1|Page
BSN 225 HESI RN Specialty Fundamentals of Nursing
Exam V1
Comprehensive Exam Prep with Practice Questions,
Detailed Rationales & Answer Explanations
1. A client who is 2 days post-operative from abdominal surgery reports a sudden onset of sharp chest
pain and shortness of breath. What is the nurse's priority action?
A. Administer the prescribed PRN pain medication.
B. Encourage the client to take deep breaths.
C. Assess the client's oxygen saturation and vital signs.
D. Document the client's complaint in the medical record.
Correct Answer: C. Assess the client's oxygen saturation and vital signs.
The client's symptoms are classic for a pulmonary embolism, a life-threatening post-operative
complication. The nurse's first action is to assess the client's respiratory status and vital signs to
determine the severity of the situation and guide immediate interventions. Administering pain medication
or encouraging deep breathing without a full assessment could mask or worsen a critical condition.
Documentation is important but not the priority.
2. The nurse is preparing to administer a blood transfusion to a client. Which IV fluid should the nurse use
to prime the blood administration tubing?
A. 5% Dextrose in Water (D5W)
B. Lactated Ringer's (LR)
C. 0.9% Normal Saline (NS)
D. 0.45% Normal Saline (1/2 NS)
Correct Answer: C. 0.9% Normal Saline (NS).
Normal saline is the only isotonic solution that is compatible with blood products. Dextrose solutions can
cause hemolysis of red blood cells, and Lactated Ringer's contains calcium, which can cause clotting in
the IV tubing.
,2|Page
3. A client with a history of heart failure is receiving a continuous IV infusion of a vasopressor. The nurse
needs to administer a new, incompatible IV medication. What is the safest action for the nurse to take?
A. Connect the new medication to the same IV port.
B. Turn off the vasopressor infusion and flush the line.
C. Start a new IV line for the new medication.
D. Administer the new medication orally if possible.
Correct Answer: C. Start a new IV line for the new medication.
To prevent a life-threatening interaction or a sudden change in the vasopressor's effect, incompatible
medications should never be given through the same line. Starting a new, separate IV line for the new
medication is the safest option. Flushing the line is not a safe practice with continuous infusions of
critical medications.
4. The nurse is providing discharge teaching to a client with a new prescription for warfarin. Which
statement by the client indicates a need for further teaching?
A. "I will report any unusual bleeding to my doctor."
B. "I should avoid eating large amounts of green leafy vegetables."
C. "I will use a soft-bristled toothbrush."
D. "I can take ibuprofen for my occasional headaches."
Correct Answer: D. "I can take ibuprofen for my occasional headaches."
Ibuprofen and other NSAIDs increase the risk of bleeding and should be avoided while taking warfarin.
The other statements are correct: bleeding should be reported, vitamin K-rich foods like green leafy
vegetables should be eaten in consistent amounts, and a soft-bristled toothbrush helps prevent gum
bleeding.
5. A client tells the nurse, "I feel like I'm going to pass out." Before the nurse can assist the client to a
chair, the client begins to fall. What is the most appropriate action for the nurse to take?
A. Grab the client's arm to break the fall.
B. Step back and allow the client to fall to the floor.
C. Gently lower the client to the floor while protecting the client's head.
D. Try to catch the client to prevent injury.
,3|Page
Correct Answer: C. Gently lower the client to the floor while protecting the client's head.
The priority is to prevent injury to both the client and the nurse. Lowering the client in a controlled
manner, using proper body mechanics, is the safest way to manage a patient's fall. Trying to catch a
falling patient can cause serious injury to the nurse and the patient.
6. The nurse is documenting a client's pain level. The client has their eyes closed, is breathing deeply, and
is unresponsive to questions. Which is the most appropriate documentation?
A. Client is asleep and resting comfortably.
B. Client's eyes closed, breathing deeply, no response to verbal stimuli.
C. Client appears to be in a deep sleep.
D. Client is unresponsive and appears comfortable.
Correct Answer: B. Client's eyes closed, breathing deeply, no response to verbal stimuli.
Objective documentation is crucial. The nurse should document what is observed (eyes closed, breathing
deeply) and what the client's response is to stimuli (no response to verbal stimuli). Avoid subjective
interpretations like "resting comfortably" or "appears comfortable."
7. The nurse needs to collect a stool sample for culture and sensitivity from a client with diarrhea. What is
the best method for the nurse to use?
A. Collect a sample from the client's bedpan.
B. Instruct the client to void before defecating into a clean container.
C. Use a cotton-tipped swab to obtain a small sample from the toilet bowl.
D. Ask the client to defecate directly into a sterile specimen cup.
Correct Answer: B. Instruct the client to void before defecating into a clean container.
To prevent contamination of the sample with urine, the client should be instructed to void first. A clean
container is acceptable for a stool culture. A sterile container is not typically required unless specified.
Samples from bedpans or toilet bowls are easily contaminated.
8. The nurse is teaching a client with a new colostomy about dietary choices to help reduce gas and odor.
Which food should the nurse recommend?
A. Cabbage
B. Beans
, 4|Page
C. Yogurt
D. Onions
Correct Answer: C. Yogurt.
Yogurt contains probiotics that can help reduce gas and odor. Cabbage, beans, and onions are all foods
known to produce gas and odor and should initially be limited.
9. A client with a urinary tract infection (UTI) is prescribed phenazopyridine. Which statement by the
client indicates a correct understanding of the medication's effect?
A. "This medication will cure my infection."
B. "I should take this medication with food."
C. "I may see an orange-red color in my urine."
D. "This will help with my fever and chills."
Correct Answer: C. "I may see an orange-red color in my urine."
Phenazopyridine is a urinary analgesic that provides relief from the burning and pain of a UTI. It is not
an antibiotic and does not treat the infection itself. A harmless side effect is that it turns the urine a bright
orange-red color, which can stain clothing.
10. The nurse is caring for a client who is 1 day post-operative after a total hip replacement. What is the
most important nursing intervention to prevent dislocation of the new hip?
A. Maintain the client in a high Fowler's position.
B. Keep the client's legs crossed at the ankle.
C. Position the client on the operative side.
D. Use an abduction pillow between the client's legs.
Correct Answer: D. Use an abduction pillow between the client's legs.
An abduction pillow helps keep the hip in proper alignment by preventing adduction (crossing the legs)
and internal rotation. This is a critical intervention to prevent post-operative dislocation after a hip
replacement, especially in the immediate post-operative period.
11. The nurse is calculating the intake and output for a client over a 12-hour shift. The client's intake
includes: 2 cups of coffee (240 mL each), 1 bowl of ice chips (200 mL), and 1 can of soda (355 mL).
BSN 225 HESI RN Specialty Fundamentals of Nursing
Exam V1
Comprehensive Exam Prep with Practice Questions,
Detailed Rationales & Answer Explanations
1. A client who is 2 days post-operative from abdominal surgery reports a sudden onset of sharp chest
pain and shortness of breath. What is the nurse's priority action?
A. Administer the prescribed PRN pain medication.
B. Encourage the client to take deep breaths.
C. Assess the client's oxygen saturation and vital signs.
D. Document the client's complaint in the medical record.
Correct Answer: C. Assess the client's oxygen saturation and vital signs.
The client's symptoms are classic for a pulmonary embolism, a life-threatening post-operative
complication. The nurse's first action is to assess the client's respiratory status and vital signs to
determine the severity of the situation and guide immediate interventions. Administering pain medication
or encouraging deep breathing without a full assessment could mask or worsen a critical condition.
Documentation is important but not the priority.
2. The nurse is preparing to administer a blood transfusion to a client. Which IV fluid should the nurse use
to prime the blood administration tubing?
A. 5% Dextrose in Water (D5W)
B. Lactated Ringer's (LR)
C. 0.9% Normal Saline (NS)
D. 0.45% Normal Saline (1/2 NS)
Correct Answer: C. 0.9% Normal Saline (NS).
Normal saline is the only isotonic solution that is compatible with blood products. Dextrose solutions can
cause hemolysis of red blood cells, and Lactated Ringer's contains calcium, which can cause clotting in
the IV tubing.
,2|Page
3. A client with a history of heart failure is receiving a continuous IV infusion of a vasopressor. The nurse
needs to administer a new, incompatible IV medication. What is the safest action for the nurse to take?
A. Connect the new medication to the same IV port.
B. Turn off the vasopressor infusion and flush the line.
C. Start a new IV line for the new medication.
D. Administer the new medication orally if possible.
Correct Answer: C. Start a new IV line for the new medication.
To prevent a life-threatening interaction or a sudden change in the vasopressor's effect, incompatible
medications should never be given through the same line. Starting a new, separate IV line for the new
medication is the safest option. Flushing the line is not a safe practice with continuous infusions of
critical medications.
4. The nurse is providing discharge teaching to a client with a new prescription for warfarin. Which
statement by the client indicates a need for further teaching?
A. "I will report any unusual bleeding to my doctor."
B. "I should avoid eating large amounts of green leafy vegetables."
C. "I will use a soft-bristled toothbrush."
D. "I can take ibuprofen for my occasional headaches."
Correct Answer: D. "I can take ibuprofen for my occasional headaches."
Ibuprofen and other NSAIDs increase the risk of bleeding and should be avoided while taking warfarin.
The other statements are correct: bleeding should be reported, vitamin K-rich foods like green leafy
vegetables should be eaten in consistent amounts, and a soft-bristled toothbrush helps prevent gum
bleeding.
5. A client tells the nurse, "I feel like I'm going to pass out." Before the nurse can assist the client to a
chair, the client begins to fall. What is the most appropriate action for the nurse to take?
A. Grab the client's arm to break the fall.
B. Step back and allow the client to fall to the floor.
C. Gently lower the client to the floor while protecting the client's head.
D. Try to catch the client to prevent injury.
,3|Page
Correct Answer: C. Gently lower the client to the floor while protecting the client's head.
The priority is to prevent injury to both the client and the nurse. Lowering the client in a controlled
manner, using proper body mechanics, is the safest way to manage a patient's fall. Trying to catch a
falling patient can cause serious injury to the nurse and the patient.
6. The nurse is documenting a client's pain level. The client has their eyes closed, is breathing deeply, and
is unresponsive to questions. Which is the most appropriate documentation?
A. Client is asleep and resting comfortably.
B. Client's eyes closed, breathing deeply, no response to verbal stimuli.
C. Client appears to be in a deep sleep.
D. Client is unresponsive and appears comfortable.
Correct Answer: B. Client's eyes closed, breathing deeply, no response to verbal stimuli.
Objective documentation is crucial. The nurse should document what is observed (eyes closed, breathing
deeply) and what the client's response is to stimuli (no response to verbal stimuli). Avoid subjective
interpretations like "resting comfortably" or "appears comfortable."
7. The nurse needs to collect a stool sample for culture and sensitivity from a client with diarrhea. What is
the best method for the nurse to use?
A. Collect a sample from the client's bedpan.
B. Instruct the client to void before defecating into a clean container.
C. Use a cotton-tipped swab to obtain a small sample from the toilet bowl.
D. Ask the client to defecate directly into a sterile specimen cup.
Correct Answer: B. Instruct the client to void before defecating into a clean container.
To prevent contamination of the sample with urine, the client should be instructed to void first. A clean
container is acceptable for a stool culture. A sterile container is not typically required unless specified.
Samples from bedpans or toilet bowls are easily contaminated.
8. The nurse is teaching a client with a new colostomy about dietary choices to help reduce gas and odor.
Which food should the nurse recommend?
A. Cabbage
B. Beans
, 4|Page
C. Yogurt
D. Onions
Correct Answer: C. Yogurt.
Yogurt contains probiotics that can help reduce gas and odor. Cabbage, beans, and onions are all foods
known to produce gas and odor and should initially be limited.
9. A client with a urinary tract infection (UTI) is prescribed phenazopyridine. Which statement by the
client indicates a correct understanding of the medication's effect?
A. "This medication will cure my infection."
B. "I should take this medication with food."
C. "I may see an orange-red color in my urine."
D. "This will help with my fever and chills."
Correct Answer: C. "I may see an orange-red color in my urine."
Phenazopyridine is a urinary analgesic that provides relief from the burning and pain of a UTI. It is not
an antibiotic and does not treat the infection itself. A harmless side effect is that it turns the urine a bright
orange-red color, which can stain clothing.
10. The nurse is caring for a client who is 1 day post-operative after a total hip replacement. What is the
most important nursing intervention to prevent dislocation of the new hip?
A. Maintain the client in a high Fowler's position.
B. Keep the client's legs crossed at the ankle.
C. Position the client on the operative side.
D. Use an abduction pillow between the client's legs.
Correct Answer: D. Use an abduction pillow between the client's legs.
An abduction pillow helps keep the hip in proper alignment by preventing adduction (crossing the legs)
and internal rotation. This is a critical intervention to prevent post-operative dislocation after a hip
replacement, especially in the immediate post-operative period.
11. The nurse is calculating the intake and output for a client over a 12-hour shift. The client's intake
includes: 2 cups of coffee (240 mL each), 1 bowl of ice chips (200 mL), and 1 can of soda (355 mL).
