BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam V2 (Latest Update 2026/2027)
Questions and Verified Answers | 100% Correct | Grade A
Nightingale College
Section 1: Nursing Process and Critical Thinking
Questions 1-20
Q1. A nurse is caring for a client admitted with dehydration. The nurse collects data through the admission
interview, reviews the medical record, and performs a physical examination. Which step of the nursing process is
the nurse performing?
A. Diagnosis
B. Assessment [CORRECT]
C. Planning
D. Implementation
Correct Answer: B
Rationale: Assessment is the first step of the nursing process (ADPIE) and involves collecting comprehensive data through interview, physical
examination, and record review. The nurse gathers both subjective and objective data to establish a baseline for care. Diagnosis (Option A)
follows assessment and involves analyzing the collected data. Planning (Option C) and Implementation (Option D) are subsequent steps that
depend on completed assessment data. Without thorough assessment, the remaining steps cannot be accurately performed.
Q2. Which statement best describes a nursing diagnosis?
A. A medical disease identified by the physician
B. The patient's response to an actual or potential health problem [CORRECT]
C. A prescribed treatment plan for the patient
D. An outcome criterion established by the nurse
Correct Answer: B
Rationale: A nursing diagnosis describes the patient's response to an actual or potential health problem that the nurse is licensed to treat. It
differs from a medical diagnosis (Option A), which identifies a disease or pathology. A treatment plan (Option C) and outcome criteria
(Option D) are parts of the planning step, not the diagnostic step. The nursing diagnosis focuses on the human response, not the disease itself,
and guides the selection of nursing interventions.
Q3. A nurse is developing a care plan for a client recovering from hip replacement surgery. The nurse identifies
that the client will ambulate 50 feet with a walker by postoperative day 3. This statement represents which
component of the nursing process?
A. Nursing diagnosis
B. Implementation
C. Expected outcome [CORRECT]
D. Evaluation
Correct Answer: C
Rationale: Expected outcomes (also called goals or outcome identification) describe the specific, measurable behaviors or responses the
patient is expected to achieve as a result of nursing care. A patient's goals are outcomes of care based on the individualized health situation.
The nursing diagnosis (Option A) identifies the problem. Implementation (Option B) is the execution of interventions. Evaluation (Option D)
determines whether outcomes have been met. This statement is a measurable, time-specific goal representing the expected outcome of care.
,BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V2 | Nightingale College | 2026/2027
Q4. The nurse explains a dressing change procedure to the patient and obtains verbal agreement before
beginning. In which phase of the nursing process does this action occur?
A. Assessment
B. Planning
C. Implementation [CORRECT]
D. Evaluation
Correct Answer: C
Rationale: Implementation is the phase where nursing interventions are executed, and this includes introducing interventions to the patient.
Interventions in the implementation phase begin when the patient is informed and consents to the care. While explaining the procedure may
involve aspects of planning, actually beginning the intervention with patient consent places it in the implementation phase. Assessment
(Option A) is data collection. Planning (Option B) develops the strategy. Evaluation (Option D) assesses outcomes after intervention.
Q5. A nurse administered pain medication to a postoperative client and returns 45 minutes later to ask the client
to rate their pain on a scale of 0 to 10. What is the primary purpose of this action?
A. To collect additional assessment data
B. To assess the effectiveness of the nursing intervention [CORRECT]
C. To implement a new nursing diagnosis
D. To plan additional interventions
Correct Answer: B
Rationale: Evaluation is the step of the nursing process that determines whether patient outcomes have been met and whether interventions
were effective. Returning to reassess the patient's pain after administering medication evaluates the therapeutic effect of the intervention.
While this also yields additional data (Option A) and may lead to new interventions (Option D), the primary purpose at this moment is
evaluation. A new diagnosis (Option C) would require separate assessment and analysis.
Q6. A nurse administers a diuretic to a client with fluid overload. One hour later, the nurse measures the client's
intake and output, checks lung sounds, and assesses for peripheral edema. What process is the nurse performing?
A. Initial assessment
B. Reassessment [CORRECT]
C. Nursing diagnosis
D. Discharge planning
Correct Answer: B
Rationale: Reassessment is the process of re-evaluating a patient's condition after nursing interventions have been implemented. Reassessing
the patient after interventions is how the nurse determines if actions were effective. The nurse is checking whether the diuretic reduced fluid
overload by reassessing lung sounds, edema, and urine output. Initial assessment (Option A) occurs before interventions. Nursing diagnosis
(Option C) and discharge planning (Option D) are not reassessment activities.
Q7. During a clinical conference, a nursing student states, "The patient's blood pressure has decreased from
140/90 to 120/80 after receiving the prescribed antihypertensive, but the heart rate has increased from 72 to 98
bpm." This is an example of which cognitive skill?
A. Memorization of drug side effects
B. Data interpretation using clinical judgment [CORRECT]
C. Implementation of nursing care
D. Evaluation of nursing outcomes
Correct Answer: B
Rationale: Data interpretation involves using clinical judgment to analyze patient data and identify patterns. The student is recognizing both
the therapeutic effect (lowered BP) and a potential adverse response (increased HR), demonstrating the ability to interpret multiple data
points simultaneously. While this may inform evaluation (Option D), the specific act of analyzing and making sense of the data is data
interpretation. Memorization (Option A) and implementation (Option C) do not describe this analytical process.
Q8. A nurse cares for a client with pneumonia who has a temperature of 101.8°F, HR 96, RR 24, and decreased
breath sounds in the right lower lobe. The nurse administers prescribed antibiotics, encourages fluid intake, and
elevates the head of the bed. Which cognitive skill is the nurse demonstrating by connecting these assessment
Page 2
, BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V2 | Nightingale College | 2026/2027
findings with appropriate interventions?
A. Data interpretation
B. Clinical reasoning [CORRECT]
C. Evaluation
D. Documentation
Correct Answer: B
Rationale: Clinical reasoning is the process of applying knowledge and experience to clinical situations, synthesizing patient data to make
clinical decisions. The nurse is connecting multiple assessment findings (fever, tachycardia, tachypnea, decreased breath sounds) with their
knowledge of pneumonia pathophysiology to select appropriate interventions. Data interpretation (Option A) is a component of clinical
reasoning but does not encompass the full decision-making process. Evaluation (Option D) occurs after interventions. Documentation (Option
D) is a separate activity.
Q9. What is the most important reason for a nurse to document care provided in the patient's medical record?
A. To protect the nurse from legal liability
B. To communicate with other health care team members to ensure continuity of care [CORRECT]
C. To satisfy accreditation requirements
D. To bill insurance companies for services rendered
Correct Answer: B
Rationale: The most important reason for documentation is to communicate with other health care team members to ensure continuity of care.
Accurate documentation allows all members of the healthcare team to understand the patient's status, interventions performed, and responses
to treatment. While documentation does serve legal (Option A), accreditation (Option C), and billing (Option D) purposes, its primary
purpose is facilitating communication and continuity of patient care across shifts and providers.
Q10. A nurse is reviewing a newly admitted patient's home medications. The patient takes lisinopril 10 mg daily,
metformin 500 mg twice daily, and aspirin 81 mg daily. The nurse notes the metformin dose was recently
increased by the prescriber. Which action reflects the assessment phase of the nursing process in pharmacology?
A. Administering the medications as prescribed
B. Collecting the complete medication history and noting recent changes [CORRECT]
C. Developing a teaching plan about the medications
D. Monitoring for therapeutic effects of the medications
Correct Answer: B
Rationale: In the nursing process applied to pharmacology, assessment includes obtaining a complete medication history, including current
medications, doses, frequencies, and recent changes. The nurse is gathering data about the patient's medication regimen to inform subsequent
steps. Administering medications (Option A) is implementation. Developing a teaching plan (Option C) is planning. Monitoring therapeutic
effects (Option D) is evaluation. Collecting the medication history is a data-gathering activity that belongs in the assessment phase.
Q11. A nurse identifies "Risk for Injury related to side effects of anticoagulant therapy" for a patient starting
warfarin. Which phase of the nursing process does this represent in the context of pharmacology?
A. Assessment
B. Nursing diagnosis [CORRECT]
C. Planning
D. Evaluation
Correct Answer: B
Rationale: Identifying a risk for injury related to medication side effects is a nursing diagnosis. In pharmacology, the diagnostic phase
includes identifying potential risks associated with medications, such as bleeding risk with anticoagulants. This is a risk nursing diagnosis
(potential problem) rather than an actual diagnosis. Assessment (Option A) would involve collecting data about the medication. Planning
(Option C) would involve developing prevention strategies. Evaluation (Option D) monitors outcomes.
Q12. A nurse is caring for multiple patients on a medical-surgical unit. Which patient should the nurse assess
first?
A. A patient requesting pain medication for chronic back pain rated 4/10
Page 3
of Nursing Exam V2 (Latest Update 2026/2027)
Questions and Verified Answers | 100% Correct | Grade A
Nightingale College
Section 1: Nursing Process and Critical Thinking
Questions 1-20
Q1. A nurse is caring for a client admitted with dehydration. The nurse collects data through the admission
interview, reviews the medical record, and performs a physical examination. Which step of the nursing process is
the nurse performing?
A. Diagnosis
B. Assessment [CORRECT]
C. Planning
D. Implementation
Correct Answer: B
Rationale: Assessment is the first step of the nursing process (ADPIE) and involves collecting comprehensive data through interview, physical
examination, and record review. The nurse gathers both subjective and objective data to establish a baseline for care. Diagnosis (Option A)
follows assessment and involves analyzing the collected data. Planning (Option C) and Implementation (Option D) are subsequent steps that
depend on completed assessment data. Without thorough assessment, the remaining steps cannot be accurately performed.
Q2. Which statement best describes a nursing diagnosis?
A. A medical disease identified by the physician
B. The patient's response to an actual or potential health problem [CORRECT]
C. A prescribed treatment plan for the patient
D. An outcome criterion established by the nurse
Correct Answer: B
Rationale: A nursing diagnosis describes the patient's response to an actual or potential health problem that the nurse is licensed to treat. It
differs from a medical diagnosis (Option A), which identifies a disease or pathology. A treatment plan (Option C) and outcome criteria
(Option D) are parts of the planning step, not the diagnostic step. The nursing diagnosis focuses on the human response, not the disease itself,
and guides the selection of nursing interventions.
Q3. A nurse is developing a care plan for a client recovering from hip replacement surgery. The nurse identifies
that the client will ambulate 50 feet with a walker by postoperative day 3. This statement represents which
component of the nursing process?
A. Nursing diagnosis
B. Implementation
C. Expected outcome [CORRECT]
D. Evaluation
Correct Answer: C
Rationale: Expected outcomes (also called goals or outcome identification) describe the specific, measurable behaviors or responses the
patient is expected to achieve as a result of nursing care. A patient's goals are outcomes of care based on the individualized health situation.
The nursing diagnosis (Option A) identifies the problem. Implementation (Option B) is the execution of interventions. Evaluation (Option D)
determines whether outcomes have been met. This statement is a measurable, time-specific goal representing the expected outcome of care.
,BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V2 | Nightingale College | 2026/2027
Q4. The nurse explains a dressing change procedure to the patient and obtains verbal agreement before
beginning. In which phase of the nursing process does this action occur?
A. Assessment
B. Planning
C. Implementation [CORRECT]
D. Evaluation
Correct Answer: C
Rationale: Implementation is the phase where nursing interventions are executed, and this includes introducing interventions to the patient.
Interventions in the implementation phase begin when the patient is informed and consents to the care. While explaining the procedure may
involve aspects of planning, actually beginning the intervention with patient consent places it in the implementation phase. Assessment
(Option A) is data collection. Planning (Option B) develops the strategy. Evaluation (Option D) assesses outcomes after intervention.
Q5. A nurse administered pain medication to a postoperative client and returns 45 minutes later to ask the client
to rate their pain on a scale of 0 to 10. What is the primary purpose of this action?
A. To collect additional assessment data
B. To assess the effectiveness of the nursing intervention [CORRECT]
C. To implement a new nursing diagnosis
D. To plan additional interventions
Correct Answer: B
Rationale: Evaluation is the step of the nursing process that determines whether patient outcomes have been met and whether interventions
were effective. Returning to reassess the patient's pain after administering medication evaluates the therapeutic effect of the intervention.
While this also yields additional data (Option A) and may lead to new interventions (Option D), the primary purpose at this moment is
evaluation. A new diagnosis (Option C) would require separate assessment and analysis.
Q6. A nurse administers a diuretic to a client with fluid overload. One hour later, the nurse measures the client's
intake and output, checks lung sounds, and assesses for peripheral edema. What process is the nurse performing?
A. Initial assessment
B. Reassessment [CORRECT]
C. Nursing diagnosis
D. Discharge planning
Correct Answer: B
Rationale: Reassessment is the process of re-evaluating a patient's condition after nursing interventions have been implemented. Reassessing
the patient after interventions is how the nurse determines if actions were effective. The nurse is checking whether the diuretic reduced fluid
overload by reassessing lung sounds, edema, and urine output. Initial assessment (Option A) occurs before interventions. Nursing diagnosis
(Option C) and discharge planning (Option D) are not reassessment activities.
Q7. During a clinical conference, a nursing student states, "The patient's blood pressure has decreased from
140/90 to 120/80 after receiving the prescribed antihypertensive, but the heart rate has increased from 72 to 98
bpm." This is an example of which cognitive skill?
A. Memorization of drug side effects
B. Data interpretation using clinical judgment [CORRECT]
C. Implementation of nursing care
D. Evaluation of nursing outcomes
Correct Answer: B
Rationale: Data interpretation involves using clinical judgment to analyze patient data and identify patterns. The student is recognizing both
the therapeutic effect (lowered BP) and a potential adverse response (increased HR), demonstrating the ability to interpret multiple data
points simultaneously. While this may inform evaluation (Option D), the specific act of analyzing and making sense of the data is data
interpretation. Memorization (Option A) and implementation (Option C) do not describe this analytical process.
Q8. A nurse cares for a client with pneumonia who has a temperature of 101.8°F, HR 96, RR 24, and decreased
breath sounds in the right lower lobe. The nurse administers prescribed antibiotics, encourages fluid intake, and
elevates the head of the bed. Which cognitive skill is the nurse demonstrating by connecting these assessment
Page 2
, BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V2 | Nightingale College | 2026/2027
findings with appropriate interventions?
A. Data interpretation
B. Clinical reasoning [CORRECT]
C. Evaluation
D. Documentation
Correct Answer: B
Rationale: Clinical reasoning is the process of applying knowledge and experience to clinical situations, synthesizing patient data to make
clinical decisions. The nurse is connecting multiple assessment findings (fever, tachycardia, tachypnea, decreased breath sounds) with their
knowledge of pneumonia pathophysiology to select appropriate interventions. Data interpretation (Option A) is a component of clinical
reasoning but does not encompass the full decision-making process. Evaluation (Option D) occurs after interventions. Documentation (Option
D) is a separate activity.
Q9. What is the most important reason for a nurse to document care provided in the patient's medical record?
A. To protect the nurse from legal liability
B. To communicate with other health care team members to ensure continuity of care [CORRECT]
C. To satisfy accreditation requirements
D. To bill insurance companies for services rendered
Correct Answer: B
Rationale: The most important reason for documentation is to communicate with other health care team members to ensure continuity of care.
Accurate documentation allows all members of the healthcare team to understand the patient's status, interventions performed, and responses
to treatment. While documentation does serve legal (Option A), accreditation (Option C), and billing (Option D) purposes, its primary
purpose is facilitating communication and continuity of patient care across shifts and providers.
Q10. A nurse is reviewing a newly admitted patient's home medications. The patient takes lisinopril 10 mg daily,
metformin 500 mg twice daily, and aspirin 81 mg daily. The nurse notes the metformin dose was recently
increased by the prescriber. Which action reflects the assessment phase of the nursing process in pharmacology?
A. Administering the medications as prescribed
B. Collecting the complete medication history and noting recent changes [CORRECT]
C. Developing a teaching plan about the medications
D. Monitoring for therapeutic effects of the medications
Correct Answer: B
Rationale: In the nursing process applied to pharmacology, assessment includes obtaining a complete medication history, including current
medications, doses, frequencies, and recent changes. The nurse is gathering data about the patient's medication regimen to inform subsequent
steps. Administering medications (Option A) is implementation. Developing a teaching plan (Option C) is planning. Monitoring therapeutic
effects (Option D) is evaluation. Collecting the medication history is a data-gathering activity that belongs in the assessment phase.
Q11. A nurse identifies "Risk for Injury related to side effects of anticoagulant therapy" for a patient starting
warfarin. Which phase of the nursing process does this represent in the context of pharmacology?
A. Assessment
B. Nursing diagnosis [CORRECT]
C. Planning
D. Evaluation
Correct Answer: B
Rationale: Identifying a risk for injury related to medication side effects is a nursing diagnosis. In pharmacology, the diagnostic phase
includes identifying potential risks associated with medications, such as bleeding risk with anticoagulants. This is a risk nursing diagnosis
(potential problem) rather than an actual diagnosis. Assessment (Option A) would involve collecting data about the medication. Planning
(Option C) would involve developing prevention strategies. Evaluation (Option D) monitors outcomes.
Q12. A nurse is caring for multiple patients on a medical-surgical unit. Which patient should the nurse assess
first?
A. A patient requesting pain medication for chronic back pain rated 4/10
Page 3
