BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V1
Latest Update | Nightingale College | 100 Questions
100% Correct | Grade A Verified
Section 1: Nursing Process and Critical Thinking (Q1–Q20)
Q1: A nurse is caring for a patient admitted with dehydration. The nurse completes the initial assessment, identifies
deficient fluid volume as the nursing diagnosis, and develops a care plan. Which step of the nursing process should the
nurse perform NEXT?
A. Reassess the patient’s vital signs and hydration status
B. Implement the planned nursing interventions
C. Evaluate the effectiveness of the interventions
D. Document the patient’s response to the care plan
Correct Answer: B
Rationale: After completing assessment, diagnosis, and planning, the next step in the nursing process is
implementation—executing the planned interventions. The nursing process follows a sequential order: Assessment, Diagnosis,
Planning, Implementation, and Evaluation (ADPIE). Evaluation occurs after interventions have been implemented to determine
whether outcomes have been met. Documentation occurs throughout and after all phases. Reassessing vital signs is part of ongoing
assessment but does not replace the implementation step.
Q2: A nurse on a medical-surgical unit receives report on four patients. Which patient should the nurse assess FIRST
based on prioritization principles?
A. A patient scheduled for a computed tomography scan at 1000
B. A patient with a blood pressure of 88/54 mmHg reporting dizziness
C. A patient requesting pain medication for chronic knee pain rated 4/10
D. A patient who needs assistance with ambulation post-surgery day 2
Correct Answer: B
Rationale: Using the ABC (Airway, Breathing, Circulation) framework and Maslow’s hierarchy, the patient with a blood pressure
of 88/54 mmHg and dizziness has an unstable circulatory status requiring immediate assessment and intervention. This patient is
potentially unstable and at risk for shock, falls, and injury. The other patients have stable, non-urgent, or chronic needs. HESI
prioritization questions require selecting the least stable or most acutely ill patient first.
Q3: A nurse is caring for a post-operative patient who has not had a bowel movement in 3 days. The nurse identifies
the nursing diagnosis of Constipation. Which statement represents the PLANNING phase of the nursing process?
A. The patient reports abdominal discomfort and bloating
B. Administer prescribed stool softener and encourage fluid intake
C. The patient will have a bowel movement within 48 hours of implementing interventions
D. The patient had a small bowel movement after receiving the stool softener
Correct Answer: C
Rationale: The planning phase involves developing expected outcomes and goals. Stating that the patient will have a bowel
movement within 48 hours is an expected outcome/goal, which is part of the planning phase. Assessment involves collecting data
(option A). Implementation involves executing interventions (option B). Evaluation involves determining if the outcome was met
(option D). Distinguishing between nursing process phases is a core HESI Fundamentals competency.
,Q4: A nursing student is learning about clinical judgment. Which action best demonstrates the application of critical
thinking in nursing practice?
A. Following the provider’s order to administer a medication without questioning it
B. Analyzing patient data to make an informed, evidence-based clinical decision
C. Documenting all care provided in the patient’s medical record
D. Delegating tasks to the unlicensed assistive personnel (UAP) as assigned
Correct Answer: B
Rationale: Critical thinking in nursing involves analyzing information and making informed decisions based on evidence rather
than following orders blindly. The nurse’s role is to make informed clinical decisions by synthesizing patient data, applying
knowledge and experience. Following orders without questioning is not critical thinking. Documentation and delegation are
important nursing responsibilities but do not primarily demonstrate critical thinking. HESI questions frequently test the distinction
between rote task completion and clinical reasoning.
Q5: The primary purpose of the evaluation phase of the nursing process is to:
A. Identify new nursing diagnoses for the patient
B. Determine whether the patient’s expected outcomes have been met
C. Develop a new plan of care for the patient
D. Collect additional data about the patient’s health status
Correct Answer: B
Rationale: The primary purpose of the evaluation phase is to determine if the patient’s expected outcomes have been achieved
through the implemented nursing interventions. This continuous process assesses the patient’s response to care and determines
whether the care plan needs to be modified. While evaluation may lead to identifying new diagnoses, developing new plans, or
collecting additional data, these are secondary actions that follow the primary purpose of determining outcome achievement.
Q6: A nurse is providing care to multiple patients. Which task is MOST appropriate to delegate to the unlicensed
assistive personnel (UAP)?
A. Assess a patient’s wound for signs of infection
B. Obtain a blood pressure reading on a stable post-operative patient
C. Administer oral medications to a patient with diabetes
D. Teach a patient how to use an incentive spirometer
Correct Answer: B
Rationale: Delegation to UAP should involve tasks that do not require nursing judgment, assessment, or teaching. Obtaining a
blood pressure on a stable patient is a routine, non-invasive task appropriate for delegation. Assessment of a wound requires
clinical judgment. Medication administration requires nursing education and licensure. Patient teaching requires nursing
knowledge and assessment of learning needs. Delegation decisions must consider the task, circumstance, person,
direction/communication, and supervision/evaluation per the HESI Fundamentals blueprint.
Q7: A nurse has implemented interventions for a patient with impaired gas exchange. The patient’s oxygen saturation
has improved from 88% to 96% on room air. Which action should the nurse take NEXT?
A. Discontinue oxygen therapy and discharge the patient
B. Continue current interventions and monitor the patient’s status
C. Modify the care plan because the patient is fully recovered
D. Notify the provider that the patient no longer needs care
Correct Answer: B
Rationale: During the evaluation phase, when outcomes are being met (oxygen saturation improved to 96%), the nurse should
continue current interventions and continue to monitor the patient’s status. The improvement is positive but does not indicate full
recovery or readiness for discharge. The nurse must continue to evaluate the patient’s response over time. Modifying or
discontinuing the care plan prematurely is not appropriate. HESI questions test the nurse’s understanding that evaluation is a
, continuous, ongoing process.
Q8: A nurse is preparing to perform a focused assessment on a patient complaining of shortness of breath. Which
statement best describes a focused assessment?
A. A complete head-to-toe evaluation of all body systems
B. An assessment directed at a specific problem or concern
C. An assessment performed only on admission to the facility
D. An assessment that includes a comprehensive health history
Correct Answer: B
Rationale: A focused assessment is directed at a specific problem or concern rather than a complete health evaluation. When a
patient complains of shortness of breath, the nurse would focus the assessment on the respiratory and cardiovascular systems rather
than performing a full head-to-toe assessment. A comprehensive assessment includes all body systems and is typically performed
on admission. Focused assessments are efficient and targeted based on the patient’s current complaints and needs.
Q9: According to Benner’s model of clinical competence, which level describes a nurse who has a deep understanding
of clinical situations and can anticipate patient needs based on past experiences?
A. Novice
B. Advanced Beginner
C. Competent
D. Expert
Correct Answer: D
Rationale: According to Benner’s Levels of Nursing Experience, the Expert nurse has a deep understanding of clinical situations,
an intuitive grasp of clinical situations, and can anticipate patient needs based on extensive past experiences. The Novice has no
experience and relies on rules. The Advanced Beginner recognizes recurring patterns. The Competent nurse has 2-3 years of
experience and can plan and organize effectively. The Proficient nurse perceives situations as wholes rather than parts. This model
is part of the HESI Fundamentals nursing process curriculum.
Q10: The most important reason for documenting nursing care is to:
A. Protect the nurse from legal liability
B. Communicate with other health care team members to ensure continuity of care
C. Satisfy accreditation and regulatory requirements
D. Provide evidence for reimbursement purposes
Correct Answer: B
Rationale: The most important reason for documentation is to communicate with other health care team members to ensure
continuity of care. While documentation does serve legal, regulatory, and reimbursement purposes, its primary purpose in the HESI
Fundamentals curriculum is facilitating communication among the healthcare team. Accurate, timely documentation ensures that
all team members have access to the same patient information for safe, coordinated care delivery.
Q11: A nurse is caring for a patient with chest pain. The nurse assesses the pain, obtains vital signs, and notifies the
provider. Which nursing process step did the nurse perform when notifying the provider?
A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation
Correct Answer: C
Rationale: Notifying the provider of a patient’s condition is an implementation action—it is executing a nursing intervention
(communicating with the healthcare team). Assessment involves collecting data (obtaining vital signs, assessing pain). Diagnosis
involves analyzing data to identify patient problems. Evaluation involves determining if outcomes have been met. Notifying the
Latest Update | Nightingale College | 100 Questions
100% Correct | Grade A Verified
Section 1: Nursing Process and Critical Thinking (Q1–Q20)
Q1: A nurse is caring for a patient admitted with dehydration. The nurse completes the initial assessment, identifies
deficient fluid volume as the nursing diagnosis, and develops a care plan. Which step of the nursing process should the
nurse perform NEXT?
A. Reassess the patient’s vital signs and hydration status
B. Implement the planned nursing interventions
C. Evaluate the effectiveness of the interventions
D. Document the patient’s response to the care plan
Correct Answer: B
Rationale: After completing assessment, diagnosis, and planning, the next step in the nursing process is
implementation—executing the planned interventions. The nursing process follows a sequential order: Assessment, Diagnosis,
Planning, Implementation, and Evaluation (ADPIE). Evaluation occurs after interventions have been implemented to determine
whether outcomes have been met. Documentation occurs throughout and after all phases. Reassessing vital signs is part of ongoing
assessment but does not replace the implementation step.
Q2: A nurse on a medical-surgical unit receives report on four patients. Which patient should the nurse assess FIRST
based on prioritization principles?
A. A patient scheduled for a computed tomography scan at 1000
B. A patient with a blood pressure of 88/54 mmHg reporting dizziness
C. A patient requesting pain medication for chronic knee pain rated 4/10
D. A patient who needs assistance with ambulation post-surgery day 2
Correct Answer: B
Rationale: Using the ABC (Airway, Breathing, Circulation) framework and Maslow’s hierarchy, the patient with a blood pressure
of 88/54 mmHg and dizziness has an unstable circulatory status requiring immediate assessment and intervention. This patient is
potentially unstable and at risk for shock, falls, and injury. The other patients have stable, non-urgent, or chronic needs. HESI
prioritization questions require selecting the least stable or most acutely ill patient first.
Q3: A nurse is caring for a post-operative patient who has not had a bowel movement in 3 days. The nurse identifies
the nursing diagnosis of Constipation. Which statement represents the PLANNING phase of the nursing process?
A. The patient reports abdominal discomfort and bloating
B. Administer prescribed stool softener and encourage fluid intake
C. The patient will have a bowel movement within 48 hours of implementing interventions
D. The patient had a small bowel movement after receiving the stool softener
Correct Answer: C
Rationale: The planning phase involves developing expected outcomes and goals. Stating that the patient will have a bowel
movement within 48 hours is an expected outcome/goal, which is part of the planning phase. Assessment involves collecting data
(option A). Implementation involves executing interventions (option B). Evaluation involves determining if the outcome was met
(option D). Distinguishing between nursing process phases is a core HESI Fundamentals competency.
,Q4: A nursing student is learning about clinical judgment. Which action best demonstrates the application of critical
thinking in nursing practice?
A. Following the provider’s order to administer a medication without questioning it
B. Analyzing patient data to make an informed, evidence-based clinical decision
C. Documenting all care provided in the patient’s medical record
D. Delegating tasks to the unlicensed assistive personnel (UAP) as assigned
Correct Answer: B
Rationale: Critical thinking in nursing involves analyzing information and making informed decisions based on evidence rather
than following orders blindly. The nurse’s role is to make informed clinical decisions by synthesizing patient data, applying
knowledge and experience. Following orders without questioning is not critical thinking. Documentation and delegation are
important nursing responsibilities but do not primarily demonstrate critical thinking. HESI questions frequently test the distinction
between rote task completion and clinical reasoning.
Q5: The primary purpose of the evaluation phase of the nursing process is to:
A. Identify new nursing diagnoses for the patient
B. Determine whether the patient’s expected outcomes have been met
C. Develop a new plan of care for the patient
D. Collect additional data about the patient’s health status
Correct Answer: B
Rationale: The primary purpose of the evaluation phase is to determine if the patient’s expected outcomes have been achieved
through the implemented nursing interventions. This continuous process assesses the patient’s response to care and determines
whether the care plan needs to be modified. While evaluation may lead to identifying new diagnoses, developing new plans, or
collecting additional data, these are secondary actions that follow the primary purpose of determining outcome achievement.
Q6: A nurse is providing care to multiple patients. Which task is MOST appropriate to delegate to the unlicensed
assistive personnel (UAP)?
A. Assess a patient’s wound for signs of infection
B. Obtain a blood pressure reading on a stable post-operative patient
C. Administer oral medications to a patient with diabetes
D. Teach a patient how to use an incentive spirometer
Correct Answer: B
Rationale: Delegation to UAP should involve tasks that do not require nursing judgment, assessment, or teaching. Obtaining a
blood pressure on a stable patient is a routine, non-invasive task appropriate for delegation. Assessment of a wound requires
clinical judgment. Medication administration requires nursing education and licensure. Patient teaching requires nursing
knowledge and assessment of learning needs. Delegation decisions must consider the task, circumstance, person,
direction/communication, and supervision/evaluation per the HESI Fundamentals blueprint.
Q7: A nurse has implemented interventions for a patient with impaired gas exchange. The patient’s oxygen saturation
has improved from 88% to 96% on room air. Which action should the nurse take NEXT?
A. Discontinue oxygen therapy and discharge the patient
B. Continue current interventions and monitor the patient’s status
C. Modify the care plan because the patient is fully recovered
D. Notify the provider that the patient no longer needs care
Correct Answer: B
Rationale: During the evaluation phase, when outcomes are being met (oxygen saturation improved to 96%), the nurse should
continue current interventions and continue to monitor the patient’s status. The improvement is positive but does not indicate full
recovery or readiness for discharge. The nurse must continue to evaluate the patient’s response over time. Modifying or
discontinuing the care plan prematurely is not appropriate. HESI questions test the nurse’s understanding that evaluation is a
, continuous, ongoing process.
Q8: A nurse is preparing to perform a focused assessment on a patient complaining of shortness of breath. Which
statement best describes a focused assessment?
A. A complete head-to-toe evaluation of all body systems
B. An assessment directed at a specific problem or concern
C. An assessment performed only on admission to the facility
D. An assessment that includes a comprehensive health history
Correct Answer: B
Rationale: A focused assessment is directed at a specific problem or concern rather than a complete health evaluation. When a
patient complains of shortness of breath, the nurse would focus the assessment on the respiratory and cardiovascular systems rather
than performing a full head-to-toe assessment. A comprehensive assessment includes all body systems and is typically performed
on admission. Focused assessments are efficient and targeted based on the patient’s current complaints and needs.
Q9: According to Benner’s model of clinical competence, which level describes a nurse who has a deep understanding
of clinical situations and can anticipate patient needs based on past experiences?
A. Novice
B. Advanced Beginner
C. Competent
D. Expert
Correct Answer: D
Rationale: According to Benner’s Levels of Nursing Experience, the Expert nurse has a deep understanding of clinical situations,
an intuitive grasp of clinical situations, and can anticipate patient needs based on extensive past experiences. The Novice has no
experience and relies on rules. The Advanced Beginner recognizes recurring patterns. The Competent nurse has 2-3 years of
experience and can plan and organize effectively. The Proficient nurse perceives situations as wholes rather than parts. This model
is part of the HESI Fundamentals nursing process curriculum.
Q10: The most important reason for documenting nursing care is to:
A. Protect the nurse from legal liability
B. Communicate with other health care team members to ensure continuity of care
C. Satisfy accreditation and regulatory requirements
D. Provide evidence for reimbursement purposes
Correct Answer: B
Rationale: The most important reason for documentation is to communicate with other health care team members to ensure
continuity of care. While documentation does serve legal, regulatory, and reimbursement purposes, its primary purpose in the HESI
Fundamentals curriculum is facilitating communication among the healthcare team. Accurate, timely documentation ensures that
all team members have access to the same patient information for safe, coordinated care delivery.
Q11: A nurse is caring for a patient with chest pain. The nurse assesses the pain, obtains vital signs, and notifies the
provider. Which nursing process step did the nurse perform when notifying the provider?
A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation
Correct Answer: C
Rationale: Notifying the provider of a patient’s condition is an implementation action—it is executing a nursing intervention
(communicating with the healthcare team). Assessment involves collecting data (obtaining vital signs, assessing pain). Diagnosis
involves analyzing data to identify patient problems. Evaluation involves determining if outcomes have been met. Notifying the
