BSN 225 HESI RN Specialty
Fundamentals of Nursing Exam V3
Latest Update 2026/2027 | 100% Correct | Grade A - Nightingale
Aligned with 2026-2027 HESI Fundamentals Examination Standards, NCLEX-RN Test Plan, and
Nightingale College BSN Curriculum Competencies
100 Questions | Comprehensive Rationales with Clinical Reasoning
Format Multiple Choice (A-D), One Correct Answer
Cognitive Levels 30% Recall, 50% Application, 20% Analysis
Questions 75% Scenario-Based, 20% Direct Recall, 5% Clinical Analysis
Section 1: Safe, Effective Care Environment (Management of
Care, Safety & Infection Control)
Q1: The nurse is preparing to obtain informed consent from a client scheduled
for a colonoscopy. Which action should the nurse take?
A. Explain the procedure, risks, benefits, and alternatives to the client
B. Witness the client's signature and confirm the client understands the
procedure [CORRECT]
C. Contact the family member to obtain verbal consent on behalf of the client
D. Provide written materials about the procedure and leave the room
Correct Answer: B
Rationale: The nurse's role in informed consent is to witness the client's signature and verify that the client understands what
was explained by the provider, not to perform the actual explanation of the procedure. The provider is responsible for
explaining the procedure, risks, benefits, and alternatives. Contacting a family member for verbal consent is inappropriate
unless the client lacks decision-making capacity, and merely leaving written materials does not constitute adequate informed
consent verification.
Q2: A client with a history of seizures is admitted to the nursing unit. Which
intervention is the highest priority for the nurse to implement?
A. Place the bed in the highest position to facilitate visualization
B. Pad the side rails and keep suction equipment at the bedside [CORRECT]
C. Restrict the client's fluid intake to prevent aspiration during a seizure
D. Apply soft wrist restraints as a preventive measure
Correct Answer: B
Rationale: Seizure precautions include padding the side rails to prevent injury, keeping suction and oxygen equipment at the
bedside for airway management, and having an airway adjunct available. The bed should be in the lowest position, not the
, BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V3 (2026/2027)
highest, to reduce fall risk. Restricting fluids is not indicated for seizure precautions, and restraints should never be applied
prophylactically as they violate client rights and are not a standard seizure precaution.
Q3: The charge nurse is making client assignments for the shift. Which task is
most appropriate to delegate to an unlicensed assistive personnel (UAP)?
A. Assess a postoperative client's incision for signs of infection
B. Administer oral medications to a stable client with hypertension
C. Measure and record intake and output for a client with heart failure
[CORRECT]
D. Teach a newly diagnosed diabetic client about insulin injection technique
Correct Answer: C
Rationale: Measuring and recording intake and output is within the scope of practice for UAP, as it involves basic data
collection and documentation. Assessment of a surgical incision requires nursing judgment and clinical evaluation skills that
are within the RN scope. Medication administration, even oral medications, requires nursing knowledge and is within the RN
or LPN scope depending on state regulations. Client teaching requires assessment of learning needs and evaluation of
understanding, which are RN-level responsibilities.
Q4: A client has a Durable Power of Attorney for Health Care (DPOA-HC) in
place. The client becomes unresponsive following a stroke, and the family
disagrees about the treatment plan. What should the nurse do?
A. Follow the instructions of the DPOA-HC designee for health care decisions
[CORRECT]
B. Ask the physician to make the final treatment decision for the family
C. Request an ethics committee consultation to resolve the dispute
D. Follow the wishes of the majority of family members present
Correct Answer: A
Rationale: When a client has a DPOA-HC and becomes unable to make decisions, the legally designated agent has the
authority to make health care decisions on the client's behalf. The nurse should follow the instructions of the DPOA-HC
designee. While an ethics committee consultation may be helpful in complex situations, the DPOA-HC designee has legal
authority. The physician does not make decisions for the family, and majority family opinion does not supersede a legal
advance directive.
Q5: A fire is discovered in the medication room of the nursing unit. Using the
RACE protocol, what is the nurse's first action?
A. Confine the fire by closing all doors and windows on the unit
B. Extinguish the fire using the nearest fire extinguisher
C. Rescue clients in immediate danger by moving them to safety [CORRECT]
D. Activate the fire alarm system and notify the switchboard
Correct Answer: C
Rationale: The RACE protocol stands for Rescue, Alarm, Confine, and Extinguish/Evacuate. The first priority is always to
rescue and remove clients in immediate danger, following the ABCs of safety. After rescuing clients, the nurse should activate
the alarm (A), then confine the fire by closing doors (C), and only then attempt to extinguish the fire (E) if it is safe to do so.
This sequence ensures human life is protected before property.
Q6: A nurse is caring for a client diagnosed with Clostridioides difficile (C. diff)
infection. Which type of transmission-based precautions should the nurse
implement?
Page 2
, BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V3 (2026/2027)
A. Airborne precautions including N95 respirator and negative pressure room
B. Droplet precautions including surgical mask within 3 feet of the client
C. Contact precautions including gown and gloves for all client interactions
[CORRECT]
D. Standard precautions only, as C. diff is not transmitted person-to-person
Correct Answer: C
Rationale: C. diff is transmitted through the fecal-oral route and requires contact precautions, which include wearing a gown
and gloves during all client interactions. Hand hygiene must be performed with soap and water rather than alcohol-based
hand rub, as C. diff spores are resistant to alcohol. Airborne precautions are for pathogens like TB and measles, while
droplet precautions are for infections like influenza and pertussis spread through respiratory droplets.
Q7: The nurse is preparing to administer a blood transfusion to a client. Which
action is most important to ensure client safety?
A. Pre-warm the blood product to body temperature before infusion
B. Verify the client's identity and blood product with another licensed nurse
[CORRECT]
C. Administer the transfusion within 2 hours of removing it from the blood bank
D. Obtain a prescription for pre-transfusion antihistamine medication
Correct Answer: B
Rationale: The most critical safety measure in blood transfusion administration is verifying the client's identity and the blood
product compatibility with another licensed nurse at the bedside. This double-check system prevents transfusion reactions
from ABO incompatibility, which can be fatal. Blood should be administered within 30 minutes of removal from the blood
bank and infused within 4 hours. Pre-warming is not routinely required, and pre-medication is not universally mandated.
Q8: A client who is competent and alert refuses to take a prescribed medication.
What is the nurse's best response?
A. Explain that the medication is legally required and document the refusal
B. Document the refusal, notify the provider, and explore the client's concerns
[CORRECT]
C. Administer the medication against the client's will to prevent harm
D. Contact the family to persuade the client to take the medication
Correct Answer: B
Rationale: Competent adults have the legal right to refuse treatment, including medications. The nurse should respect this
right, document the refusal thoroughly, notify the healthcare provider, and explore the client's reasons for refusing. This
approach respects client autonomy while ensuring the care team is informed. Coercing or forcing medication administration
on a competent client constitutes battery, and involving family to persuade the client undermines the client's right to
self-determination.
Q9: The nurse receives a telephone order from a physician for a new medication.
Which action is most appropriate?
A. Administer the medication immediately and document the order later
B. Write the order, read it back to the physician, and obtain the physician's
signature [CORRECT]
C. Ask the unit secretary to transcribe the order into the medical record
D. Refuse to accept the telephone order under any circumstances
Correct Answer: B
Page 3
, BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V3 (2026/2027)
Rationale: Telephone orders should be accepted only when necessary. The nurse should write the complete order, read it
back to the prescriber for verification (read-back verification), and then obtain the prescriber's signature within the facility's
specified timeframe. The order should never be administered before proper verification. Refusing all telephone orders is
impractical in emergency situations, and delegation of transcription does not eliminate the nurse's responsibility for verifying
accuracy.
Q10: A nurse is caring for a client who has been placed in bilateral soft wrist
restraints. Which intervention is required by regulation?
A. Remove restraints every 4 hours to assess circulation and skin integrity
B. Obtain a new physician order every 8 hours for continued restraint use
C. Document the client's behavior that necessitated restraint application
[CORRECT]
D. Ensure restraints are applied tightly to prevent the client from removing them
Correct Answer: C
Rationale: When restraints are applied, the nurse must document the clinical rationale, including the specific client behavior
that necessitated restraint use, alternative interventions attempted, and the type of restraint applied. For adults, restraints
must be released every 2 hours for range of motion, circulation assessment, toileting, and nutrition. A face-to-face physician
evaluation is required within 1 hour of initiation, and reassessment is required every 4 hours for adults. Restraints should
never be applied tightly, as this can cause injury and impair circulation.
Q11: The nurse observes a colleague arrive for the shift with slurred speech and
unsteady gait. What is the nurse's most appropriate action?
A. Confront the colleague directly and ask them to go home
B. Report the observation to the charge nurse or nursing supervisor immediately
[CORRECT]
C. Wait to see if the colleague's condition improves during the shift
D. Reassign the colleague to non-critical clients to minimize risk
Correct Answer: B
Rationale: Reporting an impaired nurse is a mandatory legal and ethical obligation. The nurse should report the observation
to the charge nurse or nursing supervisor immediately, as impaired practitioners pose a serious safety risk to clients. Direct
confrontation may cause defensive behavior or escalation. Waiting to observe further puts patients at risk, and reassigning to
non-critical clients does not address the underlying impairment or protect all patients adequately.
Q12: A client with active tuberculosis (TB) is admitted to the medical unit.
Which precautions are required for this client?
A. Contact precautions with gown and gloves for all interactions
B. Droplet precautions with a surgical mask within 3 feet of the client
C. Airborne precautions with N95 respirator and negative pressure room
[CORRECT]
D. Standard precautions with enhanced hand hygiene only
Correct Answer: C
Rationale: Tuberculosis is transmitted via airborne droplet nuclei that remain suspended in the air and requires airborne
precautions. This includes placement in a negative pressure room and use of an N95 respirator or higher-level respiratory
protection by healthcare personnel. Contact precautions are for pathogens like MRSA and C. diff spread by direct or indirect
contact. Droplet precautions with surgical masks are for infections like influenza spread by large respiratory droplets within
3 feet.
Page 4
Fundamentals of Nursing Exam V3
Latest Update 2026/2027 | 100% Correct | Grade A - Nightingale
Aligned with 2026-2027 HESI Fundamentals Examination Standards, NCLEX-RN Test Plan, and
Nightingale College BSN Curriculum Competencies
100 Questions | Comprehensive Rationales with Clinical Reasoning
Format Multiple Choice (A-D), One Correct Answer
Cognitive Levels 30% Recall, 50% Application, 20% Analysis
Questions 75% Scenario-Based, 20% Direct Recall, 5% Clinical Analysis
Section 1: Safe, Effective Care Environment (Management of
Care, Safety & Infection Control)
Q1: The nurse is preparing to obtain informed consent from a client scheduled
for a colonoscopy. Which action should the nurse take?
A. Explain the procedure, risks, benefits, and alternatives to the client
B. Witness the client's signature and confirm the client understands the
procedure [CORRECT]
C. Contact the family member to obtain verbal consent on behalf of the client
D. Provide written materials about the procedure and leave the room
Correct Answer: B
Rationale: The nurse's role in informed consent is to witness the client's signature and verify that the client understands what
was explained by the provider, not to perform the actual explanation of the procedure. The provider is responsible for
explaining the procedure, risks, benefits, and alternatives. Contacting a family member for verbal consent is inappropriate
unless the client lacks decision-making capacity, and merely leaving written materials does not constitute adequate informed
consent verification.
Q2: A client with a history of seizures is admitted to the nursing unit. Which
intervention is the highest priority for the nurse to implement?
A. Place the bed in the highest position to facilitate visualization
B. Pad the side rails and keep suction equipment at the bedside [CORRECT]
C. Restrict the client's fluid intake to prevent aspiration during a seizure
D. Apply soft wrist restraints as a preventive measure
Correct Answer: B
Rationale: Seizure precautions include padding the side rails to prevent injury, keeping suction and oxygen equipment at the
bedside for airway management, and having an airway adjunct available. The bed should be in the lowest position, not the
, BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V3 (2026/2027)
highest, to reduce fall risk. Restricting fluids is not indicated for seizure precautions, and restraints should never be applied
prophylactically as they violate client rights and are not a standard seizure precaution.
Q3: The charge nurse is making client assignments for the shift. Which task is
most appropriate to delegate to an unlicensed assistive personnel (UAP)?
A. Assess a postoperative client's incision for signs of infection
B. Administer oral medications to a stable client with hypertension
C. Measure and record intake and output for a client with heart failure
[CORRECT]
D. Teach a newly diagnosed diabetic client about insulin injection technique
Correct Answer: C
Rationale: Measuring and recording intake and output is within the scope of practice for UAP, as it involves basic data
collection and documentation. Assessment of a surgical incision requires nursing judgment and clinical evaluation skills that
are within the RN scope. Medication administration, even oral medications, requires nursing knowledge and is within the RN
or LPN scope depending on state regulations. Client teaching requires assessment of learning needs and evaluation of
understanding, which are RN-level responsibilities.
Q4: A client has a Durable Power of Attorney for Health Care (DPOA-HC) in
place. The client becomes unresponsive following a stroke, and the family
disagrees about the treatment plan. What should the nurse do?
A. Follow the instructions of the DPOA-HC designee for health care decisions
[CORRECT]
B. Ask the physician to make the final treatment decision for the family
C. Request an ethics committee consultation to resolve the dispute
D. Follow the wishes of the majority of family members present
Correct Answer: A
Rationale: When a client has a DPOA-HC and becomes unable to make decisions, the legally designated agent has the
authority to make health care decisions on the client's behalf. The nurse should follow the instructions of the DPOA-HC
designee. While an ethics committee consultation may be helpful in complex situations, the DPOA-HC designee has legal
authority. The physician does not make decisions for the family, and majority family opinion does not supersede a legal
advance directive.
Q5: A fire is discovered in the medication room of the nursing unit. Using the
RACE protocol, what is the nurse's first action?
A. Confine the fire by closing all doors and windows on the unit
B. Extinguish the fire using the nearest fire extinguisher
C. Rescue clients in immediate danger by moving them to safety [CORRECT]
D. Activate the fire alarm system and notify the switchboard
Correct Answer: C
Rationale: The RACE protocol stands for Rescue, Alarm, Confine, and Extinguish/Evacuate. The first priority is always to
rescue and remove clients in immediate danger, following the ABCs of safety. After rescuing clients, the nurse should activate
the alarm (A), then confine the fire by closing doors (C), and only then attempt to extinguish the fire (E) if it is safe to do so.
This sequence ensures human life is protected before property.
Q6: A nurse is caring for a client diagnosed with Clostridioides difficile (C. diff)
infection. Which type of transmission-based precautions should the nurse
implement?
Page 2
, BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V3 (2026/2027)
A. Airborne precautions including N95 respirator and negative pressure room
B. Droplet precautions including surgical mask within 3 feet of the client
C. Contact precautions including gown and gloves for all client interactions
[CORRECT]
D. Standard precautions only, as C. diff is not transmitted person-to-person
Correct Answer: C
Rationale: C. diff is transmitted through the fecal-oral route and requires contact precautions, which include wearing a gown
and gloves during all client interactions. Hand hygiene must be performed with soap and water rather than alcohol-based
hand rub, as C. diff spores are resistant to alcohol. Airborne precautions are for pathogens like TB and measles, while
droplet precautions are for infections like influenza and pertussis spread through respiratory droplets.
Q7: The nurse is preparing to administer a blood transfusion to a client. Which
action is most important to ensure client safety?
A. Pre-warm the blood product to body temperature before infusion
B. Verify the client's identity and blood product with another licensed nurse
[CORRECT]
C. Administer the transfusion within 2 hours of removing it from the blood bank
D. Obtain a prescription for pre-transfusion antihistamine medication
Correct Answer: B
Rationale: The most critical safety measure in blood transfusion administration is verifying the client's identity and the blood
product compatibility with another licensed nurse at the bedside. This double-check system prevents transfusion reactions
from ABO incompatibility, which can be fatal. Blood should be administered within 30 minutes of removal from the blood
bank and infused within 4 hours. Pre-warming is not routinely required, and pre-medication is not universally mandated.
Q8: A client who is competent and alert refuses to take a prescribed medication.
What is the nurse's best response?
A. Explain that the medication is legally required and document the refusal
B. Document the refusal, notify the provider, and explore the client's concerns
[CORRECT]
C. Administer the medication against the client's will to prevent harm
D. Contact the family to persuade the client to take the medication
Correct Answer: B
Rationale: Competent adults have the legal right to refuse treatment, including medications. The nurse should respect this
right, document the refusal thoroughly, notify the healthcare provider, and explore the client's reasons for refusing. This
approach respects client autonomy while ensuring the care team is informed. Coercing or forcing medication administration
on a competent client constitutes battery, and involving family to persuade the client undermines the client's right to
self-determination.
Q9: The nurse receives a telephone order from a physician for a new medication.
Which action is most appropriate?
A. Administer the medication immediately and document the order later
B. Write the order, read it back to the physician, and obtain the physician's
signature [CORRECT]
C. Ask the unit secretary to transcribe the order into the medical record
D. Refuse to accept the telephone order under any circumstances
Correct Answer: B
Page 3
, BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V3 (2026/2027)
Rationale: Telephone orders should be accepted only when necessary. The nurse should write the complete order, read it
back to the prescriber for verification (read-back verification), and then obtain the prescriber's signature within the facility's
specified timeframe. The order should never be administered before proper verification. Refusing all telephone orders is
impractical in emergency situations, and delegation of transcription does not eliminate the nurse's responsibility for verifying
accuracy.
Q10: A nurse is caring for a client who has been placed in bilateral soft wrist
restraints. Which intervention is required by regulation?
A. Remove restraints every 4 hours to assess circulation and skin integrity
B. Obtain a new physician order every 8 hours for continued restraint use
C. Document the client's behavior that necessitated restraint application
[CORRECT]
D. Ensure restraints are applied tightly to prevent the client from removing them
Correct Answer: C
Rationale: When restraints are applied, the nurse must document the clinical rationale, including the specific client behavior
that necessitated restraint use, alternative interventions attempted, and the type of restraint applied. For adults, restraints
must be released every 2 hours for range of motion, circulation assessment, toileting, and nutrition. A face-to-face physician
evaluation is required within 1 hour of initiation, and reassessment is required every 4 hours for adults. Restraints should
never be applied tightly, as this can cause injury and impair circulation.
Q11: The nurse observes a colleague arrive for the shift with slurred speech and
unsteady gait. What is the nurse's most appropriate action?
A. Confront the colleague directly and ask them to go home
B. Report the observation to the charge nurse or nursing supervisor immediately
[CORRECT]
C. Wait to see if the colleague's condition improves during the shift
D. Reassign the colleague to non-critical clients to minimize risk
Correct Answer: B
Rationale: Reporting an impaired nurse is a mandatory legal and ethical obligation. The nurse should report the observation
to the charge nurse or nursing supervisor immediately, as impaired practitioners pose a serious safety risk to clients. Direct
confrontation may cause defensive behavior or escalation. Waiting to observe further puts patients at risk, and reassigning to
non-critical clients does not address the underlying impairment or protect all patients adequately.
Q12: A client with active tuberculosis (TB) is admitted to the medical unit.
Which precautions are required for this client?
A. Contact precautions with gown and gloves for all interactions
B. Droplet precautions with a surgical mask within 3 feet of the client
C. Airborne precautions with N95 respirator and negative pressure room
[CORRECT]
D. Standard precautions with enhanced hand hygiene only
Correct Answer: C
Rationale: Tuberculosis is transmitted via airborne droplet nuclei that remain suspended in the air and requires airborne
precautions. This includes placement in a negative pressure room and use of an N95 respirator or higher-level respiratory
protection by healthcare personnel. Contact precautions are for pathogens like MRSA and C. diff spread by direct or indirect
contact. Droplet precautions with surgical masks are for infections like influenza spread by large respiratory droplets within
3 feet.
Page 4
