BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V2 (Latest Update 2026/2027)
OBJECTIVE ASSESSMENT - EXAM
BSN 225 HESI RN Specialty
Fundamentals of Nursing Exam V2
QUESTIONS VERIFIED ANSWERS EDITION PASSING SCORE
75 100% 2026/2027 80%
TOPICS COVERED
* Nursing Process & Clinical Decision-Making * Health Assessment & Vital Signs
* Patient Safety & Infection Control * Therapeutic Communication & Patient Education
* Medication Administration & Pharmacology
COVER PAGE - 1
, Section 1: Nursing Process & Clinical Decision-Making Section 1 of 5
QUESTION 1
A 68-year-old patient with chronic heart failure is admitted to the medical-surgical unit with worsening
dyspnea and peripheral edema. During the initial assessment, the nurse collects subjective data from the
patient, including reports of fatigue and anxiety about managing medications at home. Which phase of
the nursing process is the nurse primarily engaged in when gathering this subjective and objective
patient information?
A. Diagnosis
B. Assessment
C. Planning
D. Evaluation
Correct Answer: B
Rationale:
Assessment is the first phase of the nursing process and involves systematic collection of subjective (patient-reported) and
objective (observable/measurable) data. Diagnosis involves analyzing assessment data to identify patient problems, while
planning establishes goals and interventions.
QUESTION 2
A postoperative patient who underwent abdominal surgery 24 hours ago reports pain rated 8/10 and
exhibits guarding behavior when the nurse palpates the incision site. The nurse documents 'Acute Pain
related to surgical incision as evidenced by verbal report of 8/10 pain and protective guarding behavior.'
Which type of nursing statement does this documentation represent?
A. A nursing goal statement
B. A PES-format nursing diagnosis
C. An implementation note
D. An evaluation summary
Correct Answer: B
Rationale:
A PES-format nursing diagnosis includes the Problem (Acute Pain), Etiology (related to surgical incision), and
Signs/Symptoms (evidenced by verbal report and guarding). Nursing goals describe desired outcomes, implementation notes
document actions taken, and evaluation summaries assess goal achievement.
QUESTION 3
A nurse is caring for a newly diagnosed diabetic patient who needs to learn how to self-administer insulin
before discharge. The nurse establishes the goal that the patient will independently demonstrate insulin
self-administration with 100% accuracy within three days. Which phase of the nursing process involves
setting measurable, patient-centered goals and expected outcomes?
A. Assessment
B. Diagnosis
C. Planning
, D. Implementation
Correct Answer: C
Rationale:
Planning is the nursing process phase where measurable, patient-centered goals and expected outcomes are established to
guide care. Assessment involves data collection, diagnosis identifies patient problems, and implementation involves carrying
out planned nursing interventions.
QUESTION 4
A patient with pneumonia has a nursing diagnosis of 'Ineffective Airway Clearance related to excessive
secretions.' The nurse performs chest percussion, positions the patient in semi-Fowler's, and encourages
deep breathing exercises every two hours. Which phase of the nursing process is the nurse actively
performing when carrying out these planned interventions?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Correct Answer: C
Rationale:
Implementation is the nursing process phase where the nurse carries out planned interventions to achieve established goals.
Assessment involves data gathering, planning involves setting goals, and evaluation determines whether goals were met after
interventions are implemented.
QUESTION 5
A nurse evaluates a patient's progress three days after initiating a plan of care for impaired mobility. The
patient can now ambulate 50 feet with a walker independently, exceeding the original goal of 30 feet with
assistance. The nurse documents that the goal has been exceeded and revises the plan to increase the
distance. Which phase of the nursing process is the nurse completing?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Correct Answer: D
Rationale:
Evaluation is the nursing process phase where the nurse determines whether goals and expected outcomes have been met,
partially met, or not met, and revises the care plan accordingly. The nurse is measuring outcomes against established goals
and adjusting the plan based on results.
QUESTION 6
A 45-year-old patient admitted with acute appendicitis develops a fever of 101.8F, tachycardia of 112 bpm,
and reports increasing abdominal pain 8 hours post-surgery. The nurse recognizes these findings as
signs of a potential surgical complication and immediately notifies the surgeon. Which critical thinking
component involves recognizing significant changes in patient status and taking appropriate action?
OBJECTIVE ASSESSMENT - EXAM
BSN 225 HESI RN Specialty
Fundamentals of Nursing Exam V2
QUESTIONS VERIFIED ANSWERS EDITION PASSING SCORE
75 100% 2026/2027 80%
TOPICS COVERED
* Nursing Process & Clinical Decision-Making * Health Assessment & Vital Signs
* Patient Safety & Infection Control * Therapeutic Communication & Patient Education
* Medication Administration & Pharmacology
COVER PAGE - 1
, Section 1: Nursing Process & Clinical Decision-Making Section 1 of 5
QUESTION 1
A 68-year-old patient with chronic heart failure is admitted to the medical-surgical unit with worsening
dyspnea and peripheral edema. During the initial assessment, the nurse collects subjective data from the
patient, including reports of fatigue and anxiety about managing medications at home. Which phase of
the nursing process is the nurse primarily engaged in when gathering this subjective and objective
patient information?
A. Diagnosis
B. Assessment
C. Planning
D. Evaluation
Correct Answer: B
Rationale:
Assessment is the first phase of the nursing process and involves systematic collection of subjective (patient-reported) and
objective (observable/measurable) data. Diagnosis involves analyzing assessment data to identify patient problems, while
planning establishes goals and interventions.
QUESTION 2
A postoperative patient who underwent abdominal surgery 24 hours ago reports pain rated 8/10 and
exhibits guarding behavior when the nurse palpates the incision site. The nurse documents 'Acute Pain
related to surgical incision as evidenced by verbal report of 8/10 pain and protective guarding behavior.'
Which type of nursing statement does this documentation represent?
A. A nursing goal statement
B. A PES-format nursing diagnosis
C. An implementation note
D. An evaluation summary
Correct Answer: B
Rationale:
A PES-format nursing diagnosis includes the Problem (Acute Pain), Etiology (related to surgical incision), and
Signs/Symptoms (evidenced by verbal report and guarding). Nursing goals describe desired outcomes, implementation notes
document actions taken, and evaluation summaries assess goal achievement.
QUESTION 3
A nurse is caring for a newly diagnosed diabetic patient who needs to learn how to self-administer insulin
before discharge. The nurse establishes the goal that the patient will independently demonstrate insulin
self-administration with 100% accuracy within three days. Which phase of the nursing process involves
setting measurable, patient-centered goals and expected outcomes?
A. Assessment
B. Diagnosis
C. Planning
, D. Implementation
Correct Answer: C
Rationale:
Planning is the nursing process phase where measurable, patient-centered goals and expected outcomes are established to
guide care. Assessment involves data collection, diagnosis identifies patient problems, and implementation involves carrying
out planned nursing interventions.
QUESTION 4
A patient with pneumonia has a nursing diagnosis of 'Ineffective Airway Clearance related to excessive
secretions.' The nurse performs chest percussion, positions the patient in semi-Fowler's, and encourages
deep breathing exercises every two hours. Which phase of the nursing process is the nurse actively
performing when carrying out these planned interventions?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Correct Answer: C
Rationale:
Implementation is the nursing process phase where the nurse carries out planned interventions to achieve established goals.
Assessment involves data gathering, planning involves setting goals, and evaluation determines whether goals were met after
interventions are implemented.
QUESTION 5
A nurse evaluates a patient's progress three days after initiating a plan of care for impaired mobility. The
patient can now ambulate 50 feet with a walker independently, exceeding the original goal of 30 feet with
assistance. The nurse documents that the goal has been exceeded and revises the plan to increase the
distance. Which phase of the nursing process is the nurse completing?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Correct Answer: D
Rationale:
Evaluation is the nursing process phase where the nurse determines whether goals and expected outcomes have been met,
partially met, or not met, and revises the care plan accordingly. The nurse is measuring outcomes against established goals
and adjusting the plan based on results.
QUESTION 6
A 45-year-old patient admitted with acute appendicitis develops a fever of 101.8F, tachycardia of 112 bpm,
and reports increasing abdominal pain 8 hours post-surgery. The nurse recognizes these findings as
signs of a potential surgical complication and immediately notifies the surgeon. Which critical thinking
component involves recognizing significant changes in patient status and taking appropriate action?
