Comfort, and Patient Legal Issues
Q5
An older adult client who is alert and oriented states, "I do not want to take that
medication today because it makes me feel dizzy." The nurse administers the
medication anyway while the client is distracted. What legal tort has the nurse
committed?
A. Assault
B. Malpractice
C. Battery
D. Negligence
Correct Answer: C
Rationale: Battery is the intentional, unconsented, and offensive touching or physical
contact of a person. Because the alert and oriented client exercised their legal right to
refuse a medication, giving it anyway constitutes battery. Assault is a threat of harm that
causes fear, while negligence and malpractice imply a failure to meet standards of care
resulting in unintentional injury.
Q6
A nurse is preparing to transfer an older adult client from the bed to a chair. The client
has a history of orthostatic hypotension and has been on prolonged bed rest. Which
action should the nurse take first?
A. Apply a transfer belt snugly around the client's waist.
B. Place non-skid footwear on the client's feet.
C. Dangle the client's legs over the edge of the bed for 1 to 2 minutes.
D. Position the chair at a 45-degree angle to the bed.
