BSN 225 HESI Prep Fundamentals of Nursing Exam —
100-Question Comprehensive Study Guide
Verified Questions and Answers — Latest Update 2026
SECTION A: NURSING PROCESS & CRITICAL THINKING (Questions 1–25)
1. A nurse is using the nursing process to plan care for a client. What is the primary purpose of the
nursing process?
A. To provide a standardized medical diagnosis
B. To organize clinical thinking and decision-making about client needs
C. To replace communication with other healthcare professionals
D. To eliminate the need for reassessment
Answer: B.
Rationale: The nursing process provides a systematic framework for assessment, clinical judgment,
planning, implementation, and evaluation of client care. It does not replace communication or eliminate
reassessment .
2. Which finding is subjective data?
A. Temperature of 38.5°C (101.3°F)
B. Heart rate of 104/min
C. "I feel nauseated."
D. Oxygen saturation of 91%
Answer: C.
Rationale: Subjective data are symptoms or experiences reported by the client that cannot be directly
measured. Vital signs are objective data .
,3. Which action represents the assessment phase of the nursing process?
A. Establishing a measurable goal
B. Collecting subjective and objective information
C. Administering prescribed medication
D. Determining whether the goal was achieved
Answer: B.
Rationale: Assessment involves systematic collection and validation of information about the client's
health status. Establishing goals is planning; administering medication is implementation .
4. A nurse identifies that a client has a risk for falling because of weakness and an unsteady gait. Which
type of nursing diagnosis is this?
A. Actual
B. Risk
C. Syndrome
D. Health-promotion
Answer: B.
Rationale: A risk diagnosis identifies a potential problem when risk factors are present but the problem
has not yet occurred. An actual diagnosis describes a current problem .
5. Which client should the nurse assess first?
A. Client requesting assistance with bathing
B. Client reporting sudden difficulty breathing
C. Client waiting for discharge instructions
D. Client requesting a snack
,Answer: B.
Rationale: Breathing problems can represent an immediate threat to life. The nurse prioritizes airway,
breathing, and circulation .
6. A nurse reassesses a client's pain 30 minutes after administering an analgesic. Which nursing-process
phase is being performed?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Answer: D.
Rationale: Evaluation determines whether the intervention achieved the desired outcome.
Reassessment after an intervention helps determine its effectiveness .
7. Which outcome is written appropriately?
A. "Client will feel better."
B. "Client will understand the treatment."
C. "Client will report pain at or below 3/10 within 1 hour."
D. "Client will improve."
Answer: C.
Rationale: A good outcome is specific, measurable, and time-limited (SMART). Option C meets all criteria
.
8. A nurse is preparing to administer medication. Which action is essential for client identification?
A. Ask the client's roommate to identify the client
, B. Use two approved client identifiers
C. Identify the client by room number only
D. Ask the family member to confirm the client's identity
Answer: B.
Rationale: Two identifiers help prevent wrong-client medication and treatment errors. Room numbers
should not be used as an identifier .
9. A nurse receives an unclear medication prescription. What should the nurse do?
A. Administer the medication based on the most likely interpretation
B. Ask another client what the prescription means
C. Clarify the prescription with the appropriate prescriber
D. Skip the medication without notifying anyone
Answer: C.
Rationale: Nurses should never guess about unclear prescriptions. Clarification prevents medication
errors .
10. Which action is most effective in preventing healthcare-associated infection?
A. Wearing gloves for every client interaction
B. Performing appropriate hand hygiene
C. Wearing a gown for every procedure
D. Using antibiotics prophylactically for every client
Answer: B.
Rationale: Hand hygiene is a fundamental infection-prevention measure. Gloves do not replace hand
hygiene .
100-Question Comprehensive Study Guide
Verified Questions and Answers — Latest Update 2026
SECTION A: NURSING PROCESS & CRITICAL THINKING (Questions 1–25)
1. A nurse is using the nursing process to plan care for a client. What is the primary purpose of the
nursing process?
A. To provide a standardized medical diagnosis
B. To organize clinical thinking and decision-making about client needs
C. To replace communication with other healthcare professionals
D. To eliminate the need for reassessment
Answer: B.
Rationale: The nursing process provides a systematic framework for assessment, clinical judgment,
planning, implementation, and evaluation of client care. It does not replace communication or eliminate
reassessment .
2. Which finding is subjective data?
A. Temperature of 38.5°C (101.3°F)
B. Heart rate of 104/min
C. "I feel nauseated."
D. Oxygen saturation of 91%
Answer: C.
Rationale: Subjective data are symptoms or experiences reported by the client that cannot be directly
measured. Vital signs are objective data .
,3. Which action represents the assessment phase of the nursing process?
A. Establishing a measurable goal
B. Collecting subjective and objective information
C. Administering prescribed medication
D. Determining whether the goal was achieved
Answer: B.
Rationale: Assessment involves systematic collection and validation of information about the client's
health status. Establishing goals is planning; administering medication is implementation .
4. A nurse identifies that a client has a risk for falling because of weakness and an unsteady gait. Which
type of nursing diagnosis is this?
A. Actual
B. Risk
C. Syndrome
D. Health-promotion
Answer: B.
Rationale: A risk diagnosis identifies a potential problem when risk factors are present but the problem
has not yet occurred. An actual diagnosis describes a current problem .
5. Which client should the nurse assess first?
A. Client requesting assistance with bathing
B. Client reporting sudden difficulty breathing
C. Client waiting for discharge instructions
D. Client requesting a snack
,Answer: B.
Rationale: Breathing problems can represent an immediate threat to life. The nurse prioritizes airway,
breathing, and circulation .
6. A nurse reassesses a client's pain 30 minutes after administering an analgesic. Which nursing-process
phase is being performed?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Answer: D.
Rationale: Evaluation determines whether the intervention achieved the desired outcome.
Reassessment after an intervention helps determine its effectiveness .
7. Which outcome is written appropriately?
A. "Client will feel better."
B. "Client will understand the treatment."
C. "Client will report pain at or below 3/10 within 1 hour."
D. "Client will improve."
Answer: C.
Rationale: A good outcome is specific, measurable, and time-limited (SMART). Option C meets all criteria
.
8. A nurse is preparing to administer medication. Which action is essential for client identification?
A. Ask the client's roommate to identify the client
, B. Use two approved client identifiers
C. Identify the client by room number only
D. Ask the family member to confirm the client's identity
Answer: B.
Rationale: Two identifiers help prevent wrong-client medication and treatment errors. Room numbers
should not be used as an identifier .
9. A nurse receives an unclear medication prescription. What should the nurse do?
A. Administer the medication based on the most likely interpretation
B. Ask another client what the prescription means
C. Clarify the prescription with the appropriate prescriber
D. Skip the medication without notifying anyone
Answer: C.
Rationale: Nurses should never guess about unclear prescriptions. Clarification prevents medication
errors .
10. Which action is most effective in preventing healthcare-associated infection?
A. Wearing gloves for every client interaction
B. Performing appropriate hand hygiene
C. Wearing a gown for every procedure
D. Using antibiotics prophylactically for every client
Answer: B.
Rationale: Hand hygiene is a fundamental infection-prevention measure. Gloves do not replace hand
hygiene .
