BSN225 Final Exam Actual Exam Style V3
| BSN 225 HESI RN Specialty
Fundamentals of Nursing Exam |
Nightingale
1. A nurse is preparing to change the linens for a client who is on contact precautions for C.
difficile. Which of the following actions should the nurse take?
A. Place the soiled linens in a leak-proof laundry bag.
B. Shake the linens to remove any loose debris before bagging.
C. Carry the soiled linens close to the body to prevent dripping.
D. Use an alcohol-based hand rub for hand hygiene after removing gloves.
Answer: A
Rationale: C. difficile requires contact precautions to prevent the spread of spores. Soiled
linens must be placed in a leak-proof bag to contain infectious material and prevent
environmental contamination. The nurse must use soap and water for hand hygiene
because alcohol-based rubs are ineffective against C. difficile spores.
2. A nurse is caring for a client who is at risk for falls. Which of the following interventions is
the priority?
A. Assess the client’s gait and balance.
B. Place the bedside table within the client’s reach.
,C. Apply physical restraints to the client’s wrists.
D. Provide the client with non-skid footwear.
Answer: A
Rationale: The nursing process dictates that assessment is the first step when caring for a
client. Evaluating the client’s gait and balance allows the nurse to identify specific risks and
tailor interventions. Once the assessment is complete, other safety measures like providing
non-skid footwear can be implemented.
3. A nurse is assessing a client’s blood pressure and notes that the cuff is too small. Which of
the following findings should the nurse expect?
A. The blood pressure reading will not be affected by cuff size.
B. The blood pressure reading will be falsely low.
C. The diastolic pressure will be accurate but the systolic will be low.
D. The blood pressure reading will be falsely high.
Answer: D
Rationale: Using a blood pressure cuff that is too small for the client’s arm circumference
will result in a falsely elevated reading. This occurs because the cuff requires more
pressure to occlude the artery. It is essential to select the correct cuff size to ensure an
accurate clinical assessment.
, 4. A nurse is teaching a client how to use an incentive spirometer. Which of the following
instructions should the nurse include?
A. Use the device once every 4 hours while awake.
B. Exhale forcefully into the mouthpiece.
C. Inhale slowly and deeply through the mouthpiece.
D. Hold your breath for at least 15 seconds after inhalation.
Answer: C
Rationale: The purpose of an incentive spirometer is to promote lung expansion through
slow, deep inhalations. Forceful exhalation does not achieve the goal of opening the alveoli.
The nurse should instruct the client to use the device approximately 10 times every hour
while awake.
5. A nurse is performing a physical assessment on a client. Which of the following techniques
should the nurse use first when assessing the abdomen?
A. Palpation
B. Inspection
C. Percussion
D. Auscultation
Answer: B
| BSN 225 HESI RN Specialty
Fundamentals of Nursing Exam |
Nightingale
1. A nurse is preparing to change the linens for a client who is on contact precautions for C.
difficile. Which of the following actions should the nurse take?
A. Place the soiled linens in a leak-proof laundry bag.
B. Shake the linens to remove any loose debris before bagging.
C. Carry the soiled linens close to the body to prevent dripping.
D. Use an alcohol-based hand rub for hand hygiene after removing gloves.
Answer: A
Rationale: C. difficile requires contact precautions to prevent the spread of spores. Soiled
linens must be placed in a leak-proof bag to contain infectious material and prevent
environmental contamination. The nurse must use soap and water for hand hygiene
because alcohol-based rubs are ineffective against C. difficile spores.
2. A nurse is caring for a client who is at risk for falls. Which of the following interventions is
the priority?
A. Assess the client’s gait and balance.
B. Place the bedside table within the client’s reach.
,C. Apply physical restraints to the client’s wrists.
D. Provide the client with non-skid footwear.
Answer: A
Rationale: The nursing process dictates that assessment is the first step when caring for a
client. Evaluating the client’s gait and balance allows the nurse to identify specific risks and
tailor interventions. Once the assessment is complete, other safety measures like providing
non-skid footwear can be implemented.
3. A nurse is assessing a client’s blood pressure and notes that the cuff is too small. Which of
the following findings should the nurse expect?
A. The blood pressure reading will not be affected by cuff size.
B. The blood pressure reading will be falsely low.
C. The diastolic pressure will be accurate but the systolic will be low.
D. The blood pressure reading will be falsely high.
Answer: D
Rationale: Using a blood pressure cuff that is too small for the client’s arm circumference
will result in a falsely elevated reading. This occurs because the cuff requires more
pressure to occlude the artery. It is essential to select the correct cuff size to ensure an
accurate clinical assessment.
, 4. A nurse is teaching a client how to use an incentive spirometer. Which of the following
instructions should the nurse include?
A. Use the device once every 4 hours while awake.
B. Exhale forcefully into the mouthpiece.
C. Inhale slowly and deeply through the mouthpiece.
D. Hold your breath for at least 15 seconds after inhalation.
Answer: C
Rationale: The purpose of an incentive spirometer is to promote lung expansion through
slow, deep inhalations. Forceful exhalation does not achieve the goal of opening the alveoli.
The nurse should instruct the client to use the device approximately 10 times every hour
while awake.
5. A nurse is performing a physical assessment on a client. Which of the following techniques
should the nurse use first when assessing the abdomen?
A. Palpation
B. Inspection
C. Percussion
D. Auscultation
Answer: B
