HESI EXAM REVIEW: NURSING
FUNDAMENTALS BSN 225 HESI,
2025/2026 WITH CORRECT/ACCURATE
ANSWERS
Korotkoff sound-immediate - CORRECT ANSWERS- 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 - CORRECT ANSWERS- 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 - CORRECT ANSWERS- 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 - CORRECT ANSWERS- 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 - CORRECT ANSWERS-
=2.5 ml
Therapeautic communication - CORRECT ANSWERS- 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 - CORRECT ANSWERS- 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 - CORRECT ANSWERS- 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 - CORRECT ANSWERS- The client has legally
separated themselves from their parents before they reach 18-
FUNDAMENTALS BSN 225 HESI,
2025/2026 WITH CORRECT/ACCURATE
ANSWERS
Korotkoff sound-immediate - CORRECT ANSWERS- 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 - CORRECT ANSWERS- 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 - CORRECT ANSWERS- 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 - CORRECT ANSWERS- 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 - CORRECT ANSWERS-
=2.5 ml
Therapeautic communication - CORRECT ANSWERS- 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 - CORRECT ANSWERS- 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 - CORRECT ANSWERS- 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 - CORRECT ANSWERS- The client has legally
separated themselves from their parents before they reach 18-
