BSN 225 HESI RN SPECIALTY –
FUNDAMENTALS OF NURSING EXAM V2,
(LATEST UPDATE 2026/2027) WITH
CORRECT/ACCURATE ANSWERS
✓
✓
BACHELOR OF SCIENCE IN NURSING
PROGRAM
AT NIGHTINGALE
(BSN225 HESI RN V2)
Part 1 (Questions 1–25)
1. A nurse is caring for a client with congestive heart failure (CHF) who is receiving furosemide (Lasix).
Which assessment finding indicates that the client may be experiencing a complication of this medication?
A. Elevated blood pressure
B. Hypokalemia (low potassium levels)
C. Bradycardia (slow heart rate)
D. Pink, frothy sputum
Correct Answer:
B. Hypokalemia (low potassium levels)
Rationale:
• Furosemide is a loop diuretic that promotes diuresis to remove excess fluid in CHF.
, • A common complication is potassium loss, leading to hypokalemia, which can cause muscle
weakness, cramps, and cardiac arrhythmias.
• Elevated blood pressure (A) is not expected; furosemide usually lowers blood pressure.
• Bradycardia (C) is not a direct effect of furosemide, though arrhythmias may occur with
hypokalemia.
• Pink, frothy sputum (D) indicates pulmonary edema, a symptom of worsening CHF, not a direct
complication of the diuretic.
2. The home health nurse assigns UAP to provide foot care. Which findings indicate the
need for this intervention? (Select all that apply)
A. Diminished visual acuity
B. Syncope with bending
C. Hand tremors
D. Good balance
Correct Answers: A, B, C
Rationale: Clients with poor vision, dizziness, or tremors are at higher risk for injury during foot care.
Assigning UAP ensures safety while maintaining routine hygiene. Clients without these risks may perform
foot care independently.
3. A young male client with testicular cancer has a living will specifying DNR. Physician
refuses DNR. Nurse should:
A. Follow physician’s orders
B. Initiate ethics committee review
C. Ignore the living will
D. Delay care
Correct Answer: B
Rationale: Ethical dilemmas arise when patient autonomy conflicts with provider judgment. Involving the
ethics committee ensures a structured review while protecting the patient’s rights and guiding legal, ethical
decisions.
4. Evaluating activity intolerance: Best assessment indicator for tolerance
A. Client ambulating without assistance
B. Normal heart rate before and after ambulation
C. Verbal report of fatigue
D. Respiratory rate at rest
Correct Answer: B
Rationale: Objective measures such as heart rate before and after activity provide reliable indicators of
physiologic response. Subjective reports support but do not replace objective data.
, 5. Earliest PACU sign of pressure ulcer formation
A. Swelling
B. Persistent redness over bony prominence
C. Warmth
D. Moisture
Correct Answer: B
Rationale: Non-blanchable redness is the first sign of pressure injury. Early recognition prevents
progression to more severe tissue damage. Redness over bony areas is particularly concerning due to
pressure susceptibility.
6. Nurse measures client temperature of 102°F (38.9°C). Additional assessment includes
(Select all that apply):
A. Palpate skin temperature
B. Observe skin color
C. Determine pulse rate
D. Only rely on thermometer reading
Correct Answers: A, B, C
Rationale: Fever affects vital signs and skin appearance. Assessing these parameters supports accurate
evaluation and guides interventions like fluid replacement or antipyretic therapy.
7. Penicillin 1.2 million units IM, vial 600,000 units/2 mL. How many mL to administer?
A. 2 mL
B. 3 mL
C. 4 mL
D. 5 mL
Correct Answer: C
Rationale: Dose calculation: 1,200,000600,000×2 mL=4 mL\frac{1,200,000}{600,000} \times 2 \text{ mL}
= 4 \text{ mL}600,0001,200,000×2 mL=4 mL. Accurate calculations prevent under- or overdosing.
8. Self-care outcome for post-stroke client with left-sided hemiparesis
A. Client washes only unaffected side
B. Client verbalizes importance of hygiene
C. Client walks independently
D. Client refuses care
Correct Answer: B
FUNDAMENTALS OF NURSING EXAM V2,
(LATEST UPDATE 2026/2027) WITH
CORRECT/ACCURATE ANSWERS
✓
✓
BACHELOR OF SCIENCE IN NURSING
PROGRAM
AT NIGHTINGALE
(BSN225 HESI RN V2)
Part 1 (Questions 1–25)
1. A nurse is caring for a client with congestive heart failure (CHF) who is receiving furosemide (Lasix).
Which assessment finding indicates that the client may be experiencing a complication of this medication?
A. Elevated blood pressure
B. Hypokalemia (low potassium levels)
C. Bradycardia (slow heart rate)
D. Pink, frothy sputum
Correct Answer:
B. Hypokalemia (low potassium levels)
Rationale:
• Furosemide is a loop diuretic that promotes diuresis to remove excess fluid in CHF.
, • A common complication is potassium loss, leading to hypokalemia, which can cause muscle
weakness, cramps, and cardiac arrhythmias.
• Elevated blood pressure (A) is not expected; furosemide usually lowers blood pressure.
• Bradycardia (C) is not a direct effect of furosemide, though arrhythmias may occur with
hypokalemia.
• Pink, frothy sputum (D) indicates pulmonary edema, a symptom of worsening CHF, not a direct
complication of the diuretic.
2. The home health nurse assigns UAP to provide foot care. Which findings indicate the
need for this intervention? (Select all that apply)
A. Diminished visual acuity
B. Syncope with bending
C. Hand tremors
D. Good balance
Correct Answers: A, B, C
Rationale: Clients with poor vision, dizziness, or tremors are at higher risk for injury during foot care.
Assigning UAP ensures safety while maintaining routine hygiene. Clients without these risks may perform
foot care independently.
3. A young male client with testicular cancer has a living will specifying DNR. Physician
refuses DNR. Nurse should:
A. Follow physician’s orders
B. Initiate ethics committee review
C. Ignore the living will
D. Delay care
Correct Answer: B
Rationale: Ethical dilemmas arise when patient autonomy conflicts with provider judgment. Involving the
ethics committee ensures a structured review while protecting the patient’s rights and guiding legal, ethical
decisions.
4. Evaluating activity intolerance: Best assessment indicator for tolerance
A. Client ambulating without assistance
B. Normal heart rate before and after ambulation
C. Verbal report of fatigue
D. Respiratory rate at rest
Correct Answer: B
Rationale: Objective measures such as heart rate before and after activity provide reliable indicators of
physiologic response. Subjective reports support but do not replace objective data.
, 5. Earliest PACU sign of pressure ulcer formation
A. Swelling
B. Persistent redness over bony prominence
C. Warmth
D. Moisture
Correct Answer: B
Rationale: Non-blanchable redness is the first sign of pressure injury. Early recognition prevents
progression to more severe tissue damage. Redness over bony areas is particularly concerning due to
pressure susceptibility.
6. Nurse measures client temperature of 102°F (38.9°C). Additional assessment includes
(Select all that apply):
A. Palpate skin temperature
B. Observe skin color
C. Determine pulse rate
D. Only rely on thermometer reading
Correct Answers: A, B, C
Rationale: Fever affects vital signs and skin appearance. Assessing these parameters supports accurate
evaluation and guides interventions like fluid replacement or antipyretic therapy.
7. Penicillin 1.2 million units IM, vial 600,000 units/2 mL. How many mL to administer?
A. 2 mL
B. 3 mL
C. 4 mL
D. 5 mL
Correct Answer: C
Rationale: Dose calculation: 1,200,000600,000×2 mL=4 mL\frac{1,200,000}{600,000} \times 2 \text{ mL}
= 4 \text{ mL}600,0001,200,000×2 mL=4 mL. Accurate calculations prevent under- or overdosing.
8. Self-care outcome for post-stroke client with left-sided hemiparesis
A. Client washes only unaffected side
B. Client verbalizes importance of hygiene
C. Client walks independently
D. Client refuses care
Correct Answer: B
