Download BSN NSG 3213 Fundamentals of Nursing Final HESI ) Questions And Correct Answers (Verified and more Exams Nursing in PDF only on Docsity!
BSN NSG 3213 Fundamentals of Nursing Final HESI ) Questions
And Correct Answers (Verified Answers) Plus Rationales 2025
Q&A | Instant Download PDF South College
- A nurse is caring for a client with dyspnea. Which position is most effective to promote oxygenation? a. Supine b. High Fowler’s c. Side-lying d. Trendelenburg High Fowler’s position allows maximum lung expansion and improves oxygenation by decreasing pressure on the diaphragm.
- Which action best demonstrates evidence-based practice in nursing? a. Performing tasks based on experience b. Using current research to guide interventions c. Asking colleagues for advice d. Repeating standard procedures without change Evidence-based practice involves integrating clinical expertise with the best available research evidence.
- The nurse prepares to administer a medication via a nasogastric tube. What is the priority step? a. Flush the tube with water b. Crush the medication c. Verify tube placement d. Position the client flat Verifying tube placement is essential to prevent aspiration and ensure correct administration.
- A patient with an indwelling urinary catheter is at risk for which complication? a. Diarrhea b. Urinary tract infection (UTI) c. Hypertension d. Incontinence Indwelling catheters bypass the body’s natural defense mechanisms and increase the risk of UTIs.
- The nurse documents that a patient has cheyne-stokes respirations. What does this indicate? a. Normal breathing b. Apnea followed by rapid breathing
a. Suction continuously b. Use clean technique c. Preoxygenate the patient d. Suction for 20 seconds Preoxygenation helps prevent hypoxia during suctioning by ensuring the patient has adequate oxygen reserves.
- A nurse notes that a patient has clear drainage from a surgical wound. This is classified as: a. Purulent b. Serous c. Sanguineous d. Serosanguineous Serous drainage is clear, watery fluid, typical of healing wounds. 10.A client is on contact precautions. What PPE is required? a. Mask only b. Gloves and mask c. Gloves and gown d. Gown and face shield Contact precautions require gloves and gown to prevent direct or indirect transmission from patient or environment.
11.Which intervention best prevents foot drop in a bedridden patient? a. Use of SCDs b. Application of heel protectors c. Placement of footboard d. Daily massage A footboard maintains foot alignment and prevents plantar flexion, reducing the risk of foot drop. 12.A client is confused and attempts to remove their IV. What is the nurse's priority? a. Apply mitt restraints b. Remove the IV c. Call security d. Reorient and supervise the client The first approach should always be the least restrictive—reorienting and supervising. 13.Which is the best action when performing a sterile dressing change? a. Keep sterile gloves on the table b. Touch the wound with bare hands c. Maintain sterile field above waist level d. Turn back to the sterile field
The ventrogluteal site is preferred for larger volume IM injections due to muscle mass and low risk of nerve damage. 17.The nurse is assessing for orthostatic hypotension. What findings indicate a positive result? a. BP decreases 5 mmHg b. BP drops 20 mmHg systolic or 10 mmHg diastolic c. Pulse increases by 5 bpm d. No change in vitals A drop of 20 systolic or 10 diastolic when standing is considered orthostatic hypotension. 18.A client has a stage 3 pressure injury. What tissue is exposed? a. Muscle b. Subcutaneous tissue c. Bone d. Dermis only Stage 3 ulcers extend into subcutaneous tissue, but not to muscle or bone. 19.Which symptom best indicates fluid overload? a. Hypotension b. Crackles in lungs
c. Thirst d. Dry mucous membranes Crackles in the lungs are a hallmark sign of pulmonary edema from fluid overload. 20.Which strategy helps prevent falls in the hospital? a. Keep bed in high position b. Use scatter rugs c. Ensure call light is within reach d. Encourage nighttime ambulation Ensuring call light accessibility allows patients to ask for help, reducing fall risk. 21.A client is on a clear liquid diet. Which food should the nurse include? a. Milk b. Ice cream c. Gelatin d. Yogurt Gelatin is considered a clear liquid; dairy products are not. 22.The nurse is assessing a patient with pneumonia. Which finding requires immediate attention? a. Fever of 101°F b. Respiratory rate of 32
a. Incision edges approximated b. Purulent drainage from the wound c. Pink wound bed d. Pain level 2/ Purulent (pus-like) drainage is a classic sign of infection. 26.When delegating to a UAP, which task is appropriate? a. Initial vital signs b. Assisting with ambulation c. Medication administration d. Wound assessment UAPs may assist with ambulation but cannot assess, evaluate, or administer medications. 27.Which assessment technique is used first in abdominal examination? a. Percussion b. Inspection c. Palpation d. Auscultation Inspection is always the first step in physical assessment to observe for any abnormalities.
28.A nurse notes the patient’s radial pulse is irregular. What should be the next step? a. Record as normal b. Assess apical pulse for 1 minute c. Call the provider d. Recheck blood pressure An irregular peripheral pulse warrants apical pulse auscultation to determine heart rhythm and rate. 29.Which intervention helps prevent aspiration in a client with dysphagia? a. Encourage large bites b. Recline the client after eating c. Sit the client upright during meals d. Offer thin liquids An upright position reduces the risk of food entering the airway. 30.Which term describes a wound with partial-thickness skin loss? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 Stage 2 pressure injuries involve partial-thickness skin loss with exposed dermis.
34.Which best describes informed consent? a. Nurse explains procedure b. Provider explains risks and benefits, and patient agrees c. Family signs on behalf of patient d. Consent required only for surgery Informed consent is the provider's responsibility and must include risks, benefits, and alternatives. 35.A nurse is teaching about proper body mechanics. Which action should be included? a. Bend at the waist b. Keep feet together c. Lift with the legs d. Twist while lifting Lifting with the legs protects the back and reduces risk of injury. 36.Which of the following describes the appropriate way to administer eye drops? a. Instill drops in upper eyelid b. Touch dropper to the eye c. Place drops in conjunctival sac d. Apply drops directly on cornea
Eye drops should be instilled into the conjunctival sac to avoid injury and promote absorption. 37.The nurse notes a client has clear, watery, nasal drainage after head trauma. What is the priority action? a. Offer tissues b. Raise head of bed c. Test for glucose d. Encourage fluids Testing for glucose identifies CSF, suggesting a skull fracture. 38.What is the best method for preventing pressure injuries in immobile clients? a. Apply lotion every 2 hours b. Reposition every 2 hours c. Encourage fluid intake d. Massage bony prominences Frequent repositioning helps relieve pressure and prevent skin breakdown. 39.A client has an IV infiltration. What should the nurse do first? a. Elevate the extremity b. Discontinue the IV
a. Diarrhea b. Insomnia c. Constipation d. Increased appetite Opioids slow bowel motility and commonly cause constipation. 43.Which technique is appropriate for measuring a nasogastric tube? a. From the chin to the navel b. From the nose to sternum c. From nose to earlobe to xiphoid d. From ear to belly button This measurement ensures the tube reaches the stomach. 44.Which intervention prevents venous thromboembolism? a. Restrict fluids b. Encourage leg exercises c. Elevate the head of bed d. Keep patient immobile Leg exercises promote circulation and reduce clot risk in immobile patients. 45.A client reports pain at 8/10. What is the nurse’s priority action?
a. Document the pain b. Administer prescribed analgesic c. Reposition the client d. Offer distraction Treating reported pain is the priority to promote comfort and prevent complications. 46.What is the expected effect of administering a hypotonic IV solution? a. Cells shrink b. Cells swell c. No change in cell size d. Fluid remains in intravascular space Hypotonic solutions cause water to move into cells, making them swell. 47.A nurse notes that a client’s potassium is 6.2 mEq/L. What is the most serious risk? a. Constipation b. Fatigue c. Cardiac arrhythmias d. Confusion Hyperkalemia can cause life-threatening cardiac arrhythmias. 48.Which is a priority in therapeutic communication?
a. Hemoglobin 14 g/dL b. Platelet count 200,000/mm³ c. Platelet count 90,000/mm³ d. Hematocrit 42% A platelet count below 100,000/mm³ (thrombocytopenia) increases the risk for bleeding. 52.The nurse prepares to administer NPH insulin. When will the nurse expect the insulin to peak? a. 30 minutes b. 4 to 12 hours c. 1 hour d. 18 to 24 hours NPH insulin peaks between 4–12 hours, which is important to monitor for hypoglycemia. 53.Which is a correct method to prevent contamination during a sterile procedure? a. Keep hands below waist b. Avoid reaching over the sterile field c. Use clean gloves only d. Turn back to sterile field briefly Reaching over a sterile field can cause contamination and should be avoided.
54.A client has a new colostomy. Which finding should the nurse report? a. Red, moist stoma b. Pale or bluish stoma c. Stool output d. Slight bleeding around the stoma A pale or cyanotic stoma indicates poor blood supply and requires immediate attention. 55.Which finding indicates a possible adverse effect of furosemide? a. Bradycardia b. Muscle cramps c. Increased appetite d. Constipation Muscle cramps may indicate hypokalemia, a common side effect of furosemide. 56.A client asks why incentive spirometry is used after surgery. The best response is: a. "It helps you sleep." b. "It reduces pain." c. "It helps prevent pneumonia." d. "It speeds wound healing."
