BSN 225 HESI RN SPECIALTY FUNDAMENTALS OF NURSING EXAM V1 QUESTIONS AND CORRECT ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES 2026 Q&A |LATEST EXAM UPDATE 2026/2027.
Section One: Questions 1–100
A nurse is caring for a client who is preoperative. Which action is the most important responsibility of the nurse when obtaining
informed consent?
A. Explaining the risks and benefits of the surgery to the client.
B. Witnessing the client’s signature on the consent form.
C. Determining if the client is capable of understanding the procedure.
D. Ensuring the surgeon has explained the procedure to the client.
🟢B
🔴 RATIONALE: The nurse's primary role in informed consent is to act as a witness to the signature, verifying that the client is
competent and signed voluntarily. Explaining the procedure is the surgeon's responsibility.
A nurse is assessing a client with fluid volume deficit. Which finding should the nurse expect?
A. Distended neck veins.
B. Bounding peripheral pulses.
C. Increased hematocrit levels.
D. Decreased serum osmolality.
🟢C
🔴 RATIONALE: In fluid volume deficit (dehydration), the plasma volume decreases, causing hemoconcentration, which results in
elevated hematocrit levels.
Which nursing action is appropriate when providing care to a client who requires a sterile dressing change?
A. Keep the sterile field below waist level.
B. Open the outermost flap of the sterile kit toward the body.
C. Use sterile gloves to touch the inside of the sterile drape.
D. Avoid talking across the sterile field.
🟢D
🔴 RATIONALE: Speaking across a sterile field introduces microorganisms from the respiratory tract, contaminating the field.
A nurse is caring for an older adult client who is at risk for falls. Which intervention is the highest priority?
A. Keep the bed in the lowest position.
B. Encourage the use of non-slip socks.
C. Perform a fall risk assessment on admission.
D. Keep the call light within reach.
🟢C
,🔴 RATIONALE: Identifying the risk through a standardized assessment is the foundational step that dictates the implementation of
specific fall prevention interventions.
A client asks the nurse about the purpose of an advance directive. Which response is most accurate?
A. It allows the family to make all medical decisions.
B. It provides a legal document outlining the client's wishes for end-of-life care.
C. It ensures the client will not receive any painful procedures.
D. It is only required for clients over the age of 80.
🟢B
🔴 RATIONALE: Advance directives, such as a living will or durable power of attorney for health care, legally express a person's
preferences regarding medical treatment if they become incapacitated.
A nurse is preparing to administer medication via a nasogastric tube. Which action is correct?
A. Crush enteric-coated tablets for administration.
B. Aspirate stomach contents to check for placement before flushing.
C. Administer all medications mixed together in one syringe.
D. Flush the tube with 50 mL of water after medication administration.
🟢B
🔴 RATIONALE: Verifying tube placement by aspirating gastric contents and checking pH is a standard safety measure before
administering any medication via an NG tube.
Which client is most at risk for developing a pressure ulcer?
A. A client who is mobile and eats a high-protein diet.
B. A client with fecal incontinence and limited mobility.
C. A client with a BMI of 25 who walks daily.
D. A client who is well-hydrated and cognitively intact.
🟢B
🔴 RATIONALE: Moisture from incontinence macerates the skin, and limited mobility prevents pressure relief, both of which are major
risk factors for pressure ulcer development.
A nurse is teaching a client how to use a cane. Which instruction should be included?
A. Hold the cane on the affected side.
B. Advance the cane and the affected leg simultaneously.
C. Keep the cane at least 12 inches away from the foot.
D. Ensure the elbow is flexed at a 45-degree angle.
🟢B
, 🔴 RATIONALE: When using a cane, the device should be held on the unaffected (stronger) side, and the cane and the weaker leg
should advance together for stability.
A nurse identifies a medication error. What is the first action the nurse should take?
A. Complete an incident report.
B. Notify the nurse manager.
C. Assess the client’s condition.
D. Call the prescribing physician.
🟢C
🔴 RATIONALE: Patient safety is the priority; the nurse must first assess the client for any adverse effects resulting from the
medication error.
A client is experiencing tachycardia and tachypnea. Which stage of General Adaptation Syndrome (GAS) is the client likely in?
A. Alarm.
B. Resistance.
C. Exhaustion.
D. Recovery.
🟢A
🔴 RATIONALE: During the alarm stage of GAS, the body activates the sympathetic nervous system, resulting in the "fight or flight"
response, characterized by increased heart and respiratory rates.
Which action by the nurse demonstrates proper use of body mechanics?
A. Keeping feet together when lifting an object.
B. Twisting the trunk while moving a heavy load.
C. Using the muscles of the back to lift heavy objects.
D. Flexing the hips and knees when lifting.
🟢D
🔴 RATIONALE: Flexing the hips and knees lowers the center of gravity and utilizes the stronger leg muscles rather than the weaker
back muscles, preventing injury.
A nurse is caring for a client with a BMI of 32. Which finding would support a diagnosis of obesity?
A. Serum albumin of 4.0 g/dL.
B. Waist circumference of 42 inches in a male.
C. Blood glucose level of 90 mg/dL.
D. Respiratory rate of 16 breaths/min.
🟢B
ANSWERS) PLUS RATIONALES 2026 Q&A |LATEST EXAM UPDATE 2026/2027.
Section One: Questions 1–100
A nurse is caring for a client who is preoperative. Which action is the most important responsibility of the nurse when obtaining
informed consent?
A. Explaining the risks and benefits of the surgery to the client.
B. Witnessing the client’s signature on the consent form.
C. Determining if the client is capable of understanding the procedure.
D. Ensuring the surgeon has explained the procedure to the client.
🟢B
🔴 RATIONALE: The nurse's primary role in informed consent is to act as a witness to the signature, verifying that the client is
competent and signed voluntarily. Explaining the procedure is the surgeon's responsibility.
A nurse is assessing a client with fluid volume deficit. Which finding should the nurse expect?
A. Distended neck veins.
B. Bounding peripheral pulses.
C. Increased hematocrit levels.
D. Decreased serum osmolality.
🟢C
🔴 RATIONALE: In fluid volume deficit (dehydration), the plasma volume decreases, causing hemoconcentration, which results in
elevated hematocrit levels.
Which nursing action is appropriate when providing care to a client who requires a sterile dressing change?
A. Keep the sterile field below waist level.
B. Open the outermost flap of the sterile kit toward the body.
C. Use sterile gloves to touch the inside of the sterile drape.
D. Avoid talking across the sterile field.
🟢D
🔴 RATIONALE: Speaking across a sterile field introduces microorganisms from the respiratory tract, contaminating the field.
A nurse is caring for an older adult client who is at risk for falls. Which intervention is the highest priority?
A. Keep the bed in the lowest position.
B. Encourage the use of non-slip socks.
C. Perform a fall risk assessment on admission.
D. Keep the call light within reach.
🟢C
,🔴 RATIONALE: Identifying the risk through a standardized assessment is the foundational step that dictates the implementation of
specific fall prevention interventions.
A client asks the nurse about the purpose of an advance directive. Which response is most accurate?
A. It allows the family to make all medical decisions.
B. It provides a legal document outlining the client's wishes for end-of-life care.
C. It ensures the client will not receive any painful procedures.
D. It is only required for clients over the age of 80.
🟢B
🔴 RATIONALE: Advance directives, such as a living will or durable power of attorney for health care, legally express a person's
preferences regarding medical treatment if they become incapacitated.
A nurse is preparing to administer medication via a nasogastric tube. Which action is correct?
A. Crush enteric-coated tablets for administration.
B. Aspirate stomach contents to check for placement before flushing.
C. Administer all medications mixed together in one syringe.
D. Flush the tube with 50 mL of water after medication administration.
🟢B
🔴 RATIONALE: Verifying tube placement by aspirating gastric contents and checking pH is a standard safety measure before
administering any medication via an NG tube.
Which client is most at risk for developing a pressure ulcer?
A. A client who is mobile and eats a high-protein diet.
B. A client with fecal incontinence and limited mobility.
C. A client with a BMI of 25 who walks daily.
D. A client who is well-hydrated and cognitively intact.
🟢B
🔴 RATIONALE: Moisture from incontinence macerates the skin, and limited mobility prevents pressure relief, both of which are major
risk factors for pressure ulcer development.
A nurse is teaching a client how to use a cane. Which instruction should be included?
A. Hold the cane on the affected side.
B. Advance the cane and the affected leg simultaneously.
C. Keep the cane at least 12 inches away from the foot.
D. Ensure the elbow is flexed at a 45-degree angle.
🟢B
, 🔴 RATIONALE: When using a cane, the device should be held on the unaffected (stronger) side, and the cane and the weaker leg
should advance together for stability.
A nurse identifies a medication error. What is the first action the nurse should take?
A. Complete an incident report.
B. Notify the nurse manager.
C. Assess the client’s condition.
D. Call the prescribing physician.
🟢C
🔴 RATIONALE: Patient safety is the priority; the nurse must first assess the client for any adverse effects resulting from the
medication error.
A client is experiencing tachycardia and tachypnea. Which stage of General Adaptation Syndrome (GAS) is the client likely in?
A. Alarm.
B. Resistance.
C. Exhaustion.
D. Recovery.
🟢A
🔴 RATIONALE: During the alarm stage of GAS, the body activates the sympathetic nervous system, resulting in the "fight or flight"
response, characterized by increased heart and respiratory rates.
Which action by the nurse demonstrates proper use of body mechanics?
A. Keeping feet together when lifting an object.
B. Twisting the trunk while moving a heavy load.
C. Using the muscles of the back to lift heavy objects.
D. Flexing the hips and knees when lifting.
🟢D
🔴 RATIONALE: Flexing the hips and knees lowers the center of gravity and utilizes the stronger leg muscles rather than the weaker
back muscles, preventing injury.
A nurse is caring for a client with a BMI of 32. Which finding would support a diagnosis of obesity?
A. Serum albumin of 4.0 g/dL.
B. Waist circumference of 42 inches in a male.
C. Blood glucose level of 90 mg/dL.
D. Respiratory rate of 16 breaths/min.
🟢B
