BSN Program Exit ACTUAL EXAM ALL QUESTIONS
AND ANSWERS ALREADY GRADED A+. 100%
VERIFIED SOLUTIONS | UPDATED PER LATEST
GUIDELINES | GRADED A+
Section 1: Fundamentals of Nursing and Safety (Questions 1–15)
Question 1
A nurse is preparing to administer medications to a client. Which action should the nurse take
FIRST to ensure client safety?
A) Check the client’s allergy band
B) Verify the client’s identity using two identifiers
C) Review the medication administration record (MAR)
D) Perform hand hygiene
Answer: B) Verify the client’s identity using two identifiers
Rationale: According to the National Patient Safety Goals, verifying client identity using two
unique identifiers (e.g., name and date of birth) is the FIRST critical step before any medication
administration. This is the core of the "Right Patient" right. Checking allergies, reviewing the
MAR, and hand hygiene are essential steps but occur after confirming the correct patient.
Question 2
Which task can the nurse delegate to an unlicensed assistive personnel (UAP)?
A) Perform a catheter insertion
B) Assist with ambulation
C) Administer oral medications
D) Evaluate wound healing
Answer: B) Assist with ambulation
,Rationale: UAPs are trained to assist with activities of daily living (ADLs), including ambulation.
Medication administration, sterile procedures (like catheter insertion), and nursing
assessments/evaluations require the clinical judgment of a licensed nurse.
Question 3
A nurse is providing discharge teaching to a client who has heart failure. Which of the following
statements should the nurse include?
A) “Weigh yourself daily at the same time each morning before breakfast.”
B) “Increase your fluid intake to 3 liters per day.”
C) “You should walk for 2 hours every day without rest.”
D) “You can stop taking your medications when you feel better.”
Answer: A) “Weigh yourself daily at the same time each morning before breakfast.”
Rationale: Daily weights at the same time are the most reliable indicator of fluid status in heart
failure clients. A sudden weight gain of 2-3 pounds in a day or 5 pounds in a week indicates
worsening fluid retention and should be reported.
Question 4
The nurse is caring for a client with a stage 3 pressure injury on the sacrum. Which finding
indicates the wound is healing?
A) Presence of yellow slough in the wound bed
B) Increase in wound drainage amount
C) Formation of granulation tissue
D) Expansion of wound edges
Answer: C) Formation of granulation tissue
Rationale: Granulation tissue (beefy red, bumpy tissue) is a key indicator of wound healing.
Yellow slough indicates necrotic tissue requiring debridement. Increased drainage may signal
infection, and expansion of wound edges suggests wound deterioration.
Question 5
A nurse is caring for a postoperative client who is at risk for venous thromboembolism (VTE).
Which of the following is the most effective nursing intervention to prevent VTE?
,A) Encourage ambulation as soon as possible
B) Massage the client’s legs
C) Keep the client on strict bed rest
D) Elevate the client’s legs above the heart
Answer: A) Encourage ambulation as soon as possible
Rationale: Early ambulation is the most effective nursing intervention to prevent VTE by
promoting venous return and preventing stasis. Sequential compression devices and
prophylactic anticoagulants are also used. Massaging legs can dislodge a clot and is
contraindicated.
Question 6
Which action by the nurse demonstrates proper technique when donning sterile gloves?
A) Touching the outside of the glove with bare hands to adjust fit
B) Picking up the second glove by grasping the folded cuff edge with the gloved hand
C) Allowing gloved hands to drop below waist level during procedure
D) Using the dominant hand to pick up the first glove by the cuff
Answer: B) Picking up the second glove by grasping the folded cuff edge with the gloved hand
Rationale: When donning sterile gloves, the first glove is picked up by the cuff (non-sterile edge)
with the bare hand. The second glove is then picked up by sliding the gloved fingers under the
folded cuff (sterile surface) of the second glove. Touching the outside sterile surface with bare
hands (A) contaminates the glove. Gloved hands must remain above waist level (C) to maintain
sterility. The nondominant hand typically picks up the first glove (D).
Question 7
A client on fall precautions is being cared for. Which of the following interventions should be
included in the plan of care?
A) Keep all four side rails up at all times.
B) Place the call light within the client’s reach.
C) Encourage the client to wear socks without non-skid soles.
D) Ensure the bed is in the lowest position.
Answer: D) Ensure the bed is in the lowest position.
, Rationale: Keeping the bed in the lowest position is a key fall prevention strategy as it minimizes
injury risk if the client attempts to get out of bed. Placing the call light within reach is also
important, but a low bed position is a more direct physical safety measure. Restraints or all four
side rails up are not recommended and can increase fall risk.
Question 8
When performing tracheostomy care, which action should the nurse take first?
A) Cleanse around the stoma.
B) Suction the tracheostomy.
C) Oxygenate with 100% oxygen.
D) Secure the new neck strap.
Answer: C) Oxygenate with 100% oxygen.
Rationale: Before suctioning or changing a tracheostomy tube, the nurse should preoxygenate
the client with 100% oxygen for 30 seconds to 1 minute to prevent hypoxemia. This is a critical
safety step before any manipulation of the airway.
Question 9
A client is prescribed 1000 mL of 0.9% sodium chloride to infuse over 8 hours. The IV tubing has
a drop factor of 15 gtt/mL. At how many drops per minute should the nurse set the infusion?
A) 21 gtt/min
B) 31 gtt/min
C) 42 gtt/min
D) 63 gtt/min
Answer: B) 31 gtt/min
Rationale: The formula for IV drip rate is: (Volume in mL × Drop factor) ÷ Time in minutes.
Calculation: (1000 × 15) ÷ (8 × 60) = 15,000 ÷ 480 = 31.25 → round to 31 gtt/min.
Question 10
A client with dysphagia is prescribed a mechanical soft diet. Which food should the nurse offer?
A) Whole grapes
B) Chunky peanut butter
AND ANSWERS ALREADY GRADED A+. 100%
VERIFIED SOLUTIONS | UPDATED PER LATEST
GUIDELINES | GRADED A+
Section 1: Fundamentals of Nursing and Safety (Questions 1–15)
Question 1
A nurse is preparing to administer medications to a client. Which action should the nurse take
FIRST to ensure client safety?
A) Check the client’s allergy band
B) Verify the client’s identity using two identifiers
C) Review the medication administration record (MAR)
D) Perform hand hygiene
Answer: B) Verify the client’s identity using two identifiers
Rationale: According to the National Patient Safety Goals, verifying client identity using two
unique identifiers (e.g., name and date of birth) is the FIRST critical step before any medication
administration. This is the core of the "Right Patient" right. Checking allergies, reviewing the
MAR, and hand hygiene are essential steps but occur after confirming the correct patient.
Question 2
Which task can the nurse delegate to an unlicensed assistive personnel (UAP)?
A) Perform a catheter insertion
B) Assist with ambulation
C) Administer oral medications
D) Evaluate wound healing
Answer: B) Assist with ambulation
,Rationale: UAPs are trained to assist with activities of daily living (ADLs), including ambulation.
Medication administration, sterile procedures (like catheter insertion), and nursing
assessments/evaluations require the clinical judgment of a licensed nurse.
Question 3
A nurse is providing discharge teaching to a client who has heart failure. Which of the following
statements should the nurse include?
A) “Weigh yourself daily at the same time each morning before breakfast.”
B) “Increase your fluid intake to 3 liters per day.”
C) “You should walk for 2 hours every day without rest.”
D) “You can stop taking your medications when you feel better.”
Answer: A) “Weigh yourself daily at the same time each morning before breakfast.”
Rationale: Daily weights at the same time are the most reliable indicator of fluid status in heart
failure clients. A sudden weight gain of 2-3 pounds in a day or 5 pounds in a week indicates
worsening fluid retention and should be reported.
Question 4
The nurse is caring for a client with a stage 3 pressure injury on the sacrum. Which finding
indicates the wound is healing?
A) Presence of yellow slough in the wound bed
B) Increase in wound drainage amount
C) Formation of granulation tissue
D) Expansion of wound edges
Answer: C) Formation of granulation tissue
Rationale: Granulation tissue (beefy red, bumpy tissue) is a key indicator of wound healing.
Yellow slough indicates necrotic tissue requiring debridement. Increased drainage may signal
infection, and expansion of wound edges suggests wound deterioration.
Question 5
A nurse is caring for a postoperative client who is at risk for venous thromboembolism (VTE).
Which of the following is the most effective nursing intervention to prevent VTE?
,A) Encourage ambulation as soon as possible
B) Massage the client’s legs
C) Keep the client on strict bed rest
D) Elevate the client’s legs above the heart
Answer: A) Encourage ambulation as soon as possible
Rationale: Early ambulation is the most effective nursing intervention to prevent VTE by
promoting venous return and preventing stasis. Sequential compression devices and
prophylactic anticoagulants are also used. Massaging legs can dislodge a clot and is
contraindicated.
Question 6
Which action by the nurse demonstrates proper technique when donning sterile gloves?
A) Touching the outside of the glove with bare hands to adjust fit
B) Picking up the second glove by grasping the folded cuff edge with the gloved hand
C) Allowing gloved hands to drop below waist level during procedure
D) Using the dominant hand to pick up the first glove by the cuff
Answer: B) Picking up the second glove by grasping the folded cuff edge with the gloved hand
Rationale: When donning sterile gloves, the first glove is picked up by the cuff (non-sterile edge)
with the bare hand. The second glove is then picked up by sliding the gloved fingers under the
folded cuff (sterile surface) of the second glove. Touching the outside sterile surface with bare
hands (A) contaminates the glove. Gloved hands must remain above waist level (C) to maintain
sterility. The nondominant hand typically picks up the first glove (D).
Question 7
A client on fall precautions is being cared for. Which of the following interventions should be
included in the plan of care?
A) Keep all four side rails up at all times.
B) Place the call light within the client’s reach.
C) Encourage the client to wear socks without non-skid soles.
D) Ensure the bed is in the lowest position.
Answer: D) Ensure the bed is in the lowest position.
, Rationale: Keeping the bed in the lowest position is a key fall prevention strategy as it minimizes
injury risk if the client attempts to get out of bed. Placing the call light within reach is also
important, but a low bed position is a more direct physical safety measure. Restraints or all four
side rails up are not recommended and can increase fall risk.
Question 8
When performing tracheostomy care, which action should the nurse take first?
A) Cleanse around the stoma.
B) Suction the tracheostomy.
C) Oxygenate with 100% oxygen.
D) Secure the new neck strap.
Answer: C) Oxygenate with 100% oxygen.
Rationale: Before suctioning or changing a tracheostomy tube, the nurse should preoxygenate
the client with 100% oxygen for 30 seconds to 1 minute to prevent hypoxemia. This is a critical
safety step before any manipulation of the airway.
Question 9
A client is prescribed 1000 mL of 0.9% sodium chloride to infuse over 8 hours. The IV tubing has
a drop factor of 15 gtt/mL. At how many drops per minute should the nurse set the infusion?
A) 21 gtt/min
B) 31 gtt/min
C) 42 gtt/min
D) 63 gtt/min
Answer: B) 31 gtt/min
Rationale: The formula for IV drip rate is: (Volume in mL × Drop factor) ÷ Time in minutes.
Calculation: (1000 × 15) ÷ (8 × 60) = 15,000 ÷ 480 = 31.25 → round to 31 gtt/min.
Question 10
A client with dysphagia is prescribed a mechanical soft diet. Which food should the nurse offer?
A) Whole grapes
B) Chunky peanut butter
