BSN206 Final Exam Actual Exam Style V2
| BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. Which phase of the nursing process involves the collection of subjective and objective
data?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Answer: A
Rationale: Assessment is the initial step where the nurse gathers data from various
sources. This includes the patient’s history, physical examination, and laboratory results.
This step is crucial because it forms the basis for the entire nursing care plan.
2. A nurse is performing hand hygiene. What is the minimum amount of time the nurse
should rub their hands with soap and water?
A. 5 seconds
B. 10 seconds
C. 60 seconds
,D. 20 seconds
Answer: D
Rationale: Hand hygiene is the most effective way to prevent the spread of infections.
Friction should be applied for at least 15 to 20 seconds to remove transient flora. This
process helps ensure that all surfaces of the hands and fingers are thoroughly cleaned.
3. Which vital sign should be assessed first if a patient is suspected of having a systemic
infection?
A. Blood Pressure
B. Temperature
C. Respiratory Rate
D. Oxygen Saturation
Answer: B
Rationale: A fever is a primary indicator of an immune response to infection. Temperature
monitoring helps the nurse evaluate the severity of the inflammatory process. Other vital
signs may change secondary to the metabolic demands of a high temperature.
4. The nurse is providing care based on the principle of ‘autonomy.’ Which action best reflects
this?
A. Telling the patient they must take their medication
B. Keeping all patient information confidential
, C. Providing the patient with information to make an informed decision
D. Ensuring the patient does not fall during a walk
Answer: C
Rationale: Autonomy refers to the patient’s right to self-determination and independent
decision-making. Nurses support this by ensuring the patient understands their choices
and the consequences thereof. Respecting autonomy is a cornerstone of ethical nursing
practice.
5. To prevent pressure ulcers in a bedridden patient, how often should the nurse reposition
them?
A. Every 1 hour
B. Every 4 hours
C. Every 2 hours
D. Once per shift
Answer: C
Rationale: Standard practice dictates that immobile patients be turned at least every two
hours. Frequent repositioning relieves pressure on bony prominences and maintains skin
integrity. This intervention is vital in preventing tissue ischemia and subsequent
breakdown.
| BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. Which phase of the nursing process involves the collection of subjective and objective
data?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Answer: A
Rationale: Assessment is the initial step where the nurse gathers data from various
sources. This includes the patient’s history, physical examination, and laboratory results.
This step is crucial because it forms the basis for the entire nursing care plan.
2. A nurse is performing hand hygiene. What is the minimum amount of time the nurse
should rub their hands with soap and water?
A. 5 seconds
B. 10 seconds
C. 60 seconds
,D. 20 seconds
Answer: D
Rationale: Hand hygiene is the most effective way to prevent the spread of infections.
Friction should be applied for at least 15 to 20 seconds to remove transient flora. This
process helps ensure that all surfaces of the hands and fingers are thoroughly cleaned.
3. Which vital sign should be assessed first if a patient is suspected of having a systemic
infection?
A. Blood Pressure
B. Temperature
C. Respiratory Rate
D. Oxygen Saturation
Answer: B
Rationale: A fever is a primary indicator of an immune response to infection. Temperature
monitoring helps the nurse evaluate the severity of the inflammatory process. Other vital
signs may change secondary to the metabolic demands of a high temperature.
4. The nurse is providing care based on the principle of ‘autonomy.’ Which action best reflects
this?
A. Telling the patient they must take their medication
B. Keeping all patient information confidential
, C. Providing the patient with information to make an informed decision
D. Ensuring the patient does not fall during a walk
Answer: C
Rationale: Autonomy refers to the patient’s right to self-determination and independent
decision-making. Nurses support this by ensuring the patient understands their choices
and the consequences thereof. Respecting autonomy is a cornerstone of ethical nursing
practice.
5. To prevent pressure ulcers in a bedridden patient, how often should the nurse reposition
them?
A. Every 1 hour
B. Every 4 hours
C. Every 2 hours
D. Once per shift
Answer: C
Rationale: Standard practice dictates that immobile patients be turned at least every two
hours. Frequent repositioning relieves pressure on bony prominences and maintains skin
integrity. This intervention is vital in preventing tissue ischemia and subsequent
breakdown.
