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BSN 206 Hallmark Exam Actual Exam
2026/2027 | Foundations of Nursing
Fundamentals | Nightingale | Questions with
Verified Answers | 100% Correct | Pass
Guaranteed
Q001: A 68-year-old postsurgical client has just returned from PACU with a
morphine patient-controlled analgesia (PCA) pump. During the first assessment,
the nurse notes respirations 8/min, SpO₂ 89 %, and the client is difficult to arouse.
Which immediate nursing action is required?
Options:
A. Record findings and reassess in 30 minutes
B. Discontinue the PCA and encourage deep breathing
C. Administer naloxone per protocol and initiate oxygen therapy
D. Increase PCA basal rate to improve sedation
ANSWER: C
Q002: A nurse is preparing to insert an indwelling urinary catheter in a 42-year-old
female client. After explaining the procedure, the nurse notes the client’s verbal
consent but visible tension. Which action best supports patient-centered care?
Options:
A. Proceed quickly to minimize embarrassment
B. Ask about concerns and offer a relaxation technique before starting
C. Postpone the procedure until the client is calmer
D. Reassure the client that discomfort is brief
, 2
ANSWER: B
Q003: A nurse calculates the intake and output for a client over 8 hours: 500 mL
D5W IV, 250 mL PO fluids, 150 mL IV antibiotics, 400 mL urine, 100 mL
vomitus, and 50 mL wound drainage. Which net balance should the nurse
document?
Options:
A. +350 mL
B. +450 mL
C. +550 mL
D. +650 mL
ANSWER: B
Q004: A postoperative client has a prescription for morphine 4 mg IV q4h PRN
pain. The vial contains 10 mg/mL. How many milliliters should the nurse
administer? (Round to the nearest tenth.)
Options:
A. 0.2 mL
B. 0.4 mL
C. 0.6 mL
D. 0.8 mL
ANSWER: B
Q005: A nurse is repositioning an immobile client. Which intervention best reduces
shearing forces?
Options:
A. Elevate the head of the bed to 45° during repositioning
B. Use a drawsheet to lift rather than drag the client
C. Apply talcum powder before moving
, 3
D. Lower the bed height while moving the client
ANSWER: B
Q006: A nurse obtains orthostatic vital signs: supine BP 124/78 mmHg, HR 76
bpm; standing BP 106/70 mmHg, HR 96 bpm. Which conclusion and action are
appropriate?
Options:
A. Normal response; document and continue care
B. Positive orthostatic hypotension; assist client to stand slowly and increase fluids
C. Hypertensive crisis; notify provider immediately
D. Bradycardic episode; prepare for transcutaneous pacing
ANSWER: B
Q007: A client is scheduled for a chest X-ray at 0900. The nurse reviews the
EMAR and notes that the 0800 metformin dose is held “for procedure.” Which
action is appropriate?
A. Give the metformin at 0800 and document given
B. Hold the dose and ensure the radiology team is aware
C. Clarify with the provider if NPO status includes medications and document
accordingly
D. Reschedule the X-ray so medications can be given on time
ANSWER: C
Q008: A nurse is performing hand hygiene using an alcohol-based rub. Which step
is critical for maximal antimicrobial effect?
Options:
A. Rub palms only for 5 seconds
B. Cover all hand surfaces and rub until dry (≈20 seconds)
C. Rinse with water after rubbing
, 4
D. Use a paper towel to remove excess product
ANSWER: B
Q009: A client receiving total parenteral nutrition (TPN) has a blood glucose of
248 mg/dL. Which nursing action is priority?
Options:
A. Stop the TPN infusion immediately
B. Notify the provider and follow insulin protocol
C. Recheck glucose in 4 hours
D. Increase the TPN infusion rate to enhance clearance
ANSWER: B
Q010: A nurse is assessing a client’s pain 4 hours post-op. The client rates pain
8/10, BP 148/90 mmHg, HR 105 bpm, guarding the incision. Which type of data is
the nurse collecting?
Options:
A. Subjective only
B. Objective only
C. Both subjective and objective
D. Secondary subjective
ANSWER: C
Q011: A nurse is documenting client care using the SOAP format. Which statement
best belongs in the “Assessment” section?
Options:
A. “Client states ‘I feel short of breath.’”
B. “O2 saturation 88 % on room air, respiratory rate 28/min”
C. “Acute hypoxemia related to atelectasis”
BSN 206 Hallmark Exam Actual Exam
2026/2027 | Foundations of Nursing
Fundamentals | Nightingale | Questions with
Verified Answers | 100% Correct | Pass
Guaranteed
Q001: A 68-year-old postsurgical client has just returned from PACU with a
morphine patient-controlled analgesia (PCA) pump. During the first assessment,
the nurse notes respirations 8/min, SpO₂ 89 %, and the client is difficult to arouse.
Which immediate nursing action is required?
Options:
A. Record findings and reassess in 30 minutes
B. Discontinue the PCA and encourage deep breathing
C. Administer naloxone per protocol and initiate oxygen therapy
D. Increase PCA basal rate to improve sedation
ANSWER: C
Q002: A nurse is preparing to insert an indwelling urinary catheter in a 42-year-old
female client. After explaining the procedure, the nurse notes the client’s verbal
consent but visible tension. Which action best supports patient-centered care?
Options:
A. Proceed quickly to minimize embarrassment
B. Ask about concerns and offer a relaxation technique before starting
C. Postpone the procedure until the client is calmer
D. Reassure the client that discomfort is brief
, 2
ANSWER: B
Q003: A nurse calculates the intake and output for a client over 8 hours: 500 mL
D5W IV, 250 mL PO fluids, 150 mL IV antibiotics, 400 mL urine, 100 mL
vomitus, and 50 mL wound drainage. Which net balance should the nurse
document?
Options:
A. +350 mL
B. +450 mL
C. +550 mL
D. +650 mL
ANSWER: B
Q004: A postoperative client has a prescription for morphine 4 mg IV q4h PRN
pain. The vial contains 10 mg/mL. How many milliliters should the nurse
administer? (Round to the nearest tenth.)
Options:
A. 0.2 mL
B. 0.4 mL
C. 0.6 mL
D. 0.8 mL
ANSWER: B
Q005: A nurse is repositioning an immobile client. Which intervention best reduces
shearing forces?
Options:
A. Elevate the head of the bed to 45° during repositioning
B. Use a drawsheet to lift rather than drag the client
C. Apply talcum powder before moving
, 3
D. Lower the bed height while moving the client
ANSWER: B
Q006: A nurse obtains orthostatic vital signs: supine BP 124/78 mmHg, HR 76
bpm; standing BP 106/70 mmHg, HR 96 bpm. Which conclusion and action are
appropriate?
Options:
A. Normal response; document and continue care
B. Positive orthostatic hypotension; assist client to stand slowly and increase fluids
C. Hypertensive crisis; notify provider immediately
D. Bradycardic episode; prepare for transcutaneous pacing
ANSWER: B
Q007: A client is scheduled for a chest X-ray at 0900. The nurse reviews the
EMAR and notes that the 0800 metformin dose is held “for procedure.” Which
action is appropriate?
A. Give the metformin at 0800 and document given
B. Hold the dose and ensure the radiology team is aware
C. Clarify with the provider if NPO status includes medications and document
accordingly
D. Reschedule the X-ray so medications can be given on time
ANSWER: C
Q008: A nurse is performing hand hygiene using an alcohol-based rub. Which step
is critical for maximal antimicrobial effect?
Options:
A. Rub palms only for 5 seconds
B. Cover all hand surfaces and rub until dry (≈20 seconds)
C. Rinse with water after rubbing
, 4
D. Use a paper towel to remove excess product
ANSWER: B
Q009: A client receiving total parenteral nutrition (TPN) has a blood glucose of
248 mg/dL. Which nursing action is priority?
Options:
A. Stop the TPN infusion immediately
B. Notify the provider and follow insulin protocol
C. Recheck glucose in 4 hours
D. Increase the TPN infusion rate to enhance clearance
ANSWER: B
Q010: A nurse is assessing a client’s pain 4 hours post-op. The client rates pain
8/10, BP 148/90 mmHg, HR 105 bpm, guarding the incision. Which type of data is
the nurse collecting?
Options:
A. Subjective only
B. Objective only
C. Both subjective and objective
D. Secondary subjective
ANSWER: C
Q011: A nurse is documenting client care using the SOAP format. Which statement
best belongs in the “Assessment” section?
Options:
A. “Client states ‘I feel short of breath.’”
B. “O2 saturation 88 % on room air, respiratory rate 28/min”
C. “Acute hypoxemia related to atelectasis”
