BSN 225 HESI RN V1 SPECIALTY
FUNDAMENTALS OF NURSING EXAM V1:
(LATEST UPDATE 2026/2027), WITH
CORRECT/ACCURATE ANSWERS
BACHELOR OF SCIENCE IN NURSING
PROGRAM
AT NIGHTINGALE
(BSN225 HESI RN V1)
✅ PART 1 — Questions 1–25
rewritten in NCLEX/HESI style
1. Skin tenting is a sign of which condition?
A. Fluid volume overload
B. Electrolyte imbalance
C. Fluid volume deficit
D. Altered circulation
Correct Answer: C. Fluid volume deficit
Rationale: Skin tenting occurs when tissue elasticity decreases due to dehydration. Poor skin turgor is a
classic sign of fluid volume deficit because the interstitial space lacks adequate fluid. It is most commonly
seen in older adults or clients with decreased intake or excessive losses.
2. Which assessments should the community nurse complete when
assisting a college student with cocaine addiction? (Select all that
apply.)
,A. Frequency of use
B. Nature of use
C. Amount consumed
D. Past surgical history
E. Vitamin supplement use
Correct Answers: A, B, C
Rationale: Substance-use assessment includes determining how often, how much, and in what manner the
substance is used. These data help estimate severity, risk of overdose, and need for treatment. Medical
history or supplement use may be asked later but are not priority components of substance-abuse evaluation.
3. A new nurse asks why a confused client is placed in soft wrist
restraints. Which response is correct?
A. “The restraints keep the client from falling out of bed.”
B. “The restraints ensure the client receives treatments.”
C. “The restraints discourage the client from ambulating alone.”
D. “The restraints prevent all injuries.”
Correct Answer: C
Rationale: Soft restraints are used to prevent unsafe, impulsive actions such as unassisted ambulation. They
do not eliminate all injuries but help reduce risk. The nurse must also provide frequent monitoring and
release periods.
4. What is the correct order of abdominal assessment?
A. Percussion, palpation, auscultation, inspection
B. Inspection, auscultation, percussion, palpation
C. Inspection, palpation, percussion, auscultation
D. Auscultation, inspection, palpation, percussion
Correct Answer: B
Rationale: Inspection is always first because it is non-invasive. Auscultation follows to avoid altering bowel
activity. Percussion and palpation are last because they can stimulate peristalsis or cause tenderness.
5. A focused assessment is BEST described as which of the
following?
A. A complete health evaluation
B. Assessment directed at a specific problem
C. Assessment done only by physicians
D. Emergency triage assessment
Correct Answer: B
, Rationale: A focused assessment narrows in on a specific problem or system. It may include targeted
questions, system-based physical examination, and problem-specific interventions. It is used when new
symptoms arise or when monitoring an identified problem.
6. A client reports abdominal pain. What should the nurse do
FIRST?
A. Palpate the painful area first
B. Assess the painful quadrant last
C. Percuss the painful area first
D. Ask the provider to assess
Correct Answer: B
Rationale: Painful areas are assessed last to avoid guarding or increased discomfort that can interfere with
the exam. Starting away from the pain allows the nurse to observe baseline responses. This also builds client
trust and cooperation.
7. Which finding should the nurse document as subjective?
A. Blood pressure
B. Temperature
C. Wound drainage amount
D. Pain description
Correct Answer: D
Rationale: Subjective data are client-reported perceptions, such as pain, nausea, or fatigue. Objective data
are measurable or observable phenomena. Pain is always subjective because only the client can describe it.
8. Which is a legal nursing responsibility when applying restraints?
A. Document behavior
B. Obtain a provider order (unless emergency)
C. Document type of restraint
D. All of the above
Correct Answer: D
Rationale: All listed responsibilities are legally required. Proper documentation ensures safety, protects
client rights, and prevents misuse of restraints. Orders must be renewed regularly per policy.
9. A client with an indwelling catheter reports needing to void. What
is the priority nursing action?
FUNDAMENTALS OF NURSING EXAM V1:
(LATEST UPDATE 2026/2027), WITH
CORRECT/ACCURATE ANSWERS
BACHELOR OF SCIENCE IN NURSING
PROGRAM
AT NIGHTINGALE
(BSN225 HESI RN V1)
✅ PART 1 — Questions 1–25
rewritten in NCLEX/HESI style
1. Skin tenting is a sign of which condition?
A. Fluid volume overload
B. Electrolyte imbalance
C. Fluid volume deficit
D. Altered circulation
Correct Answer: C. Fluid volume deficit
Rationale: Skin tenting occurs when tissue elasticity decreases due to dehydration. Poor skin turgor is a
classic sign of fluid volume deficit because the interstitial space lacks adequate fluid. It is most commonly
seen in older adults or clients with decreased intake or excessive losses.
2. Which assessments should the community nurse complete when
assisting a college student with cocaine addiction? (Select all that
apply.)
,A. Frequency of use
B. Nature of use
C. Amount consumed
D. Past surgical history
E. Vitamin supplement use
Correct Answers: A, B, C
Rationale: Substance-use assessment includes determining how often, how much, and in what manner the
substance is used. These data help estimate severity, risk of overdose, and need for treatment. Medical
history or supplement use may be asked later but are not priority components of substance-abuse evaluation.
3. A new nurse asks why a confused client is placed in soft wrist
restraints. Which response is correct?
A. “The restraints keep the client from falling out of bed.”
B. “The restraints ensure the client receives treatments.”
C. “The restraints discourage the client from ambulating alone.”
D. “The restraints prevent all injuries.”
Correct Answer: C
Rationale: Soft restraints are used to prevent unsafe, impulsive actions such as unassisted ambulation. They
do not eliminate all injuries but help reduce risk. The nurse must also provide frequent monitoring and
release periods.
4. What is the correct order of abdominal assessment?
A. Percussion, palpation, auscultation, inspection
B. Inspection, auscultation, percussion, palpation
C. Inspection, palpation, percussion, auscultation
D. Auscultation, inspection, palpation, percussion
Correct Answer: B
Rationale: Inspection is always first because it is non-invasive. Auscultation follows to avoid altering bowel
activity. Percussion and palpation are last because they can stimulate peristalsis or cause tenderness.
5. A focused assessment is BEST described as which of the
following?
A. A complete health evaluation
B. Assessment directed at a specific problem
C. Assessment done only by physicians
D. Emergency triage assessment
Correct Answer: B
, Rationale: A focused assessment narrows in on a specific problem or system. It may include targeted
questions, system-based physical examination, and problem-specific interventions. It is used when new
symptoms arise or when monitoring an identified problem.
6. A client reports abdominal pain. What should the nurse do
FIRST?
A. Palpate the painful area first
B. Assess the painful quadrant last
C. Percuss the painful area first
D. Ask the provider to assess
Correct Answer: B
Rationale: Painful areas are assessed last to avoid guarding or increased discomfort that can interfere with
the exam. Starting away from the pain allows the nurse to observe baseline responses. This also builds client
trust and cooperation.
7. Which finding should the nurse document as subjective?
A. Blood pressure
B. Temperature
C. Wound drainage amount
D. Pain description
Correct Answer: D
Rationale: Subjective data are client-reported perceptions, such as pain, nausea, or fatigue. Objective data
are measurable or observable phenomena. Pain is always subjective because only the client can describe it.
8. Which is a legal nursing responsibility when applying restraints?
A. Document behavior
B. Obtain a provider order (unless emergency)
C. Document type of restraint
D. All of the above
Correct Answer: D
Rationale: All listed responsibilities are legally required. Proper documentation ensures safety, protects
client rights, and prevents misuse of restraints. Orders must be renewed regularly per policy.
9. A client with an indwelling catheter reports needing to void. What
is the priority nursing action?
