SN 225 HESI Fundamentals of Nursing Exam
B
V1 Nightingale College Official Practice Exam
Actual Exam 2026/2027 with Detailed Rationales |
Complete Exam-Style Questions | Pass
Guaranteed – A+ Graded
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SECTION 1: NURSING PROCESS, CRITICAL THINKING & CLINICAL JUDGMENT Q1 – Q10
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Question 1 of 60
68-year-old client presents to the emergency department with acute shortness of breath and a
A
respiratory rate of 32. What is the nurse's priority action at this time?
. Apply oxygen via nasal cannula ✓ CORRECT
A
B. Obtain a complete health history
C. Auscultate lung sounds
D. Place the client in a supine position
orrect Answer: A
C
Rationale: When a client presents with acute respiratory distress, the priority action is to apply
oxygen to address the immediate threat to airway and breathing. Obtaining a complete health
history delays essential interventions, and placing the client in a supine position will worsen
dyspnea. Remember the ABCs; airway and breathing always take precedence over assessment
steps like auscultation when oxygenation is compromised.
Question 2 of 60
45-year-old client is postoperative day 1 after a total knee replacement and reports a pain
A
level of 4 out of 10 but refuses pain medication. What is the nurse's best action?
. Document the client's refusal in the chart
A
B. Offer and implement non-pharmacological pain relief measures ✓ CORRECT
C. Notify the healthcare provider of the client's refusal
D. Encourage the client to take the medication to prevent stiffness
Correct Answer: B
, ationale: Respecting client autonomy means accepting their refusal of medication, but the
R
nurse must still address the reported pain using alternative approaches like repositioning or ice.
Encouraging the client to take medication after they have refused borders on coercion, and
simply documenting the refusal does not fulfill the nurse's duty to relieve pain.
Non-pharmacological interventions are effective for mild pain and respect the client's choices.
Question 3 of 60
68-year-old client is admitted with a urinary tract infection and sudden onset of confusion. The
A
client is pulling at the IV line. What is the nurse's priority intervention?
. Apply soft wrist restraints
A
B. Request a sedative medication
C. Reorient the client and provide a calm environment ✓ CORRECT
D. Turn off the IV pump and remove the catheter
orrect Answer: C
C
Rationale: Sudden confusion in an older adult is often delirium secondary to an infection, and
the priority is to use the least restrictive interventions first, such as reorientation and
environmental modification. Applying restraints or administering sedatives can worsen delirium
and should be last resorts. Removing the IV line removes the necessary medical treatment for
the infection.
Question 4 of 60
55-year-old client with heart failure is receiving furosemide and has a potassium level of 3.1
A
mEq/L. The provider prescribes a potassium supplement. What is the most important nursing
action before administering the supplement?
. Check the client's blood pressure
A
B. Assess the client for muscle weakness
C. Monitor the client's intake and output
D. Verify the client's renal function and urine output ✓ CORRECT
orrect Answer: D
C
Rationale: Potassium is excreted primarily by the kidneys, so verifying renal function and
ensuring adequate urine output is critical before administration to prevent life-threatening
hyperkalemia. Assessing for muscle weakness is relevant for hypokalemia but does not ensure
safe administration of the supplement. Checking blood pressure is important for heart failure
management but does not directly dictate potassium safety.
Question 5 of 60
, 30-year-old client admitted for an anxiety disorder is pacing the hallway and expressing
A
intense fear. What intervention best demonstrates the implementation phase of the nursing
process?
. Guiding the client through deep breathing exercises ✓ CORRECT
A
B. Identifying the client's current coping mechanisms
C. Formulating a plan for ongoing anxiety management
D. Determining the client's baseline anxiety triggers
orrect Answer: A
C
Rationale: Implementation involves executing the planned interventions to help the client
achieve their goals, such as actively guiding a client through deep breathing to reduce acute
anxiety. Identifying coping mechanisms and determining triggers are assessment steps, while
formulating a plan is the planning step. The nursing process requires action during the
implementation phase, not just data gathering.
Question 6 of 60
72-year-old client with pneumonia has an oxygen saturation of 88% on room air. After
A
applying 2 liters of oxygen via nasal cannula, the oxygen saturation rises to 94%. What is the
nurse's next step in the nursing process?
. Document the intervention and continue monitoring
A
B. Evaluate the client's respiratory status and response ✓ CORRECT
C. Increase the oxygen flow to 4 liters per minute
D. Notify the healthcare provider of the oxygen change
orrect Answer: B
C
Rationale: After implementing an intervention, the next step in the nursing process is evaluation
to determine if the intervention was effective and if the client's condition has improved.
Increasing the oxygen flow is unnecessary since the saturation is now within normal limits, and
simply documenting bypasses the crucial evaluation step. Evaluation connects the intervention
back to the original goal of improving oxygenation.
Question 7 of 60
60-year-old client is scheduled for a total knee replacement in the morning. During the
A
preoperative assessment, the client states, "I am terrified of waking up during the surgery." What
is the nurse's best response?
. "I will make a note in your chart so the anesthesiologist can talk to you."
A
B. "That rarely happens with modern anesthesia techniques."
C. "Tell me more about what is making you feel so terrified." ✓ CORRECT
D. "We will monitor your brain waves throughout the procedure."
B
V1 Nightingale College Official Practice Exam
Actual Exam 2026/2027 with Detailed Rationales |
Complete Exam-Style Questions | Pass
Guaranteed – A+ Graded
═════════════════════════════════════
═
SECTION 1: NURSING PROCESS, CRITICAL THINKING & CLINICAL JUDGMENT Q1 – Q10
══════════════════════════════════════
Question 1 of 60
68-year-old client presents to the emergency department with acute shortness of breath and a
A
respiratory rate of 32. What is the nurse's priority action at this time?
. Apply oxygen via nasal cannula ✓ CORRECT
A
B. Obtain a complete health history
C. Auscultate lung sounds
D. Place the client in a supine position
orrect Answer: A
C
Rationale: When a client presents with acute respiratory distress, the priority action is to apply
oxygen to address the immediate threat to airway and breathing. Obtaining a complete health
history delays essential interventions, and placing the client in a supine position will worsen
dyspnea. Remember the ABCs; airway and breathing always take precedence over assessment
steps like auscultation when oxygenation is compromised.
Question 2 of 60
45-year-old client is postoperative day 1 after a total knee replacement and reports a pain
A
level of 4 out of 10 but refuses pain medication. What is the nurse's best action?
. Document the client's refusal in the chart
A
B. Offer and implement non-pharmacological pain relief measures ✓ CORRECT
C. Notify the healthcare provider of the client's refusal
D. Encourage the client to take the medication to prevent stiffness
Correct Answer: B
, ationale: Respecting client autonomy means accepting their refusal of medication, but the
R
nurse must still address the reported pain using alternative approaches like repositioning or ice.
Encouraging the client to take medication after they have refused borders on coercion, and
simply documenting the refusal does not fulfill the nurse's duty to relieve pain.
Non-pharmacological interventions are effective for mild pain and respect the client's choices.
Question 3 of 60
68-year-old client is admitted with a urinary tract infection and sudden onset of confusion. The
A
client is pulling at the IV line. What is the nurse's priority intervention?
. Apply soft wrist restraints
A
B. Request a sedative medication
C. Reorient the client and provide a calm environment ✓ CORRECT
D. Turn off the IV pump and remove the catheter
orrect Answer: C
C
Rationale: Sudden confusion in an older adult is often delirium secondary to an infection, and
the priority is to use the least restrictive interventions first, such as reorientation and
environmental modification. Applying restraints or administering sedatives can worsen delirium
and should be last resorts. Removing the IV line removes the necessary medical treatment for
the infection.
Question 4 of 60
55-year-old client with heart failure is receiving furosemide and has a potassium level of 3.1
A
mEq/L. The provider prescribes a potassium supplement. What is the most important nursing
action before administering the supplement?
. Check the client's blood pressure
A
B. Assess the client for muscle weakness
C. Monitor the client's intake and output
D. Verify the client's renal function and urine output ✓ CORRECT
orrect Answer: D
C
Rationale: Potassium is excreted primarily by the kidneys, so verifying renal function and
ensuring adequate urine output is critical before administration to prevent life-threatening
hyperkalemia. Assessing for muscle weakness is relevant for hypokalemia but does not ensure
safe administration of the supplement. Checking blood pressure is important for heart failure
management but does not directly dictate potassium safety.
Question 5 of 60
, 30-year-old client admitted for an anxiety disorder is pacing the hallway and expressing
A
intense fear. What intervention best demonstrates the implementation phase of the nursing
process?
. Guiding the client through deep breathing exercises ✓ CORRECT
A
B. Identifying the client's current coping mechanisms
C. Formulating a plan for ongoing anxiety management
D. Determining the client's baseline anxiety triggers
orrect Answer: A
C
Rationale: Implementation involves executing the planned interventions to help the client
achieve their goals, such as actively guiding a client through deep breathing to reduce acute
anxiety. Identifying coping mechanisms and determining triggers are assessment steps, while
formulating a plan is the planning step. The nursing process requires action during the
implementation phase, not just data gathering.
Question 6 of 60
72-year-old client with pneumonia has an oxygen saturation of 88% on room air. After
A
applying 2 liters of oxygen via nasal cannula, the oxygen saturation rises to 94%. What is the
nurse's next step in the nursing process?
. Document the intervention and continue monitoring
A
B. Evaluate the client's respiratory status and response ✓ CORRECT
C. Increase the oxygen flow to 4 liters per minute
D. Notify the healthcare provider of the oxygen change
orrect Answer: B
C
Rationale: After implementing an intervention, the next step in the nursing process is evaluation
to determine if the intervention was effective and if the client's condition has improved.
Increasing the oxygen flow is unnecessary since the saturation is now within normal limits, and
simply documenting bypasses the crucial evaluation step. Evaluation connects the intervention
back to the original goal of improving oxygenation.
Question 7 of 60
60-year-old client is scheduled for a total knee replacement in the morning. During the
A
preoperative assessment, the client states, "I am terrified of waking up during the surgery." What
is the nurse's best response?
. "I will make a note in your chart so the anesthesiologist can talk to you."
A
B. "That rarely happens with modern anesthesia techniques."
C. "Tell me more about what is making you feel so terrified." ✓ CORRECT
D. "We will monitor your brain waves throughout the procedure."
