BSN 225 HESI Nursing Fundamentals Review Exam 2026

BSN 225 BSN 225 BSN 225 HESI Nursing Fundamentals Review Exam 2026 Client safety - -The nurse should help the client lie back down & then explain to the spouse the need for ambulation to reduce potential postoperative complications. ROM exercises - -Hinge Joints allow flexion & extension movements. The humeroulnuar joint at the elbow & is performed by flexing the bicep to move the ulnar to the humerus & extending the triceps to move the ulnar away from the humerus. Clear liquid diet - -A client who is on a clear liquid diet has coffee on the tray. Black coffee is considered a clear liquid, but the nurse should remind the client that no milk or creamer can be added to the coffee. Braden risk assessment- turning - -A score of 10 on the Braden risk assessment scale indicate that the client should be turned frequently. This scale is a reliable tool used to measure the clients risk for the development of pressure sores. Sores range from 6-23, with the lower scores indicating the highest risk for pressure sore development. Sleep- insomnia - -Sleeping disturbances, such as insomnia, are most common in post menopausal women. A regular routine for bedtime & morning awakening can help set the carcadian clock. Avoiding caffeine before the hours of sleep can help with sleep since coffee contains caffeine, a stimulant. Alcohol should be avoided since it can cause fragmented sleep. Pain Management - -Until the health care professional responds, the nurse should provide nonpharmacological pain modalities. Guided imagery & coaching in slow rhythmic breathing are methods that can be effective in moderate pain management. Conversion- PO- g/ml- 1000mg = 1 g. 1000 mg: X mL: 200 mg : 5 mL - -200X= 1000 (5). X= 5000/200 = 25 mL HIPAA regulations - -The client's condition is protected by the Privacy Rule under the Health Insurance Portivility & Accountability Act (HIPAA), & the communication/Marketing department can determine whether or not the client has authorized disclosure of his or her protected heath information to the media. Unauthorized disclosure of information is illegal. Informed consent - -It is the health care professionals responsibility to ensure that the client understands the risks & benefits for the procedure, & the nurse only witnesses the BSN 225 BSN 225 signature on the consent form after the client indicates they understand. The health care provider should be called back to the clients room to clarify any questions & misconceptions. Explaining the procedure again is the health care providers responsibility. Risk for Infection - -One of the most important factors impacting the spread of infection is the susceptibility of the host. Suppression of the immune system greatly increases the susceptibility of the host, & if hospitalized, increases the risk for nosocomial infection. Side effects assess - -To determine how potential side effects (expected, but undesirable effects) of a medication my impact a client, the nurse should assess the client for health alterations related to the medication & its potential side effects. Electronic Documentation - -Notifying the information services department is most important to expedite the availability of the EMR & initiate problem solving in determining nursing actions to be implemented to continue client care. Pain- Quality - -Quality of pain refers to how the client describes the pain, using words such as stabbing, throbbing, or aching provide information about pain quality. Cath insertion technique - -While inserting an urinary catheter into a client & urine is observed, the catheter should be advanced another inch, to ensure that the balloon will be inflated in the bladder, rather than the urethra. Culture- constipation - -It is common for cultures, such as Native Americans, to believe in using home remedies & herbs before seeking medical attention. Cascara Sagrada is one of the most commonly used herbal remedies for constipation & can cause significant cramping and nausea. Family care- how - -1st the nurse should assess the wife's desires & ability to cope with this life change. The best approach at this point is to obtain information about what the wife wants & ask her how she would want to participate in her husband's care. Droplet precautions - -The top edge of a surgical face mask should be secured over the bridge of the nose just below the eyeglasses to provide a snugly-fitting mask that prevents transmission of pathogens while the client is transported outside the room. Transporting the client without protective equipment endangers other persons who might come in contact with the client. A fitted respirator-style mask is not necessary unless the clients placed on airborne precautions for tuberculosis. Protective goggles are used by caregivers likely to be in contact with potentially contaminated body fluids & do not need to be worn by the client. confused client- action - -A confused client who is wandering is at risk for injury. The nurse should orient the client to her surroundings, escort the client to her room to promote sleep, & use a bed alarm to alert the nurse to further wandering behavior. BSN 225 BSN 225 Korotkoff sound-immediate - -Kortkoff sounds describe blood pressure from the first sound, which is a clear, rhythmic, tapping sound that corresponds with systolic blood pressure, to the 5th sound which is a disappearance of all sound & corresponds with diastolic blood pressure. If the 1st kortkoff sound is heard immediately after releasing the valve, it means that the cuff was not inflated high enough & all the air should be released & the cuff reflated to a higher level. Cyanosis- respiration rate - -Cyanosis, a bluish discoloration, is an indication of hypoxemia, so it is most important for the nurse to assess the client's respiratory function first, followed by the remaining vital signs. Oxygenation - -Low O2 levels may cause confusion and combativeness, sot he highest priority is assessment of peripheral O2 saturation, which evaluates oxygenation to the brain as well as distal to the restraints. The anxiolytic may be helpful, but can also mask symptoms, so this intervention may be necessary when developing a plan of care. A sitter might be helpful, but assessment of O2 saturation guides further interventions. Grimacing- assessment - -Grimacing is a nonverbal sign of pain, so first this sign should be clarified, The nurse should continue to monitor for nonverbal signs of pain if the client continues to deny pain. The pain medication should be reviewed to determine what is prescribed & then administer if the client admits to pain or discomfort. IM- mg/mL 0.4 mg : 1 ml= 0.4X=1 X=1/0.4 - -=2.5 ml Therapeautic communication - -Reflecting how difficult the situation ust befor the patient is an open-ended response the nurse should make that encourages dialogue & addresses the parents feelings. Pedal Pulse - -Firm pressure may obliterate a weak pulse, sot he nurse should 1st reduce the amount of pressure being applied at the site, If the pulse is still not palpable, the nurse may use a doppler stethoscope. Assess Feces - -Multiple hard pallets may indicate problems with constipation or inadequate fluid intake. A tarry appearance or read streaks may indicate bleeding. Brown liquid may indicate diarrhea or decal impaction. HIPAA- emancipated - -The client has legally separated themselves from their parents before they reach 18-years-old. Once emancipated, the law protects them as an adult. Providing the client's parents with the results violateds HIPAA requirements. According to HIPAA, no healthcare provider may share information with another individual unless express consent has been given by the client or assigned medical power of attorney has been established. 24 hour urine collection - -The urine collected from the 1st specimen was in the bladder before the 24 hour. Specimen collection was started, so it should be discarded.