BSN HESI 215 – Comprehensive Final Exam Review
Questions and Answers with Rationales 2026/2027
Update - Nightingale College
Fundamentals, Assessment & Safety
1. A nurse assesses a client who reports sudden shortness of breath.
Which assessment should the nurse perform first?
A. Pain assessment
B. Airway and breathing assessment
C. Dietary history
D. Psychosocial assessment
Answer: B
Rationale: Airway and breathing are immediate priorities because
impaired oxygenation can rapidly become life-threatening.
2. Which finding requires the nurse's immediate intervention?
A. Temperature 37.2°C (99°F)
B. Respiratory rate 8/min
C. Blood pressure 128/76 mmHg
D. Pulse 78/min
Answer: B
Rationale: A respiratory rate of 8/min indicates significant bradypnea
and possible respiratory depression.
3. Which action best reduces transmission of microorganisms?
A. Wearing gloves for every client interaction
B. Performing hand hygiene appropriately
C. Wearing a surgical mask continuously
D. Using sterile equipment for every procedure
,Answer: B
Rationale: Proper hand hygiene is the most fundamental measure for
preventing healthcare-associated infection.
4. A client is at high risk for falls. Which intervention is most
appropriate?
A. Keep all four side rails raised
B. Place the call light within reach
C. Keep the room dark at night
D. Encourage the client to walk independently
Answer: B
Rationale: Easy access to the call light allows the client to request
assistance before attempting to get out of bed.
5. Which patient should the nurse assess first?
A. Client requesting a blanket
B. Client with new-onset confusion and oxygen saturation of 84%
C. Client waiting for discharge instructions
D. Client reporting chronic back pain
Answer: B
Rationale: Acute confusion with severe hypoxemia indicates an
immediate oxygenation problem.
6. A nurse is preparing to administer medication. Which action is most
important before administration?
A. Ask another nurse to administer it
B. Verify the medication against the prescription and client identifiers
C. Document administration first
D. Explain every possible adverse effect
,Answer: B
Rationale: Medication verification and correct patient identification are
essential components of medication safety.
7. Which assessment finding is most concerning in a postoperative
client?
A. Incisional discomfort
B. Mild nausea
C. Oxygen saturation of 88%
D. Decreased appetite
Answer: C
Rationale: Hypoxemia is an immediate physiologic concern and
requires prompt assessment and intervention.
8. Which position generally promotes lung expansion in a client
experiencing dyspnea?
A. Supine
B. High-Fowler's
C. Trendelenburg
D. Prone with legs elevated
Answer: B
Rationale: High-Fowler's positioning facilitates diaphragmatic
expansion and improves ventilation.
9. A client suddenly becomes unresponsive. What should the nurse do
first?
A. Obtain a complete medical history
B. Assess responsiveness and breathing
C. Call the family
D. Document the event
, Answer: B
Rationale: Immediate assessment determines whether emergency
resuscitation is required.
10. Which documentation is most appropriate?
A. "Patient seems better."
B. "Patient had a bad night."
C. "Client reports pain decreased from 8/10 to 3/10 30 minutes after
medication."
D. "Client tolerated treatment well."
Answer: C
Rationale: Objective, measurable documentation is more useful than
vague statements.
11. Which finding is considered an expected age-related change in
many older adults?
A. Acute confusion
B. Decreased skin elasticity
C. New unilateral weakness
D. Sudden vision loss
Answer: B
Rationale: Reduced skin elasticity is a common physiologic change
associated with aging.
12. Which assessment technique should the nurse use first when
examining the abdomen?
A. Palpation
B. Percussion
C. Auscultation
D. Deep palpation
Questions and Answers with Rationales 2026/2027
Update - Nightingale College
Fundamentals, Assessment & Safety
1. A nurse assesses a client who reports sudden shortness of breath.
Which assessment should the nurse perform first?
A. Pain assessment
B. Airway and breathing assessment
C. Dietary history
D. Psychosocial assessment
Answer: B
Rationale: Airway and breathing are immediate priorities because
impaired oxygenation can rapidly become life-threatening.
2. Which finding requires the nurse's immediate intervention?
A. Temperature 37.2°C (99°F)
B. Respiratory rate 8/min
C. Blood pressure 128/76 mmHg
D. Pulse 78/min
Answer: B
Rationale: A respiratory rate of 8/min indicates significant bradypnea
and possible respiratory depression.
3. Which action best reduces transmission of microorganisms?
A. Wearing gloves for every client interaction
B. Performing hand hygiene appropriately
C. Wearing a surgical mask continuously
D. Using sterile equipment for every procedure
,Answer: B
Rationale: Proper hand hygiene is the most fundamental measure for
preventing healthcare-associated infection.
4. A client is at high risk for falls. Which intervention is most
appropriate?
A. Keep all four side rails raised
B. Place the call light within reach
C. Keep the room dark at night
D. Encourage the client to walk independently
Answer: B
Rationale: Easy access to the call light allows the client to request
assistance before attempting to get out of bed.
5. Which patient should the nurse assess first?
A. Client requesting a blanket
B. Client with new-onset confusion and oxygen saturation of 84%
C. Client waiting for discharge instructions
D. Client reporting chronic back pain
Answer: B
Rationale: Acute confusion with severe hypoxemia indicates an
immediate oxygenation problem.
6. A nurse is preparing to administer medication. Which action is most
important before administration?
A. Ask another nurse to administer it
B. Verify the medication against the prescription and client identifiers
C. Document administration first
D. Explain every possible adverse effect
,Answer: B
Rationale: Medication verification and correct patient identification are
essential components of medication safety.
7. Which assessment finding is most concerning in a postoperative
client?
A. Incisional discomfort
B. Mild nausea
C. Oxygen saturation of 88%
D. Decreased appetite
Answer: C
Rationale: Hypoxemia is an immediate physiologic concern and
requires prompt assessment and intervention.
8. Which position generally promotes lung expansion in a client
experiencing dyspnea?
A. Supine
B. High-Fowler's
C. Trendelenburg
D. Prone with legs elevated
Answer: B
Rationale: High-Fowler's positioning facilitates diaphragmatic
expansion and improves ventilation.
9. A client suddenly becomes unresponsive. What should the nurse do
first?
A. Obtain a complete medical history
B. Assess responsiveness and breathing
C. Call the family
D. Document the event
, Answer: B
Rationale: Immediate assessment determines whether emergency
resuscitation is required.
10. Which documentation is most appropriate?
A. "Patient seems better."
B. "Patient had a bad night."
C. "Client reports pain decreased from 8/10 to 3/10 30 minutes after
medication."
D. "Client tolerated treatment well."
Answer: C
Rationale: Objective, measurable documentation is more useful than
vague statements.
11. Which finding is considered an expected age-related change in
many older adults?
A. Acute confusion
B. Decreased skin elasticity
C. New unilateral weakness
D. Sudden vision loss
Answer: B
Rationale: Reduced skin elasticity is a common physiologic change
associated with aging.
12. Which assessment technique should the nurse use first when
examining the abdomen?
A. Palpation
B. Percussion
C. Auscultation
D. Deep palpation
