BSN206 Exam 2 Actual Exam Style V2 |
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is assessing a patient for the risk of falls. Which factor is considered the most
significant predictor of a future fall?
A. A history of previous falls.
B. The patient’s age being over 65.
C. The use of multiple medications.
D. The presence of a urinary catheter.
Answer: A
Rationale: A history of falling is the strongest predictor for future falls in clinical settings.
This allows nurses to prioritize interventions for those already known to be at high risk.
Assessment tools like the Morse Fall Scale heavily weight this specific variable.
2. When implementing the nursing process, which activity is performed during the ‘Planning’
phase?
A. Collecting subjective and objective data.
B. Setting measurable patient-centered goals.
C. Performing a physical assessment.
,D. Documenting the patient’s response to a procedure.
Answer: B
Rationale: The planning phase involves the development of strategies and goals to address
the patient’s nursing diagnoses. During this stage, the nurse identifies measurable
outcomes and selects specific nursing interventions. This ensures that the care provided is
goal-oriented and individualized.
3. A nurse is preparing a sterile field for a dressing change. Which action would contaminate
the sterile field?
A. Keeping the sterile objects above the waist level.
B. Opening the outermost flap away from the body.
C. Dropping a sterile item onto the center of the field.
D. Turning one’s back to the sterile field.
Answer: D
Rationale: Sterile fields must always be kept within the line of sight to ensure sterility is
maintained. Turning your back or leaving the field unattended results in immediate
contamination according to surgical asepsis standards. Nurses must also ensure that only
sterile items touch the sterile field to prevent infection.
4. The nurse is caring for a patient who is on bed rest. Which intervention is most effective in
preventing deep vein thrombosis (DVT)?
A. Massaging the patient’s calves twice a day.
, B. Encouraging the patient to perform ankle pumps.
C. Restricting oral fluid intake.
D. Applying a warm compress to the lower extremities.
Answer: B
Rationale: Ankle pumps and foot circles help promote venous return and prevent blood
stasis in the lower extremities. This mechanical action mimics the movement of walking
which helps maintain circulation. Massaging the legs is contraindicated because it could
dislodge an existing clot.
5. Which documentation entry is the most accurate and follows professional nursing
standards?
A. The patient seems very confused today.
B. The patient ate a good amount of their breakfast.
C. The patient is acting out and being difficult.
D. The patient is alert and oriented to person, place, and time.
Answer: D
Rationale: Nursing documentation must be objective, factual, and specific rather than
subjective or vague. Using clear descriptors like ‘alert and oriented to person, place, and
time’ provides a verifiable baseline of the patient’s status. Avoid using judgmental words
like ‘difficult’ or ‘good’ which are open to interpretation.
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is assessing a patient for the risk of falls. Which factor is considered the most
significant predictor of a future fall?
A. A history of previous falls.
B. The patient’s age being over 65.
C. The use of multiple medications.
D. The presence of a urinary catheter.
Answer: A
Rationale: A history of falling is the strongest predictor for future falls in clinical settings.
This allows nurses to prioritize interventions for those already known to be at high risk.
Assessment tools like the Morse Fall Scale heavily weight this specific variable.
2. When implementing the nursing process, which activity is performed during the ‘Planning’
phase?
A. Collecting subjective and objective data.
B. Setting measurable patient-centered goals.
C. Performing a physical assessment.
,D. Documenting the patient’s response to a procedure.
Answer: B
Rationale: The planning phase involves the development of strategies and goals to address
the patient’s nursing diagnoses. During this stage, the nurse identifies measurable
outcomes and selects specific nursing interventions. This ensures that the care provided is
goal-oriented and individualized.
3. A nurse is preparing a sterile field for a dressing change. Which action would contaminate
the sterile field?
A. Keeping the sterile objects above the waist level.
B. Opening the outermost flap away from the body.
C. Dropping a sterile item onto the center of the field.
D. Turning one’s back to the sterile field.
Answer: D
Rationale: Sterile fields must always be kept within the line of sight to ensure sterility is
maintained. Turning your back or leaving the field unattended results in immediate
contamination according to surgical asepsis standards. Nurses must also ensure that only
sterile items touch the sterile field to prevent infection.
4. The nurse is caring for a patient who is on bed rest. Which intervention is most effective in
preventing deep vein thrombosis (DVT)?
A. Massaging the patient’s calves twice a day.
, B. Encouraging the patient to perform ankle pumps.
C. Restricting oral fluid intake.
D. Applying a warm compress to the lower extremities.
Answer: B
Rationale: Ankle pumps and foot circles help promote venous return and prevent blood
stasis in the lower extremities. This mechanical action mimics the movement of walking
which helps maintain circulation. Massaging the legs is contraindicated because it could
dislodge an existing clot.
5. Which documentation entry is the most accurate and follows professional nursing
standards?
A. The patient seems very confused today.
B. The patient ate a good amount of their breakfast.
C. The patient is acting out and being difficult.
D. The patient is alert and oriented to person, place, and time.
Answer: D
Rationale: Nursing documentation must be objective, factual, and specific rather than
subjective or vague. Using clear descriptors like ‘alert and oriented to person, place, and
time’ provides a verifiable baseline of the patient’s status. Avoid using judgmental words
like ‘difficult’ or ‘good’ which are open to interpretation.
