BSN HESI 225 Fundamentals of Nursing Exam Actual
2025/2026 with Detailed Rationales | 100% Verified |
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Section 1: Foundations of Nursing Practice (12 Questions)
Q1: A nurse is caring for four clients. Which client should the nurse assess first?
A. A client requesting a sleeping pill
B. A client with a respiratory rate of 28 breaths/min and oxygen saturation of 88%
C. A client with a scheduled wound dressing change in 30 minutes
D. A client who needs discharge teaching before leaving at noon
Correct Answer: B
Rationale: Correct because the client with tachypnea and hypoxemia has
compromised airway and breathing, which are the highest priority using the ABC
approach.
Q2: A nurse is implementing the nursing process for a client with newly diagnosed
diabetes. Which step involves setting measurable goals with the client?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Correct Answer: C
Rationale: Correct because the planning phase of the nursing process involves
establishing measurable, achievable goals and expected outcomes collaboratively
with the client.
Q3: A client asks the nurse to explain the difference between a medical diagnosis
and a nursing diagnosis. Which response by the nurse is most accurate?
A. "A medical diagnosis identifies the disease, while a nursing diagnosis describes
the client's response to the disease."
B. "A medical diagnosis is made by nurses, and a nursing diagnosis is made by
physicians."
C. "There is no difference; both terms mean the same thing."
,D. "A nursing diagnosis identifies the disease, and a medical diagnosis describes the
treatment plan."
Correct Answer: A
Rationale: Correct because a medical diagnosis identifies a disease or pathological
condition, whereas a nursing diagnosis describes the client's human response to
health conditions or life processes.
Q4: A nurse is caring for a client who refuses a blood transfusion based on religious
beliefs. What is the nurse's legal and ethical obligation?
A. Administer the transfusion because the physician's order takes precedence
B. Support the client's right to refuse treatment and document the refusal
C. Obtain a court order to override the client's refusal
D. Ask the family to consent on the client's behalf
Correct Answer: B
Rationale: Correct because competent adults have the legal right to refuse
treatment; the nurse must advocate for client autonomy while ensuring informed
refusal is documented.
Q5: A nurse is using critical thinking to prioritize client care. Which factor is most
important when applying Maslow's hierarchy of needs?
A. Psychosocial needs always take priority over physiological needs
B. Physiological needs must be met before higher-level needs can be addressed
C. Self-actualization needs are the most urgent in acute care settings
D. Safety needs are less important than love and belonging needs
Correct Answer: B
Rationale: Correct because Maslow's hierarchy prioritizes physiological needs such
as airway, breathing, and circulation as the foundation; these must be addressed
before higher-level needs.
Q6: A nurse is reviewing a client's advance directive. Which action demonstrates the
nurse's understanding of this legal document?
A. Ignoring the advance directive if the family disagrees with it
B. Ensuring the client's documented wishes are communicated to the healthcare
team
C. Modifying the advance directive based on the nurse's clinical judgment
D. Storing the advance directive in the client's home without placing a copy in the
medical record
Correct Answer: B
, Rationale: Correct because advance directives are legal documents that express the
client's wishes; the nurse's role is to ensure these wishes are known and honored by
the healthcare team.
Q7: A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task
is appropriate to delegate?
A. Administering oral medications to a stable client
B. Assessing a postoperative client's incision for signs of infection
C. Assisting a client with ambulation to the bathroom
D. Teaching a newly diagnosed diabetic client about insulin administration
Correct Answer: C
Rationale: Correct because assisting with ambulation is within the UAP's scope of
practice; medication administration, assessments, and client education require
licensed nursing judgment.
Q8: A nurse discovers that a colleague has documented vital signs for a client
without actually assessing them. What is the nurse's first action?
A. Confront the colleague in front of the nursing team
B. Report the incident to the state board of nursing immediately
C. Discuss the concern with the colleague privately and report to the charge nurse if
the behavior continues
D. Document the observation in the client's medical record
Correct Answer: C
Rationale: Correct because the nurse should first address the colleague directly
using professional communication; if the behavior persists, it must be escalated to
protect client safety.
Q9: A nurse is participating in a root cause analysis after a medication error. What is
the primary purpose of this analysis?
A. To identify the nurse responsible and assign disciplinary action
B. To determine system failures and implement changes to prevent recurrence
C. To document the error for legal proceedings
D. To report the incident to the state board of nursing
Correct Answer: B
Rationale: Correct because root cause analysis focuses on identifying systemic
issues rather than individual blame to improve safety and prevent future errors.
2025/2026 with Detailed Rationales | 100% Verified |
Pass Guaranteed – A+ Graded
Section 1: Foundations of Nursing Practice (12 Questions)
Q1: A nurse is caring for four clients. Which client should the nurse assess first?
A. A client requesting a sleeping pill
B. A client with a respiratory rate of 28 breaths/min and oxygen saturation of 88%
C. A client with a scheduled wound dressing change in 30 minutes
D. A client who needs discharge teaching before leaving at noon
Correct Answer: B
Rationale: Correct because the client with tachypnea and hypoxemia has
compromised airway and breathing, which are the highest priority using the ABC
approach.
Q2: A nurse is implementing the nursing process for a client with newly diagnosed
diabetes. Which step involves setting measurable goals with the client?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Correct Answer: C
Rationale: Correct because the planning phase of the nursing process involves
establishing measurable, achievable goals and expected outcomes collaboratively
with the client.
Q3: A client asks the nurse to explain the difference between a medical diagnosis
and a nursing diagnosis. Which response by the nurse is most accurate?
A. "A medical diagnosis identifies the disease, while a nursing diagnosis describes
the client's response to the disease."
B. "A medical diagnosis is made by nurses, and a nursing diagnosis is made by
physicians."
C. "There is no difference; both terms mean the same thing."
,D. "A nursing diagnosis identifies the disease, and a medical diagnosis describes the
treatment plan."
Correct Answer: A
Rationale: Correct because a medical diagnosis identifies a disease or pathological
condition, whereas a nursing diagnosis describes the client's human response to
health conditions or life processes.
Q4: A nurse is caring for a client who refuses a blood transfusion based on religious
beliefs. What is the nurse's legal and ethical obligation?
A. Administer the transfusion because the physician's order takes precedence
B. Support the client's right to refuse treatment and document the refusal
C. Obtain a court order to override the client's refusal
D. Ask the family to consent on the client's behalf
Correct Answer: B
Rationale: Correct because competent adults have the legal right to refuse
treatment; the nurse must advocate for client autonomy while ensuring informed
refusal is documented.
Q5: A nurse is using critical thinking to prioritize client care. Which factor is most
important when applying Maslow's hierarchy of needs?
A. Psychosocial needs always take priority over physiological needs
B. Physiological needs must be met before higher-level needs can be addressed
C. Self-actualization needs are the most urgent in acute care settings
D. Safety needs are less important than love and belonging needs
Correct Answer: B
Rationale: Correct because Maslow's hierarchy prioritizes physiological needs such
as airway, breathing, and circulation as the foundation; these must be addressed
before higher-level needs.
Q6: A nurse is reviewing a client's advance directive. Which action demonstrates the
nurse's understanding of this legal document?
A. Ignoring the advance directive if the family disagrees with it
B. Ensuring the client's documented wishes are communicated to the healthcare
team
C. Modifying the advance directive based on the nurse's clinical judgment
D. Storing the advance directive in the client's home without placing a copy in the
medical record
Correct Answer: B
, Rationale: Correct because advance directives are legal documents that express the
client's wishes; the nurse's role is to ensure these wishes are known and honored by
the healthcare team.
Q7: A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task
is appropriate to delegate?
A. Administering oral medications to a stable client
B. Assessing a postoperative client's incision for signs of infection
C. Assisting a client with ambulation to the bathroom
D. Teaching a newly diagnosed diabetic client about insulin administration
Correct Answer: C
Rationale: Correct because assisting with ambulation is within the UAP's scope of
practice; medication administration, assessments, and client education require
licensed nursing judgment.
Q8: A nurse discovers that a colleague has documented vital signs for a client
without actually assessing them. What is the nurse's first action?
A. Confront the colleague in front of the nursing team
B. Report the incident to the state board of nursing immediately
C. Discuss the concern with the colleague privately and report to the charge nurse if
the behavior continues
D. Document the observation in the client's medical record
Correct Answer: C
Rationale: Correct because the nurse should first address the colleague directly
using professional communication; if the behavior persists, it must be escalated to
protect client safety.
Q9: A nurse is participating in a root cause analysis after a medication error. What is
the primary purpose of this analysis?
A. To identify the nurse responsible and assign disciplinary action
B. To determine system failures and implement changes to prevent recurrence
C. To document the error for legal proceedings
D. To report the incident to the state board of nursing
Correct Answer: B
Rationale: Correct because root cause analysis focuses on identifying systemic
issues rather than individual blame to improve safety and prevent future errors.
