HESI BSN 225 DETAILED STUDY GUIDE QUESTION AND CORRECT ANSWERS EXAM 2026 GUARANTEE A+

BSN 225 BSN 225 HESI BSN 225 DETAILED STUDY GUIDE QUESTION AND CORRECT ANSWERS EXAM 2026 GUARANTEE A+ A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time? a. Transferrin b. Prealbumin c. Serum albumin d. Urine urea nitrogen - Correct Ans-c. Serum albumin Rationale: Serum albumin has a long half-life and is the best long-term indicator of the body's entry into a catabolic state following protein depletion from malnutrition or stress of chronic illness (C). The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? a. Temperature increases from 98.8 to 99.0 F. b. Pulse rate decreases from 78 to 52 beats/min. c. Respiratory rate increases from 16 to 24 breaths/min. d. Blood pressure increases from 110/84 to 118/88 mm/Hg. - Correct Ans-b. Pulse rate decreases from 78 to 52 beats/min. Rationale: Parasympathetic reaction can occur as a result of digital stimulation of the anal sphincter, which should be stopped if the client experiences a vagal response, such as bradycardia (B). Which statement is an example of a correctly written nursing diagnosis statement? a. Altered tissue perfusion related to congestive heart failure. b. Altered urinary elimination related to urinary tract infection. c. Risk for impaired tissue integrity related to client's refusal to turn. d. Ineffective coping related to response to positive biopsy test results. - Correct Ans-d. Ineffective coping related to response to positive biopsy test results. Rationale: The first part of the nursing diagnosis statement is the "diagnostic label" and is followed by "related to" the cause, which should direct the nurse to the appropriate interventions. The daughter of an older woman who became depressed following the death of her husband asks, "My mother was always well-adjusted until my father died. Will she tend to be sick from now on?" Which response is best for the nurse to provide? a. "She is almost sure to be less able to adapt than before." b. "It's highly likely that she will recover and return to her pre-illness state." c. "If you can interest her in something besides religion, it will help her stay well." BSN 225 BSN 225 d. "Cultural strains contribute to each woman's tendencies for recurrences of depression." - Correct Ans-b. "It's highly likely that she will recover and return to her pre illness state." Rationale: Analysis of behavior patterns using Erikson's framework can identify age-appropriate or arrested development of normal interpersonal skills. Erikson describes the successful resolution of a developmental crisis in the later years (older than 65-years) to include the achievement of a sense of integrity and fulfillment, wisdom, and a willingness to face one's own mortality and accept the death of others (B). A client is demonstrating a positive Chvostek's sign. What action should the nurse take? a. Observe the client's pupil size and response to light. b. Ask the client about numbness or tingling in the hands. c. Assess the client's serum potassium level. d. Restrict dietary intake of calcium-rich foods. - Correct Ans-b. Ask the client about numbness or tingling in the hands. Rationale: A positive Chvostek's sign is an indication of hypocalcemia, so the client should be assessed for the subjective symptoms of hypocalcemia, such as numbness or tingling of the hands (B) or feet. A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement? a. Document the client's request in the medical record. b. Ask the client if this decision has been discussed with his healthcare provider. c. Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. d. Advise the client to designate a person to make healthcare decisions when the client is unable to do so. - Correct Ans-b. Ask the client if this decision has been discussed with his healthcare provider. Rationale: Advance directives are written statements of a person's wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider (B). An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first? a. Apply flannel pajamas to provide warmth. b. Administer a PRN dose of ibuprofen. c. Perform range of motion exercises in a warm tub. d. Drape the sheets over the footboard of the bed. - Correct Ans-d. Drape the sheets over the footboard of the bed. Rationale: The nurse should first provide an immediate comfort measure to address the client's complaint about the linens and drape the linens over the footboard of the bed BSN 225 BSN 225 (D) instead of tucking them under the mattress, which can add pressure perceived by the client as the source of her pain. While the nurse is administering a bolus feeding to a client via nasogastric tube, the client begins to vomit. What action should the nurse implement first? a. Discontinue the administration of the bolus feeding. b. Auscultate the client's breath sounds bilaterally. c. Elevate the head of the bed to a high Fowler's position. d. Administer a PRN dose of a prescribed antiemetic. - Correct Ans-a. Discontinue the administration of the bolus feeding. Rationale: When a client receiving a tube feeding begins to vomit, the nurse should first stop the feeding (A) to prevent further vomiting. As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the treatment room, he cries continuously. What intervention should the nurse implement? a. Take the child back to his room. b. Recruit others to restrain the child. c. Ask the mother to be present to soothe the child. d. Show the child how to manipulate the equipment. - Correct Ans-c. Ask the mother to be present to soothe the child. Rationale: A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities. The mother's assistance (C) can provide a stabilizing presence to help soothe the preschooler, who may perceive the invasive procedure as mutilating. A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration? a. Suggest that other cultural practices be substituted by the family members. b. Examine one's own culturally based values, beliefs, attitudes, and practices. c. Explain to the family that multiple visitors are exhausting to the client. d. Allow the situation to continue until a family member's action may harm the client. - Correct Ans-b. Examine one's own culturally based values, beliefs, attitudes, and practices. Rationale: Acknowledging a client's beliefs and customs related to sickness and health care are valuable components in the plan of care that prevents conflict between the goals of nursing and the client's cultural practices. Cultural sensitivity begins with examining one's own cultural values to compare, recognize, and acknowledge cultural bias. Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse effects of the medication listed in a drug reference guide and determines the priority risks to the client. While performing this action, the nurse is engaged in which step of the nursing process? a. Assessment. b. Analysis. BSN 225 BSN 225 c. Implementation. d. Evaluation. - Correct Ans-b. Analysis Rationale: The nurse is analyzing (B) data to establish an individualized nursing diagnosis, such as, "Risk for injury related to side effects of drugs." When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse respond? "There is no reason to be so angry." "Why do I need to leave your room?" "What is concerning you this morning?" "Let me call the client advocate for you." - Correct Ans-c. "What is concerning you this morning?" Rationale: (C) is an open-ended question that encourages the client to discuss personal feelings. The nurse removes the dressing on a client's heel that is covering a pressure sore one inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record? a. Stage 1 pressure sore draining sero-sanguineous drainage. b. Pressure sore at bony prominence with exudate noted. c. One-inch pressure sore draining serous fluid. d. Pressure sore on heel with a small amount of purulent drainage. - Correct Ans-c. One-inch pressure sore draining serous fluid. Rationale: Serous drainage is clear watery plasma, so (C) provides accurate documentation based on the information provided. Which client assessment data is most important for the nurse to consider before ambulating a postoperative client? a. Respiratory rate. b. Wound location. c. Pedal pulses. d. Pain rating. - Correct Ans-a. Respiratory rate. Rationale: Mobilization and ambulation increase oxygen use, so it is most important to assess the client's respiratory rate (A) before ambulation to determine tolerance for activity. A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? a. Hydrogel. b. Exudate absorber. c. Wet to moist dressing. d. Transparent adhesive film. - Correct Ans-c. Wet to moist dressing. Rationale: To provide moisture and loosen the necrotic tissue, the eschar should be covered first with wet to moist dressings (C), which are discontinued and then a BSN 225 BSN 225 hydrogel alginate can be placed in the prepared wound bed to prevent further damage of granulating any surrounding tissue. What is the rationale for using the nursing process in planning care for clients? a. As a scientific process to identify nursing diagnoses of a clients' healthcare problems. b. To establish nursing theory that incorporates the biopsychosocial nature of humans. c. As a tool to organize thinking and clinical decision making about clients' healthcare needs. d. To promote the management of client care in collaboration with other healthcare professionals. - Correct Ans-c. As a tool to organize thinking and clinical decision making about clients' healthcare needs. Rationale: The nursing process is a problem-solving approach that provides an organized, systematic, decision making process to effectively address the client's needs and problems. The nursing process includes an organized framework using knowledge, judgments, and actions by the nurse as the client's plan of care is determined, and encompasses assessment, analysis, planning, implementation, and evaluation of client care. The nurses determines a client's IV solution is infusing at 250 ml/hr. The prescribed rate is 125 ml/hr. What action should the nurse take first? a. Determine when the IV solution was started. b. Slow the IV infusion to keep vein open rate. c. Assess the IV insertion site for swelling. d. Report the finding to the healthcare provider. - Correct Ans-b. Slow the IV infusion to keep vein open rate. Rationale: The nurse should first slow the IV flow rate to keep vein open (KVO) rate (B) to prevent further risk of fluid volume overload, then gather additional assessment data, such as when the IV solution was started (A) and the appearance of the IV insertion site (C) before contacting the healthcare provider (D) for further instructions. What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? Maintain in a lateral position using protective wrist and vest devices. Position prone with a small pillow below the diaphragm. Raise the head and knee gatch when lying in a supine position. Transfer into a wheelchair close to the nurse's station for observation. - Correct Ans-b. Position prone with a small pillow below the diaphragm. Rationale: The prone position (B) using a small pillow below the diaphragm maintains alignment and provides the best pressure relief over the sacral bony prominence.