BSN225 Exam 3 Actual Exam Style V3 |
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is preparing to administer an intramuscular injection to an adult patient. Which
site is considered the safest and most preferred for this type of injection?
A. Dorsogluteal site
B. Ventrogluteal site
C. Deltoid muscle
D. Vastus lateralis
Answer: B
Rationale: The ventrogluteal site is the preferred site for intramuscular injections because
it is situated away from major nerves and blood vessels. It provides a large muscle mass
that can accommodate larger volumes of medication safely. Using this site reduces the risk
of accidental injury compared to the dorsogluteal site.
2. Which nursing action is the most effective way to break the chain of infection in a clinical
setting?
A. Performing frequent and thorough hand hygiene
B. Administering prophylactic antibiotics
C. Wearing gloves for all patient contact
,D. Using sterile technique for all bedside procedures
Answer: A
Rationale: Hand hygiene is recognized as the single most important practice to prevent the
transmission of microorganisms. It effectively removes pathogens from the hands of
healthcare providers before they can reach a susceptible host. Consistent application of this
practice is the cornerstone of infection control programs.
3. A patient is being transferred from the bed to a wheelchair. Which action should the nurse
take first to ensure patient safety?
A. Place the wheelchair at a 45-degree angle to the bed
B. Lock the brakes on both the bed and the wheelchair
C. Apply a gait belt around the patient’s waist
D. Instruct the patient to push off the bed
Answer: B
Rationale: Locking the brakes is the priority action to stabilize the equipment and prevent
accidental movement during the transfer. If the equipment moves, the patient is at a high
risk for falls and musculoskeletal injury. Once the environment is secured, other steps like
applying a gait belt can follow.
4. While performing a physical assessment, the nurse notes that the patient’s radial pulse is
irregular. What is the nurse’s best next action?
A. Document the finding and notify the physician
, B. Assess the apical pulse for one full minute
C. Measure the pulse on the opposite wrist
D. Recheck the radial pulse after the patient rests
Answer: B
Rationale: When an irregular peripheral pulse is detected, the nurse must assess the apical
pulse for a full minute to determine the actual heart rate and rhythm. This provides a more
accurate assessment of the heart’s electrical activity and mechanical function. This step is
necessary to identify potential pulse deficits or arrhythmias.
5. A nurse is caring for a patient who is on a clear liquid diet. Which of the following items can
the nurse provide?
A. Vanilla pudding
B. Apple juice
C. Orange juice with pulp
D. Cream of mushroom soup
Answer: B
Rationale: A clear liquid diet consists of fluids that are transparent and liquid at room
temperature. Apple juice is appropriate because it is clear and leaves no residue in the
gastrointestinal tract. Items like pudding or cream soups are considered part of a full liquid
diet because they contain milk or solids.
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is preparing to administer an intramuscular injection to an adult patient. Which
site is considered the safest and most preferred for this type of injection?
A. Dorsogluteal site
B. Ventrogluteal site
C. Deltoid muscle
D. Vastus lateralis
Answer: B
Rationale: The ventrogluteal site is the preferred site for intramuscular injections because
it is situated away from major nerves and blood vessels. It provides a large muscle mass
that can accommodate larger volumes of medication safely. Using this site reduces the risk
of accidental injury compared to the dorsogluteal site.
2. Which nursing action is the most effective way to break the chain of infection in a clinical
setting?
A. Performing frequent and thorough hand hygiene
B. Administering prophylactic antibiotics
C. Wearing gloves for all patient contact
,D. Using sterile technique for all bedside procedures
Answer: A
Rationale: Hand hygiene is recognized as the single most important practice to prevent the
transmission of microorganisms. It effectively removes pathogens from the hands of
healthcare providers before they can reach a susceptible host. Consistent application of this
practice is the cornerstone of infection control programs.
3. A patient is being transferred from the bed to a wheelchair. Which action should the nurse
take first to ensure patient safety?
A. Place the wheelchair at a 45-degree angle to the bed
B. Lock the brakes on both the bed and the wheelchair
C. Apply a gait belt around the patient’s waist
D. Instruct the patient to push off the bed
Answer: B
Rationale: Locking the brakes is the priority action to stabilize the equipment and prevent
accidental movement during the transfer. If the equipment moves, the patient is at a high
risk for falls and musculoskeletal injury. Once the environment is secured, other steps like
applying a gait belt can follow.
4. While performing a physical assessment, the nurse notes that the patient’s radial pulse is
irregular. What is the nurse’s best next action?
A. Document the finding and notify the physician
, B. Assess the apical pulse for one full minute
C. Measure the pulse on the opposite wrist
D. Recheck the radial pulse after the patient rests
Answer: B
Rationale: When an irregular peripheral pulse is detected, the nurse must assess the apical
pulse for a full minute to determine the actual heart rate and rhythm. This provides a more
accurate assessment of the heart’s electrical activity and mechanical function. This step is
necessary to identify potential pulse deficits or arrhythmias.
5. A nurse is caring for a patient who is on a clear liquid diet. Which of the following items can
the nurse provide?
A. Vanilla pudding
B. Apple juice
C. Orange juice with pulp
D. Cream of mushroom soup
Answer: B
Rationale: A clear liquid diet consists of fluids that are transparent and liquid at room
temperature. Apple juice is appropriate because it is clear and leaves no residue in the
gastrointestinal tract. Items like pudding or cream soups are considered part of a full liquid
diet because they contain milk or solids.
