BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam V2 (Latest Update 2026)
Questions & Answers | 100% Correct | Grade
A - Nightingale
The nurse observes a newly admitted older adult female take short steps and walk
very slowly while pushing a walker in front of her. What action should the nurse
take in response to these observations?
A) Complete a full fall risk assessment of the client.
B) Teach the client to take longer steps at faster pace.
C) Suggest that the the client use a wheelchair instead of a walker.
D) Place client on bedrest until the healthcare provider is notified. -
ANSWER A) Complete a full fall risk assessment of the client.
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen
saturation remains at 94%, which is the same reading obtained prior to starting the
procedure. What action should the nurse take in response to this finding?
A) Reposition the pulse oximeter clip to obtain a new reading.
B) Stop suctioning until the pulse oximeter reading is above 95%.
C) Complete the intermittent suction of the nasopharynx.
D) Apply an oxygen mask over the client's nose and mouth. - ANSWER
C) Complete the intermittent suction of the nasopharynx.
,An older woman with end stage heart disease is hospitalized for severe heart
failure. She is alert, oriented, and requests that no heroic measures are
implemented if her breathing stops. What action should the nurse take first?
A) Discuss with the client her meaning of heroic measures.
B) Obtain a "do not resuscitate" (DNR) prescription.
C) Set up a family conference to discuss the client's.
D) Consult the palliative care team about client's care. - ANSWER
A) Discuss with the client her meaning of heroic measures.
A client diagnosed with primary open-angle glaucoma received a prescription for
biotic eye drops, pilocarpine HCl (Pilocarpine). What instruction should the nurse
plan to include in this client's teaching?
A) "Do not allow the dropper bottle to touch the eye."
B) "Administer the medication directly on the cornea."
C) "Squeeze your eye closed after administering the drops."
D) "Wash your hands after each administration of eye drops." - ANSWER
A) "Do not allow the dropper bottle to touch the eye."
When assessing a client who starts to wheeze related data should obtain?
A) Presence of radiation.
B) Heart sounds.
C) Body temperature.
D) Precipitating factors. - ANSWER D) Precipitating
factors.
,The home health nurse is reviewing the personal care of an elderly client who lives
alone. Which client assessment findings indicate the need to assign unlicensed
assistive personnel (UAP) to provide routine foot care and file the client's toenails?
Select all that apply.
A) Syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
D) Urinary incontinence.
E) Shuffling gait. - ANSWER A) Syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
A client is discharged to a long-term care facility with an indwelling urinary
catheter. Which nursing action should be included in the plan to reduce the client's
risk for infection related to the catheter?
A) Flush the catheter daily with sterile saline.
B) Encourage increased intake of oral fluids.
C) Administer a PRN antipyretic if a fever develops.
D) Secure the drainage bag at bladder level during transport. - ANSWER
B) Encourage increased intake of oral fluids.
To assess the quality of an adult client's pain, what approach should the nurse use?
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) Ask the client to describe the pain.
D) Identify effective pain relief measures. - ANSWER C)
Ask the client to describe the pain.
, A client who has been diagnosed with terminal cancer tells the nurse, "The doctor
told me I have cancer and do not have long to live." Which response is best for the
nurse to provide?
A) "That's correct, you do not have long to live."
B) "Would you like me to call your minister?"
C) "Don't give up, you still have chemotherapy to try."
D) "Yes, your condition is serious." - ANSWER D) "Yes,
your condition is serious."
When performing blood pressure measurement to assess for orthostatic
hypotension, which action should the nurse implement first?
A) Apply the blood pressure cuff securely.
B) Record the client's pulse rate and rhythm.
C) Position the client supine for a few minutes.
D) Assist the client to stand at bedside. - ANSWER C)
Position the client supine for a few minutes.
The nurse is providing passive range of motion (ROM) exercises to the hip and
knee for a client who is unconscious. After supporting the client's knee with one
hand, what action should the nurse take next?
A) Raise the bed to a comfortable working level.
B) Bend the client's knee.
C) Move the knee toward the chest as far as it will go.
D) Cradle the client's heel. - ANSWER D) Cradle the
client's heel.
of Nursing Exam V2 (Latest Update 2026)
Questions & Answers | 100% Correct | Grade
A - Nightingale
The nurse observes a newly admitted older adult female take short steps and walk
very slowly while pushing a walker in front of her. What action should the nurse
take in response to these observations?
A) Complete a full fall risk assessment of the client.
B) Teach the client to take longer steps at faster pace.
C) Suggest that the the client use a wheelchair instead of a walker.
D) Place client on bedrest until the healthcare provider is notified. -
ANSWER A) Complete a full fall risk assessment of the client.
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen
saturation remains at 94%, which is the same reading obtained prior to starting the
procedure. What action should the nurse take in response to this finding?
A) Reposition the pulse oximeter clip to obtain a new reading.
B) Stop suctioning until the pulse oximeter reading is above 95%.
C) Complete the intermittent suction of the nasopharynx.
D) Apply an oxygen mask over the client's nose and mouth. - ANSWER
C) Complete the intermittent suction of the nasopharynx.
,An older woman with end stage heart disease is hospitalized for severe heart
failure. She is alert, oriented, and requests that no heroic measures are
implemented if her breathing stops. What action should the nurse take first?
A) Discuss with the client her meaning of heroic measures.
B) Obtain a "do not resuscitate" (DNR) prescription.
C) Set up a family conference to discuss the client's.
D) Consult the palliative care team about client's care. - ANSWER
A) Discuss with the client her meaning of heroic measures.
A client diagnosed with primary open-angle glaucoma received a prescription for
biotic eye drops, pilocarpine HCl (Pilocarpine). What instruction should the nurse
plan to include in this client's teaching?
A) "Do not allow the dropper bottle to touch the eye."
B) "Administer the medication directly on the cornea."
C) "Squeeze your eye closed after administering the drops."
D) "Wash your hands after each administration of eye drops." - ANSWER
A) "Do not allow the dropper bottle to touch the eye."
When assessing a client who starts to wheeze related data should obtain?
A) Presence of radiation.
B) Heart sounds.
C) Body temperature.
D) Precipitating factors. - ANSWER D) Precipitating
factors.
,The home health nurse is reviewing the personal care of an elderly client who lives
alone. Which client assessment findings indicate the need to assign unlicensed
assistive personnel (UAP) to provide routine foot care and file the client's toenails?
Select all that apply.
A) Syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
D) Urinary incontinence.
E) Shuffling gait. - ANSWER A) Syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
A client is discharged to a long-term care facility with an indwelling urinary
catheter. Which nursing action should be included in the plan to reduce the client's
risk for infection related to the catheter?
A) Flush the catheter daily with sterile saline.
B) Encourage increased intake of oral fluids.
C) Administer a PRN antipyretic if a fever develops.
D) Secure the drainage bag at bladder level during transport. - ANSWER
B) Encourage increased intake of oral fluids.
To assess the quality of an adult client's pain, what approach should the nurse use?
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) Ask the client to describe the pain.
D) Identify effective pain relief measures. - ANSWER C)
Ask the client to describe the pain.
, A client who has been diagnosed with terminal cancer tells the nurse, "The doctor
told me I have cancer and do not have long to live." Which response is best for the
nurse to provide?
A) "That's correct, you do not have long to live."
B) "Would you like me to call your minister?"
C) "Don't give up, you still have chemotherapy to try."
D) "Yes, your condition is serious." - ANSWER D) "Yes,
your condition is serious."
When performing blood pressure measurement to assess for orthostatic
hypotension, which action should the nurse implement first?
A) Apply the blood pressure cuff securely.
B) Record the client's pulse rate and rhythm.
C) Position the client supine for a few minutes.
D) Assist the client to stand at bedside. - ANSWER C)
Position the client supine for a few minutes.
The nurse is providing passive range of motion (ROM) exercises to the hip and
knee for a client who is unconscious. After supporting the client's knee with one
hand, what action should the nurse take next?
A) Raise the bed to a comfortable working level.
B) Bend the client's knee.
C) Move the knee toward the chest as far as it will go.
D) Cradle the client's heel. - ANSWER D) Cradle the
client's heel.
