BSN 225 HESI Fundamentals of
Nursing Exam V1 Actual Exam
2026/2027 – 100% Verified | Detailed
Rationales – Pass Guaranteed – A+
Graded
1. What is the first step of the nursing process?
A. Planning
B. Implementation
C. Assessment
D. Evaluation
Answer: C. Assessment
Rationale: Assessment is the foundational first step where the nurse
collects comprehensive data about the patient's health status, which is
necessary before any planning or intervention can occur.
2. A hospitalized client with an NG tube vomits and appears to be
choking. What should the nurse do first?
A. Elevate the head of the bed to 90 degrees
B. Perform oropharyngeal suctioning
C. Stop the enteral feeding and flush the tube
D. Call the rapid response team
Answer: B. Perform oropharyngeal suctioning
Rationale: The priority is to clear the airway to prevent aspiration.
Suctioning removes the vomitus from the airway immediately, which is the
most urgent action.
3. The nurse observes a UAP securing wrist restraints to the bed side
rails. What action is most important?
,A. Remove the restraints and reapply them to the bed frame.
B. Document the UAP's incorrect application technique.
C. Report the UAP's action to the charge nurse.
D. In-service the UAP on the proper application of restraints.
Answer: A. Remove the restraints and reapply them to the bed frame.
Rationale: Restraints must never be attached to side rails, as this can cause
injury if the rails are moved. They must be tied to a part of the bed frame
that moves with the client.
4. To assess the quality of an adult client's pain, which approach
should the nurse use?
A. Ask the client to rate the pain on a scale of 0 to 10
B. Ask the client to describe the pain
C. Observe the client's facial expressions during movement
D. Review the vital signs for tachycardia
Answer: B. Ask the client to describe the pain.
Rationale: Pain quality (sharp, burning, dull) is best determined by the
client's subjective description. A numeric scale measures intensity, not
quality. Facial expressions and vital signs are objective cues but do not
replace the client's verbal report of the pain character.
5. When initiating oxygen via mask to a client who is short of breath,
the nurse hears a loud hissing sound after inserting the flow meter
into the wall outlet. Which should the nurse do next?
A. Check the oxygen tubing for kinks
B. Release and re-insert the flow meter in the wall outlet
C. Increase the liter flow to compensate for the leak
D. Apply a nasal cannula instead
Answer: B. Release and re-insert the flow meter in the wall outlet.
Rationale: A loud hissing sound indicates that the flow meter is not seated
properly in the wall outlet, causing a leak. The nurse must release and
reinsert it securely to ensure the prescribed oxygen concentration is
delivered.
,6. The nurse observes that there are reddened areas on the cheekbones
of a client receiving oxygen per nasal cannula at 3L/minute, and the
client’s oxygen saturation level is 92%. What intervention should the
nurse implement?
A. Decrease the flow rate to 1 L/minute.
B. Discontinue the use of the nasal cannula.
C. Apply lubricant to the cannula tubing.
D. Place padding around the cannula tubing.
Answer: D. Place padding around the cannula tubing.
Rationale: Reddened areas on the skin indicate pressure injury from the
cannula. Padding reduces friction and pressure while maintaining oxygen
delivery.
7. A 35-year-old woman presents with complaints of bleeding during
bowel movements. She reports noticing bright red blood on the toilet
paper after passing stools. She denies experiencing any pain or
discomfort during defecation. Based on the clinical vignette, what is
the most likely diagnosis?
A. Colorectal cancer
B. Rectal prolapse
C. Internal hemorrhoids
D. Anal fissure
Answer: C. Internal hemorrhoids
Rationale: Painless, bright red bleeding during bowel movements is a
classic sign of internal hemorrhoids. Anal fissures typically cause pain.
8. How will the nurse administer the timed up and go test?
A. Observe the patient transition from lying to sitting to standing to walking
B. Observe as the person rises from a chair, walks 20 feet, stoops to pick up
an item on the floor
C. Observe as the person rises from a chair, walks 10 feet, turns, walks back
to the chair and sits down
D. Observe as the person rises from a chair, walks 10 feet, and sits down in
another chair
Answer: C. Observe as the person rises from a chair, walks 10 feet,
, turns, walks back to the chair and sits down.
Rationale: The Timed Up and Go (TUG) test assesses mobility and fall risk.
It involves the client standing from a chair, walking 10 feet, turning,
returning to the chair, and sitting down.
9. A client reports that he has been experiencing diarrhea for the past
week. What question by the nurse will assist in determining if this
client is truly experiencing an alteration in bowel pattern?
A. "What is the consistency of your stools?"
B. "Have you changed your food intake this week?"
C. "How many times a day are you having a bowel movement?"
D. "Do you have a bowel movement every day?"
Answer: A. "What is the consistency of your stools?"
Rationale: Diarrhea is defined by the consistency of stool (loose, watery)
rather than frequency alone. The consistency is the key to determining if it
is truly an alteration in bowel pattern.
10. What does the presence of protein in the urine indicate, as in the
case of proteinuria?
A. Strenuous exercise
B. Liver disease
C. Kidney damage or disease
D. Malnutrition
Answer: C. Kidney damage or disease.
Rationale: Protein in the urine (proteinuria) is a sign of kidney damage, as
healthy kidneys typically do not allow protein to pass into the urine.
11. In a scenario where a patient refuses medication, what steps should
a nurse take after temporarily locking the medications?
A. Immediately report the refusal to the physician without further
discussion.
B. Conduct a further assessment to understand the patient's reasons for
refusal.
C. Leave the medications unlocked for the patient to take later.
D. Administer the medication anyway to ensure compliance.
Nursing Exam V1 Actual Exam
2026/2027 – 100% Verified | Detailed
Rationales – Pass Guaranteed – A+
Graded
1. What is the first step of the nursing process?
A. Planning
B. Implementation
C. Assessment
D. Evaluation
Answer: C. Assessment
Rationale: Assessment is the foundational first step where the nurse
collects comprehensive data about the patient's health status, which is
necessary before any planning or intervention can occur.
2. A hospitalized client with an NG tube vomits and appears to be
choking. What should the nurse do first?
A. Elevate the head of the bed to 90 degrees
B. Perform oropharyngeal suctioning
C. Stop the enteral feeding and flush the tube
D. Call the rapid response team
Answer: B. Perform oropharyngeal suctioning
Rationale: The priority is to clear the airway to prevent aspiration.
Suctioning removes the vomitus from the airway immediately, which is the
most urgent action.
3. The nurse observes a UAP securing wrist restraints to the bed side
rails. What action is most important?
,A. Remove the restraints and reapply them to the bed frame.
B. Document the UAP's incorrect application technique.
C. Report the UAP's action to the charge nurse.
D. In-service the UAP on the proper application of restraints.
Answer: A. Remove the restraints and reapply them to the bed frame.
Rationale: Restraints must never be attached to side rails, as this can cause
injury if the rails are moved. They must be tied to a part of the bed frame
that moves with the client.
4. To assess the quality of an adult client's pain, which approach
should the nurse use?
A. Ask the client to rate the pain on a scale of 0 to 10
B. Ask the client to describe the pain
C. Observe the client's facial expressions during movement
D. Review the vital signs for tachycardia
Answer: B. Ask the client to describe the pain.
Rationale: Pain quality (sharp, burning, dull) is best determined by the
client's subjective description. A numeric scale measures intensity, not
quality. Facial expressions and vital signs are objective cues but do not
replace the client's verbal report of the pain character.
5. When initiating oxygen via mask to a client who is short of breath,
the nurse hears a loud hissing sound after inserting the flow meter
into the wall outlet. Which should the nurse do next?
A. Check the oxygen tubing for kinks
B. Release and re-insert the flow meter in the wall outlet
C. Increase the liter flow to compensate for the leak
D. Apply a nasal cannula instead
Answer: B. Release and re-insert the flow meter in the wall outlet.
Rationale: A loud hissing sound indicates that the flow meter is not seated
properly in the wall outlet, causing a leak. The nurse must release and
reinsert it securely to ensure the prescribed oxygen concentration is
delivered.
,6. The nurse observes that there are reddened areas on the cheekbones
of a client receiving oxygen per nasal cannula at 3L/minute, and the
client’s oxygen saturation level is 92%. What intervention should the
nurse implement?
A. Decrease the flow rate to 1 L/minute.
B. Discontinue the use of the nasal cannula.
C. Apply lubricant to the cannula tubing.
D. Place padding around the cannula tubing.
Answer: D. Place padding around the cannula tubing.
Rationale: Reddened areas on the skin indicate pressure injury from the
cannula. Padding reduces friction and pressure while maintaining oxygen
delivery.
7. A 35-year-old woman presents with complaints of bleeding during
bowel movements. She reports noticing bright red blood on the toilet
paper after passing stools. She denies experiencing any pain or
discomfort during defecation. Based on the clinical vignette, what is
the most likely diagnosis?
A. Colorectal cancer
B. Rectal prolapse
C. Internal hemorrhoids
D. Anal fissure
Answer: C. Internal hemorrhoids
Rationale: Painless, bright red bleeding during bowel movements is a
classic sign of internal hemorrhoids. Anal fissures typically cause pain.
8. How will the nurse administer the timed up and go test?
A. Observe the patient transition from lying to sitting to standing to walking
B. Observe as the person rises from a chair, walks 20 feet, stoops to pick up
an item on the floor
C. Observe as the person rises from a chair, walks 10 feet, turns, walks back
to the chair and sits down
D. Observe as the person rises from a chair, walks 10 feet, and sits down in
another chair
Answer: C. Observe as the person rises from a chair, walks 10 feet,
, turns, walks back to the chair and sits down.
Rationale: The Timed Up and Go (TUG) test assesses mobility and fall risk.
It involves the client standing from a chair, walking 10 feet, turning,
returning to the chair, and sitting down.
9. A client reports that he has been experiencing diarrhea for the past
week. What question by the nurse will assist in determining if this
client is truly experiencing an alteration in bowel pattern?
A. "What is the consistency of your stools?"
B. "Have you changed your food intake this week?"
C. "How many times a day are you having a bowel movement?"
D. "Do you have a bowel movement every day?"
Answer: A. "What is the consistency of your stools?"
Rationale: Diarrhea is defined by the consistency of stool (loose, watery)
rather than frequency alone. The consistency is the key to determining if it
is truly an alteration in bowel pattern.
10. What does the presence of protein in the urine indicate, as in the
case of proteinuria?
A. Strenuous exercise
B. Liver disease
C. Kidney damage or disease
D. Malnutrition
Answer: C. Kidney damage or disease.
Rationale: Protein in the urine (proteinuria) is a sign of kidney damage, as
healthy kidneys typically do not allow protein to pass into the urine.
11. In a scenario where a patient refuses medication, what steps should
a nurse take after temporarily locking the medications?
A. Immediately report the refusal to the physician without further
discussion.
B. Conduct a further assessment to understand the patient's reasons for
refusal.
C. Leave the medications unlocked for the patient to take later.
D. Administer the medication anyway to ensure compliance.
