BSN 225 HESI RN Specialty Fundamentals of Nursing Exam
Prep
Latest Update 2026/2027 | Questions & Answers | 100% Correct | Grade A - Nightingale College
Section 1: Nursing Process and Critical Thinking
Q1: A nurse is caring for a patient admitted with dehydration. After completing the initial assessment, the nurse identifies "Fluid
Volume Deficit" as a nursing diagnosis. Which step of the nursing process did the nurse just complete?
A. Planning
B. Assessment **[CORRECT]**
C. Implementation
D. Evaluation
Correct Answer: B
Rationale: Assessment is the first step of the nursing process involving systematic collection of comprehensive data including subjective reports
and objective findings from the physical examination and review of records. Identifying the diagnosis follows data collection during the
diagnosis phase, making assessment the step that was just completed.
Q2: A nurse is developing a care plan for a patient with chronic pain. Which type of nursing diagnosis should the nurse prioritize
when the patient has an actual problem occurring?
A. Risk diagnosis
B. Health promotion diagnosis
C. Actual diagnosis **[CORRECT]**
D. Collaborative problem
Correct Answer: C
Rationale: An actual nursing diagnosis describes a human response to a health condition that is actually occurring. When a patient has a current
problem such as chronic pain, the nurse should prioritize the actual diagnosis over risk diagnoses (potential problems) or health promotion
diagnoses (readiness for enhanced health).
Q3: A nurse is setting priorities for a patient who has multiple nursing diagnoses. Using Maslow’s Hierarchy of Needs, which
nursing diagnosis should the nurse address first?
A. Social isolation
B. Ineffective coping
C. Impaired gas exchange **[CORRECT]**
D. Disturbed body image
Correct Answer: C
Rationale: Maslow’s Hierarchy prioritizes physiological needs first, followed by safety, love/belonging, esteem, and self-actualization. Impaired
gas exchange is a physiological need affecting oxygenation and must be addressed before social isolation, ineffective coping (psychosocial), or
disturbed body image (esteem/self-actualization).
Q4: A nurse administers a prescribed medication to a patient. Which type of nursing intervention did the nurse perform?
A. Independent intervention
B. Dependent intervention **[CORRECT]**
C. Interdependent intervention
D. Collaborative problem
Correct Answer: B
, Rationale: Administering a prescribed medication is a dependent intervention requiring a provider’s order before the nurse can carry it out.
Independent interventions are nurse-initiated, while interdependent interventions involve collaboration with other healthcare team members.
Q5: After implementing nursing interventions for a patient with impaired mobility, the nurse reassesses the patient’s ability to
ambulate. Which step of the nursing process is the nurse performing?
A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation **[CORRECT]**
Correct Answer: D
Rationale: Evaluation is the step where the nurse assesses the patient’s response to interventions and determines whether expected outcomes have
been met. Reassessing ambulation ability after implementing mobility interventions evaluates the plan’s effectiveness.
Q6: A nurse is caring for multiple patients. Which patient should the nurse assess first using the ABC prioritization framework?
A. A patient reporting abdominal pain rated 6/10
B. A patient with new onset of confusion and restlessness **[CORRECT]**
C. A patient requesting pain medication for postoperative incisional pain
D. A patient who needs assistance with hygiene before breakfast
Correct Answer: B
Rationale: Using ABC (Airway, Breathing, Circulation), the nurse should first assess the patient with new onset confusion and restlessness, as
these are signs of decreased oxygenation to the brain and may indicate respiratory or circulatory compromise requiring immediate intervention.
Q7: A nurse is using critical thinking when caring for a patient. Which characteristic best describes critical thinking in nursing?
A. Following established care plans without deviation
B. Purposeful, goal-directed thinking based on nursing knowledge and evidence **[CORRECT]**
C. Delegating tasks to unlicensed assistive personnel
D. Documenting care provided in the medical record
Correct Answer: B
Rationale: Critical thinking in nursing is purposeful, goal-directed thinking based on nursing knowledge and evidence that includes reflection
and self-correction. It goes beyond following routines and involves analyzing situations, considering alternatives, and making clinical judgments.
Q8: A nurse is providing care based on current evidence. Which QSEN competency is the nurse demonstrating?
A. Patient-Centered Care
B. Teamwork and Collaboration
C. Evidence-Based Practice **[CORRECT]**
D. Informatics
Correct Answer: C
Rationale: Evidence-Based Practice (EBP) is the QSEN competency involving integration of current research evidence with clinical expertise and
patient preferences. Providing care based on current evidence rather than tradition demonstrates this competency.
Q9: A nurse identifies that a patient is at risk for falls. Which type of nursing diagnosis is this?
A. Actual diagnosis
B. Risk diagnosis **[CORRECT]**
C. Syndrome diagnosis
D. Health promotion diagnosis
Correct Answer: B
Rationale: A risk nursing diagnosis describes a human response that may develop in a vulnerable patient. "Risk for Falls" indicates the patient
has factors increasing susceptibility but the problem has not yet occurred, distinguishing it from an actual diagnosis.
Q10: A nurse is developing SMART goals for a patient. Which goal statement meets the SMART criteria?
A. Patient will feel better soon
, B. Patient will walk 50 feet with assistance by end of shift **[CORRECT]**
C. Patient will improve mobility over time
D. Patient will understand their medications before discharge
Correct Answer: B
Rationale: SMART goals are Specific, Measurable, Achievable, Relevant, and Time-bound. Walking 50 feet with assistance by end of shift is
specific (50 feet), measurable (distance), achievable (with assistance), relevant (mobility), and time-bound (end of shift).
Q11: A nurse delegates vital sign measurement to an unlicensed assistive personnel (UAP). Which responsibility does the nurse
retain?
A. Measuring the blood pressure
B. Documenting the vital signs
C. Interpreting the results and assessing for abnormalities **[CORRECT]**
D. Reporting the values to the provider
Correct Answer: C
Rationale: The RN retains responsibility for assessment, diagnosis, planning, evaluation, and teaching, which cannot be delegated. While the
UAP can measure and document vital signs, the nurse must interpret results and identify abnormalities.
Q12: A nurse is caring for a postoperative patient. Which intervention is an example of an independent nursing intervention?
A. Administering prescribed IV pain medication
B. Repositioning the patient every 2 hours to prevent skin breakdown **[CORRECT]**
C. Ordering a chest X-ray for suspected pneumonia
D. Referring the patient to physical therapy
Correct Answer: B
Rationale: Independent nursing interventions are nurse-initiated actions that do not require a provider’s order. Repositioning the patient every 2
hours to prevent skin breakdown is within the nurse’s scope and does not require a prescription.
Q13: A nurse is using clinical reasoning to care for a patient with heart failure. Which action best demonstrates clinical reasoning?
A. Following the standardized heart failure care plan for all patients
B. Synthesizing patient data, nursing knowledge, and clinical context to make decisions **[CORRECT]**
C. Documenting all care provided in the patient’s chart
D. Reporting changes in the patient’s condition to the provider
Correct Answer: B
Rationale: Clinical reasoning involves synthesizing patient data, nursing knowledge, and clinical context to make appropriate decisions using
pattern recognition and systematic analysis, going beyond following standardized plans.
Q14: A nurse is prioritizing care for four patients. Which patient should the nurse see first?
A. A patient with a blood pressure of 110/70 mmHg who is 1 day post-op
B. A patient with a blood pressure of 88/56 mmHg who reports dizziness **[CORRECT]**
C. A patient with a temperature of 100.4F who is resting comfortably
D. A patient with a pulse rate of 92 bpm who is preparing for discharge
Correct Answer: B
Rationale: Using ABC prioritization, the patient with hypotension (88/56 mmHg) and dizziness requires immediate assessment for compromised
circulation. This unstable patient takes priority over stable postoperative patients, low-grade fever, or routine discharge preparation.
Q15: A nurse coordinates a patient’s care with the physical therapist, dietitian, and social worker. Which type of intervention is
this?
A. Independent intervention
B. Dependent intervention
C. Interdependent intervention **[CORRECT]**
D. Supervisory intervention
Correct Answer: C
Prep
Latest Update 2026/2027 | Questions & Answers | 100% Correct | Grade A - Nightingale College
Section 1: Nursing Process and Critical Thinking
Q1: A nurse is caring for a patient admitted with dehydration. After completing the initial assessment, the nurse identifies "Fluid
Volume Deficit" as a nursing diagnosis. Which step of the nursing process did the nurse just complete?
A. Planning
B. Assessment **[CORRECT]**
C. Implementation
D. Evaluation
Correct Answer: B
Rationale: Assessment is the first step of the nursing process involving systematic collection of comprehensive data including subjective reports
and objective findings from the physical examination and review of records. Identifying the diagnosis follows data collection during the
diagnosis phase, making assessment the step that was just completed.
Q2: A nurse is developing a care plan for a patient with chronic pain. Which type of nursing diagnosis should the nurse prioritize
when the patient has an actual problem occurring?
A. Risk diagnosis
B. Health promotion diagnosis
C. Actual diagnosis **[CORRECT]**
D. Collaborative problem
Correct Answer: C
Rationale: An actual nursing diagnosis describes a human response to a health condition that is actually occurring. When a patient has a current
problem such as chronic pain, the nurse should prioritize the actual diagnosis over risk diagnoses (potential problems) or health promotion
diagnoses (readiness for enhanced health).
Q3: A nurse is setting priorities for a patient who has multiple nursing diagnoses. Using Maslow’s Hierarchy of Needs, which
nursing diagnosis should the nurse address first?
A. Social isolation
B. Ineffective coping
C. Impaired gas exchange **[CORRECT]**
D. Disturbed body image
Correct Answer: C
Rationale: Maslow’s Hierarchy prioritizes physiological needs first, followed by safety, love/belonging, esteem, and self-actualization. Impaired
gas exchange is a physiological need affecting oxygenation and must be addressed before social isolation, ineffective coping (psychosocial), or
disturbed body image (esteem/self-actualization).
Q4: A nurse administers a prescribed medication to a patient. Which type of nursing intervention did the nurse perform?
A. Independent intervention
B. Dependent intervention **[CORRECT]**
C. Interdependent intervention
D. Collaborative problem
Correct Answer: B
, Rationale: Administering a prescribed medication is a dependent intervention requiring a provider’s order before the nurse can carry it out.
Independent interventions are nurse-initiated, while interdependent interventions involve collaboration with other healthcare team members.
Q5: After implementing nursing interventions for a patient with impaired mobility, the nurse reassesses the patient’s ability to
ambulate. Which step of the nursing process is the nurse performing?
A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation **[CORRECT]**
Correct Answer: D
Rationale: Evaluation is the step where the nurse assesses the patient’s response to interventions and determines whether expected outcomes have
been met. Reassessing ambulation ability after implementing mobility interventions evaluates the plan’s effectiveness.
Q6: A nurse is caring for multiple patients. Which patient should the nurse assess first using the ABC prioritization framework?
A. A patient reporting abdominal pain rated 6/10
B. A patient with new onset of confusion and restlessness **[CORRECT]**
C. A patient requesting pain medication for postoperative incisional pain
D. A patient who needs assistance with hygiene before breakfast
Correct Answer: B
Rationale: Using ABC (Airway, Breathing, Circulation), the nurse should first assess the patient with new onset confusion and restlessness, as
these are signs of decreased oxygenation to the brain and may indicate respiratory or circulatory compromise requiring immediate intervention.
Q7: A nurse is using critical thinking when caring for a patient. Which characteristic best describes critical thinking in nursing?
A. Following established care plans without deviation
B. Purposeful, goal-directed thinking based on nursing knowledge and evidence **[CORRECT]**
C. Delegating tasks to unlicensed assistive personnel
D. Documenting care provided in the medical record
Correct Answer: B
Rationale: Critical thinking in nursing is purposeful, goal-directed thinking based on nursing knowledge and evidence that includes reflection
and self-correction. It goes beyond following routines and involves analyzing situations, considering alternatives, and making clinical judgments.
Q8: A nurse is providing care based on current evidence. Which QSEN competency is the nurse demonstrating?
A. Patient-Centered Care
B. Teamwork and Collaboration
C. Evidence-Based Practice **[CORRECT]**
D. Informatics
Correct Answer: C
Rationale: Evidence-Based Practice (EBP) is the QSEN competency involving integration of current research evidence with clinical expertise and
patient preferences. Providing care based on current evidence rather than tradition demonstrates this competency.
Q9: A nurse identifies that a patient is at risk for falls. Which type of nursing diagnosis is this?
A. Actual diagnosis
B. Risk diagnosis **[CORRECT]**
C. Syndrome diagnosis
D. Health promotion diagnosis
Correct Answer: B
Rationale: A risk nursing diagnosis describes a human response that may develop in a vulnerable patient. "Risk for Falls" indicates the patient
has factors increasing susceptibility but the problem has not yet occurred, distinguishing it from an actual diagnosis.
Q10: A nurse is developing SMART goals for a patient. Which goal statement meets the SMART criteria?
A. Patient will feel better soon
, B. Patient will walk 50 feet with assistance by end of shift **[CORRECT]**
C. Patient will improve mobility over time
D. Patient will understand their medications before discharge
Correct Answer: B
Rationale: SMART goals are Specific, Measurable, Achievable, Relevant, and Time-bound. Walking 50 feet with assistance by end of shift is
specific (50 feet), measurable (distance), achievable (with assistance), relevant (mobility), and time-bound (end of shift).
Q11: A nurse delegates vital sign measurement to an unlicensed assistive personnel (UAP). Which responsibility does the nurse
retain?
A. Measuring the blood pressure
B. Documenting the vital signs
C. Interpreting the results and assessing for abnormalities **[CORRECT]**
D. Reporting the values to the provider
Correct Answer: C
Rationale: The RN retains responsibility for assessment, diagnosis, planning, evaluation, and teaching, which cannot be delegated. While the
UAP can measure and document vital signs, the nurse must interpret results and identify abnormalities.
Q12: A nurse is caring for a postoperative patient. Which intervention is an example of an independent nursing intervention?
A. Administering prescribed IV pain medication
B. Repositioning the patient every 2 hours to prevent skin breakdown **[CORRECT]**
C. Ordering a chest X-ray for suspected pneumonia
D. Referring the patient to physical therapy
Correct Answer: B
Rationale: Independent nursing interventions are nurse-initiated actions that do not require a provider’s order. Repositioning the patient every 2
hours to prevent skin breakdown is within the nurse’s scope and does not require a prescription.
Q13: A nurse is using clinical reasoning to care for a patient with heart failure. Which action best demonstrates clinical reasoning?
A. Following the standardized heart failure care plan for all patients
B. Synthesizing patient data, nursing knowledge, and clinical context to make decisions **[CORRECT]**
C. Documenting all care provided in the patient’s chart
D. Reporting changes in the patient’s condition to the provider
Correct Answer: B
Rationale: Clinical reasoning involves synthesizing patient data, nursing knowledge, and clinical context to make appropriate decisions using
pattern recognition and systematic analysis, going beyond following standardized plans.
Q14: A nurse is prioritizing care for four patients. Which patient should the nurse see first?
A. A patient with a blood pressure of 110/70 mmHg who is 1 day post-op
B. A patient with a blood pressure of 88/56 mmHg who reports dizziness **[CORRECT]**
C. A patient with a temperature of 100.4F who is resting comfortably
D. A patient with a pulse rate of 92 bpm who is preparing for discharge
Correct Answer: B
Rationale: Using ABC prioritization, the patient with hypotension (88/56 mmHg) and dizziness requires immediate assessment for compromised
circulation. This unstable patient takes priority over stable postoperative patients, low-grade fever, or routine discharge preparation.
Q15: A nurse coordinates a patient’s care with the physical therapist, dietitian, and social worker. Which type of intervention is
this?
A. Independent intervention
B. Dependent intervention
C. Interdependent intervention **[CORRECT]**
D. Supervisory intervention
Correct Answer: C
