BSN 225 HESI RN SPECIALTY
FUNDAMENTALS OF NURSING EXAM V3:
(LATEST UPDATE 2026/2027) WITH
CORRECT/ACCURATE ANSWERS
BACHELOR OF SCIENCE IN NURSING
PROGRAM
AT NIGHTINGALE
(BSN225 HESI RN V3)
Part 1: Questions 1–25
Multiple-choice, correct answers, and rationales
Question 1
The nurse plans to obtain health assessment information from a primary source. Which option is a primary
source for the completion of the health assessment?
A. Client
B. Healthcare provider
C. Family member
D. Previous medical records
Answer: A. Client
Rationale: The client is considered the primary source of information because they provide firsthand data
regarding symptoms, history, and personal experiences. Family or records are secondary sources that
supplement but do not replace the client’s input.
Question 2
,The nurse assigns an unlicensed assistive personnel (UAP) to obtain vital signs from a very anxious client.
What instructions should the nurse give the UAP?
A. Remain calm with the client and record abnormal results in the chart
B. Notify the medication nurse immediately if the pulse or blood pressure is low
C. Report the results of the vital signs to the nurse
D. Reassure the client that the vital signs are normal
Answer: C. Report the results of the vital signs to the nurse
Rationale: UAPs are responsible for obtaining and reporting data but do not interpret or make clinical
judgments. The nurse uses the reported results to assess and plan care appropriately.
Question 3
A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse
document that is most accurate?
A. Demonstrates loss of remote memory
B. Exhibits expressive dysphasia
C. Has a diminished attention span
D. Is disoriented to place and time
Answer: D. Is disoriented to place and time
Rationale: Disorientation to time and place accurately reflects the client’s current cognitive state. Expressive
dysphasia is a speech problem, not confusion, and remote memory loss is not directly assessed.
Question 4
After completing an assessment and determining that a client has a problem, which action should the nurse
perform next?
A. Determine the etiology of the problem
B. Prioritize nursing care interventions
C. Plan appropriate interventions
D. Collaborate with the client to set goals
Answer: A. Determine the etiology of the problem
Rationale: Identifying the cause of the problem is the next step after assessment. Understanding the etiology
guides appropriate interventions, goal setting, and prioritization of care.
Question 5
,A resident in a skilled nursing facility tells the nurse, "I don't want any more blood taken for those useless
tests." Which narrative documentation should the nurse enter in the medical record?
A. Healthcare provider notified of failure to collect specimens
B. Blood specimens not collected because client no longer wants tests
C. Healthcare provider notified of client's refusal to have blood specimens collected for testing
D. Client irritable, uncooperative, and refuses blood collection; healthcare provider notified
Answer: C. Healthcare provider notified of client's refusal to have blood specimens collected for testing
Rationale: Documentation should be factual, objective, and professional. It should state the client’s refusal
and that the healthcare provider was notified. Avoid subjective terms like "irritable" unless clinically
relevant.
Question 6
A client is receiving alprazolam (Xanax) 0.75 mg PO twice daily. Alprazolam is available in 0.5 mg scored
tablets. How many tablets should the nurse administer? (Enter numeric value only.)
Answer: 1.5
Rationale: The dose calculation is: 0.75 mg ÷ 0.5 mg per tablet = 1.5 tablets. Accurate calculations are
critical to ensure safe medication administration.
Question 7
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse notes
no drainage in the last 2 hours. Which action should the nurse take first?
A. Irrigate the nasogastric tube with sterile normal saline
B. Reposition the client on her side
C. Advance the nasogastric tube an additional five centimeters
D. Administer an intravenous antiemetic prescribed for PRN use
Answer: B. Reposition the client on her side
Rationale: Repositioning may relieve obstruction or improve drainage before other interventions. Irrigation
is done only if patency is not restored. Medication addresses symptoms but not the underlying cause.
Question 8
An older client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a
malpractice judgment?
A. The nurse who worked the 7 to 3 shift and wrote poor nursing notes
, B. The nurse who assisted the client to ambulate safely but did not document
C. The nurse who reported the fall to the provider and initiated care promptly
D. The nurse who followed the fall protocol
Answer: B. The nurse who assisted the client to ambulate safely but did not document
Rationale: Proper documentation is part of standard care and legal protection. Failure to document
interventions, even when care is provided, increases liability risk.
Question 9
Which action is appropriate when assessing a client’s neurological status?
A. Measure blood pressure only
B. Evaluate orientation, speech, and motor function
C. Check oxygen saturation only
D. Assess temperature and pulse
Answer: B. Evaluate orientation, speech, and motor function
Rationale: Neurological assessment includes mental status (orientation), speech, motor function, reflexes,
and sensory perception. Vital signs alone do not assess neurological status fully.
Question 10
A client with diabetes mellitus reports tingling in the feet. Which assessment is the priority?
A. Blood pressure
B. Peripheral sensation and skin integrity
C. Heart rate
D. Respiratory rate
Answer: B. Peripheral sensation and skin integrity
Rationale: Diabetic neuropathy can lead to loss of sensation, increasing risk for injury or ulceration. Early
assessment allows for prevention and timely intervention.
Question 11
Which nursing intervention prevents the spread of infection in hospitalized clients?
A. Hand hygiene before and after client contact
B. Wearing gloves only during procedures
C. Reusing disposable equipment
D. Administering antibiotics prophylactically
FUNDAMENTALS OF NURSING EXAM V3:
(LATEST UPDATE 2026/2027) WITH
CORRECT/ACCURATE ANSWERS
BACHELOR OF SCIENCE IN NURSING
PROGRAM
AT NIGHTINGALE
(BSN225 HESI RN V3)
Part 1: Questions 1–25
Multiple-choice, correct answers, and rationales
Question 1
The nurse plans to obtain health assessment information from a primary source. Which option is a primary
source for the completion of the health assessment?
A. Client
B. Healthcare provider
C. Family member
D. Previous medical records
Answer: A. Client
Rationale: The client is considered the primary source of information because they provide firsthand data
regarding symptoms, history, and personal experiences. Family or records are secondary sources that
supplement but do not replace the client’s input.
Question 2
,The nurse assigns an unlicensed assistive personnel (UAP) to obtain vital signs from a very anxious client.
What instructions should the nurse give the UAP?
A. Remain calm with the client and record abnormal results in the chart
B. Notify the medication nurse immediately if the pulse or blood pressure is low
C. Report the results of the vital signs to the nurse
D. Reassure the client that the vital signs are normal
Answer: C. Report the results of the vital signs to the nurse
Rationale: UAPs are responsible for obtaining and reporting data but do not interpret or make clinical
judgments. The nurse uses the reported results to assess and plan care appropriately.
Question 3
A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse
document that is most accurate?
A. Demonstrates loss of remote memory
B. Exhibits expressive dysphasia
C. Has a diminished attention span
D. Is disoriented to place and time
Answer: D. Is disoriented to place and time
Rationale: Disorientation to time and place accurately reflects the client’s current cognitive state. Expressive
dysphasia is a speech problem, not confusion, and remote memory loss is not directly assessed.
Question 4
After completing an assessment and determining that a client has a problem, which action should the nurse
perform next?
A. Determine the etiology of the problem
B. Prioritize nursing care interventions
C. Plan appropriate interventions
D. Collaborate with the client to set goals
Answer: A. Determine the etiology of the problem
Rationale: Identifying the cause of the problem is the next step after assessment. Understanding the etiology
guides appropriate interventions, goal setting, and prioritization of care.
Question 5
,A resident in a skilled nursing facility tells the nurse, "I don't want any more blood taken for those useless
tests." Which narrative documentation should the nurse enter in the medical record?
A. Healthcare provider notified of failure to collect specimens
B. Blood specimens not collected because client no longer wants tests
C. Healthcare provider notified of client's refusal to have blood specimens collected for testing
D. Client irritable, uncooperative, and refuses blood collection; healthcare provider notified
Answer: C. Healthcare provider notified of client's refusal to have blood specimens collected for testing
Rationale: Documentation should be factual, objective, and professional. It should state the client’s refusal
and that the healthcare provider was notified. Avoid subjective terms like "irritable" unless clinically
relevant.
Question 6
A client is receiving alprazolam (Xanax) 0.75 mg PO twice daily. Alprazolam is available in 0.5 mg scored
tablets. How many tablets should the nurse administer? (Enter numeric value only.)
Answer: 1.5
Rationale: The dose calculation is: 0.75 mg ÷ 0.5 mg per tablet = 1.5 tablets. Accurate calculations are
critical to ensure safe medication administration.
Question 7
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse notes
no drainage in the last 2 hours. Which action should the nurse take first?
A. Irrigate the nasogastric tube with sterile normal saline
B. Reposition the client on her side
C. Advance the nasogastric tube an additional five centimeters
D. Administer an intravenous antiemetic prescribed for PRN use
Answer: B. Reposition the client on her side
Rationale: Repositioning may relieve obstruction or improve drainage before other interventions. Irrigation
is done only if patency is not restored. Medication addresses symptoms but not the underlying cause.
Question 8
An older client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a
malpractice judgment?
A. The nurse who worked the 7 to 3 shift and wrote poor nursing notes
, B. The nurse who assisted the client to ambulate safely but did not document
C. The nurse who reported the fall to the provider and initiated care promptly
D. The nurse who followed the fall protocol
Answer: B. The nurse who assisted the client to ambulate safely but did not document
Rationale: Proper documentation is part of standard care and legal protection. Failure to document
interventions, even when care is provided, increases liability risk.
Question 9
Which action is appropriate when assessing a client’s neurological status?
A. Measure blood pressure only
B. Evaluate orientation, speech, and motor function
C. Check oxygen saturation only
D. Assess temperature and pulse
Answer: B. Evaluate orientation, speech, and motor function
Rationale: Neurological assessment includes mental status (orientation), speech, motor function, reflexes,
and sensory perception. Vital signs alone do not assess neurological status fully.
Question 10
A client with diabetes mellitus reports tingling in the feet. Which assessment is the priority?
A. Blood pressure
B. Peripheral sensation and skin integrity
C. Heart rate
D. Respiratory rate
Answer: B. Peripheral sensation and skin integrity
Rationale: Diabetic neuropathy can lead to loss of sensation, increasing risk for injury or ulceration. Early
assessment allows for prevention and timely intervention.
Question 11
Which nursing intervention prevents the spread of infection in hospitalized clients?
A. Hand hygiene before and after client contact
B. Wearing gloves only during procedures
C. Reusing disposable equipment
D. Administering antibiotics prophylactically
