BSN206 Exam 2 Actual Exam Style V3 |
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is preparing to measure the blood pressure of a patient with a very large arm
circumference. If the nurse uses a standard-sized cuff that is too small, what is the most likely
outcome?
A. The reading will be falsely low.
B. The reading will be falsely high.
C. The reading will be accurate if the patient is sitting.
D. The diastolic pressure will be unaffected.
Answer: B
Rationale: Using a blood pressure cuff that is too small for the patient’s arm circumference
will result in a falsely high reading. The bladder must be able to encircle at least 80% of the
arm to provide an accurate measurement. If the cuff is too wide, the reading may be falsely
low.
2. Which of the following actions is the priority for a nurse when a patient’s room is filled
with smoke from a small fire in the trash can?
A. Extinguish the fire using a dry chemical extinguisher.
,B. Close all doors and windows to contain the smoke.
C. Activate the fire alarm system immediately.
D. Remove the patient from the immediate area of danger.
Answer: D
Rationale: According to the RACE acronym, the first step in fire safety is Rescue, which
involves removing patients from danger. After the patient is safe, the nurse should then
Alarm, Confine, and Extinguish/Evacuate. Prioritizing life safety over property is a core
nursing fundamental.
3. A nurse is caring for a patient diagnosed with Clostridium difficile (C. diff). Which infection
control measure is mandatory for this specific situation?
A. Performing hand hygiene with alcohol-based hand rub.
B. Wearing an N95 respirator during patient care.
C. Washing hands with soap and water after contact.
D. Maintaining the patient in a negative-pressure room.
Answer: C
Rationale: C. diff spores are resistant to alcohol-based hand sanitizers, making soap and
water necessary to physically remove them. Contact precautions are required, which
include wearing gloves and a gown. Alcohol-based rubs are generally effective for most
other bacteria but not for spore-forming organisms like C. diff.
, 4. A patient tells the nurse, ‘I am really worried about my surgery tomorrow.’ The nurse
responds, ‘You have a great surgeon, so there is nothing to worry about.’ This response is an
example of:
A. Offering false reassurance.
B. Providing therapeutic encouragement.
C. Using a clarifying technique.
D. Establishing a professional boundary.
Answer: A
Rationale: Telling a patient there is nothing to worry about is a non-therapeutic
communication technique known as false reassurance. This shuts down communication
and minimizes the patient’s valid feelings of anxiety. A therapeutic response would involve
acknowledging the patient’s fear and encouraging further discussion.
5. Which ethical principle is the nurse upholding when they support a patient’s right to refuse
a life-saving blood transfusion due to religious beliefs?
A. Beneficence.
B. Non-maleficence.
C. Autonomy.
D. Justice.
Answer: C
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is preparing to measure the blood pressure of a patient with a very large arm
circumference. If the nurse uses a standard-sized cuff that is too small, what is the most likely
outcome?
A. The reading will be falsely low.
B. The reading will be falsely high.
C. The reading will be accurate if the patient is sitting.
D. The diastolic pressure will be unaffected.
Answer: B
Rationale: Using a blood pressure cuff that is too small for the patient’s arm circumference
will result in a falsely high reading. The bladder must be able to encircle at least 80% of the
arm to provide an accurate measurement. If the cuff is too wide, the reading may be falsely
low.
2. Which of the following actions is the priority for a nurse when a patient’s room is filled
with smoke from a small fire in the trash can?
A. Extinguish the fire using a dry chemical extinguisher.
,B. Close all doors and windows to contain the smoke.
C. Activate the fire alarm system immediately.
D. Remove the patient from the immediate area of danger.
Answer: D
Rationale: According to the RACE acronym, the first step in fire safety is Rescue, which
involves removing patients from danger. After the patient is safe, the nurse should then
Alarm, Confine, and Extinguish/Evacuate. Prioritizing life safety over property is a core
nursing fundamental.
3. A nurse is caring for a patient diagnosed with Clostridium difficile (C. diff). Which infection
control measure is mandatory for this specific situation?
A. Performing hand hygiene with alcohol-based hand rub.
B. Wearing an N95 respirator during patient care.
C. Washing hands with soap and water after contact.
D. Maintaining the patient in a negative-pressure room.
Answer: C
Rationale: C. diff spores are resistant to alcohol-based hand sanitizers, making soap and
water necessary to physically remove them. Contact precautions are required, which
include wearing gloves and a gown. Alcohol-based rubs are generally effective for most
other bacteria but not for spore-forming organisms like C. diff.
, 4. A patient tells the nurse, ‘I am really worried about my surgery tomorrow.’ The nurse
responds, ‘You have a great surgeon, so there is nothing to worry about.’ This response is an
example of:
A. Offering false reassurance.
B. Providing therapeutic encouragement.
C. Using a clarifying technique.
D. Establishing a professional boundary.
Answer: A
Rationale: Telling a patient there is nothing to worry about is a non-therapeutic
communication technique known as false reassurance. This shuts down communication
and minimizes the patient’s valid feelings of anxiety. A therapeutic response would involve
acknowledging the patient’s fear and encouraging further discussion.
5. Which ethical principle is the nurse upholding when they support a patient’s right to refuse
a life-saving blood transfusion due to religious beliefs?
A. Beneficence.
B. Non-maleficence.
C. Autonomy.
D. Justice.
Answer: C
