BSN HESI 225 Fundamentals of Nursing Exam –
Questions & Answers | Grade A | 100% Correct
(Verified Solutions) – Nightingale
1. What is the primary purpose of the nursing process?
a) To delegate tasks to nursing assistants
b) To provide a systematic framework for patient-centered care
c) To replace the physician's medical diagnosis
d) To document care for legal purposes
2. During which phase of the nursing process does the nurse set
priorities and establish patient goals?
a) Assessment
b) Diagnosis
c) Planning
d) Evaluation
3. A patient has a temperature of 102.5°F (39.2°C). Which of the
following is a subjective data related to this?
a) Flushed skin
b) Tachycardia
c) "I feel very hot and sweaty."
d) Increased respiratory rate
4. The nurse is preparing to administer a tuberculin skin test. Which
needle and angle are most appropriate?
a) 25-gauge, 45-degree angle
b) 27-gauge, 15-degree angle
,c) 20-gauge, 90-degree angle
d) 22-gauge, 10-degree angle
5. Which action by the nurse best demonstrates the principle of
medical asepsis?
a) Sterilizing a surgical instrument
b) Performing hand hygiene
c) Placing a patient in a protective environment
d) Donning a sterile gown and gloves
6. A patient is on contact precautions for Clostridium difficile (C. diff).
Which personal protective equipment (PPE) is essential for the nurse?
a) Gown and Gloves
b) N95 Respirator, Gown, and Gloves
c) Surgical Mask and Gloves
d) Gloves only
7. When moving a patient up in bed, what should the nurse do to
prevent self-injury?
a) Keep the feet together
b) Bend at the waist
c) Raise the bed to waist level
d) Use the arms and back muscles to lift
8. A patient's IV infusion is not flowing. The nurse notes the area is
swollen, cool, and pale. What is the most likely problem?
a) Infiltration
b) Phlebitis
c) Infection
d) Air Embolism
,9. The "rights" of medication administration include all of the
following EXCEPT:
a) Right Patient
b) Right Dose
c) Right Route
d) Right Brand Name
10. Which vital sign is the most sensitive indicator of fluid balance in
an adult?
a) Blood Pressure
b) Pulse Rate
c) Respiratory Rate
d) Daily Weight
11. A nurse is teaching a patient about a low-sodium diet. This is an
example of which level of prevention?
a) Primary Prevention
b) Secondary Prevention
c) Tertiary Prevention
d) Risk Factor Prevention
12. What is the correct sequence for donning PPE?
a) Gown, Mask, Goggles, Gloves
b) Goggles, Mask, Gown, Gloves
c) Gown, Mask, Gloves, Goggles
d) Gown, Goggles/Mask, Gloves
13. The first action a nurse should take when discovering a fire is:
a) Extinguish the fire
b Activate the alarm
, c) Rescue the patients
d) Confine the fire
14. A patient with heart failure has 2+ pitting edema in his ankles.
How does the nurse document this finding?
a) A 1 cm depth depression that disappears rapidly
b) A 2 cm depth depression that disappears in 10-15 seconds
c) A 4 mm depth depression that disappears immediately
d) A 4 cm depth depression that lasts for over 2 minutes
15. Which finding requires immediate intervention during a
neurovascular assessment?
a) Capillary refill of 3 seconds
b) Pain with passive movement
c) Skin pink and warm to touch
d) Sensation present
16. When documenting a patient's response to pain medication, the
most objective statement is:
a) "Patient appears comfortable."
b) "Patient states pain is 2/10."
c) "Patient is resting well."
d) "Patient seems to be in less pain."
17. A nurse is preparing to insert a nasogastric (NG) tube. To
determine the correct length, the nurse should measure from the:
a) Tip of the nose to the xiphoid process
b) Earlobe to the xiphoid process
c) Tip of the nose to the umbilicus
d) Earlobe to the nose to the umbilicus
Questions & Answers | Grade A | 100% Correct
(Verified Solutions) – Nightingale
1. What is the primary purpose of the nursing process?
a) To delegate tasks to nursing assistants
b) To provide a systematic framework for patient-centered care
c) To replace the physician's medical diagnosis
d) To document care for legal purposes
2. During which phase of the nursing process does the nurse set
priorities and establish patient goals?
a) Assessment
b) Diagnosis
c) Planning
d) Evaluation
3. A patient has a temperature of 102.5°F (39.2°C). Which of the
following is a subjective data related to this?
a) Flushed skin
b) Tachycardia
c) "I feel very hot and sweaty."
d) Increased respiratory rate
4. The nurse is preparing to administer a tuberculin skin test. Which
needle and angle are most appropriate?
a) 25-gauge, 45-degree angle
b) 27-gauge, 15-degree angle
,c) 20-gauge, 90-degree angle
d) 22-gauge, 10-degree angle
5. Which action by the nurse best demonstrates the principle of
medical asepsis?
a) Sterilizing a surgical instrument
b) Performing hand hygiene
c) Placing a patient in a protective environment
d) Donning a sterile gown and gloves
6. A patient is on contact precautions for Clostridium difficile (C. diff).
Which personal protective equipment (PPE) is essential for the nurse?
a) Gown and Gloves
b) N95 Respirator, Gown, and Gloves
c) Surgical Mask and Gloves
d) Gloves only
7. When moving a patient up in bed, what should the nurse do to
prevent self-injury?
a) Keep the feet together
b) Bend at the waist
c) Raise the bed to waist level
d) Use the arms and back muscles to lift
8. A patient's IV infusion is not flowing. The nurse notes the area is
swollen, cool, and pale. What is the most likely problem?
a) Infiltration
b) Phlebitis
c) Infection
d) Air Embolism
,9. The "rights" of medication administration include all of the
following EXCEPT:
a) Right Patient
b) Right Dose
c) Right Route
d) Right Brand Name
10. Which vital sign is the most sensitive indicator of fluid balance in
an adult?
a) Blood Pressure
b) Pulse Rate
c) Respiratory Rate
d) Daily Weight
11. A nurse is teaching a patient about a low-sodium diet. This is an
example of which level of prevention?
a) Primary Prevention
b) Secondary Prevention
c) Tertiary Prevention
d) Risk Factor Prevention
12. What is the correct sequence for donning PPE?
a) Gown, Mask, Goggles, Gloves
b) Goggles, Mask, Gown, Gloves
c) Gown, Mask, Gloves, Goggles
d) Gown, Goggles/Mask, Gloves
13. The first action a nurse should take when discovering a fire is:
a) Extinguish the fire
b Activate the alarm
, c) Rescue the patients
d) Confine the fire
14. A patient with heart failure has 2+ pitting edema in his ankles.
How does the nurse document this finding?
a) A 1 cm depth depression that disappears rapidly
b) A 2 cm depth depression that disappears in 10-15 seconds
c) A 4 mm depth depression that disappears immediately
d) A 4 cm depth depression that lasts for over 2 minutes
15. Which finding requires immediate intervention during a
neurovascular assessment?
a) Capillary refill of 3 seconds
b) Pain with passive movement
c) Skin pink and warm to touch
d) Sensation present
16. When documenting a patient's response to pain medication, the
most objective statement is:
a) "Patient appears comfortable."
b) "Patient states pain is 2/10."
c) "Patient is resting well."
d) "Patient seems to be in less pain."
17. A nurse is preparing to insert a nasogastric (NG) tube. To
determine the correct length, the nurse should measure from the:
a) Tip of the nose to the xiphoid process
b) Earlobe to the xiphoid process
c) Tip of the nose to the umbilicus
d) Earlobe to the nose to the umbilicus
