BSN206 Exam 3 Actual Exam Style V2 |
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is preparing to administer an intramuscular (IM) injection to an adult patient.
Which needle gauge and length are most appropriate for a ventrogluteal injection?
A. 25-gauge, 5/8 inch
B. 22-gauge, 1.5 inch
C. 18-gauge, 1.5 inch
D. 27-gauge, 0.5 inch
Answer: B
Rationale: For an adult intramuscular injection in the ventrogluteal site, a 20- to 25-gauge
needle that is 1.5 inches long is typically recommended. This ensures the medication
reaches the deep muscle tissue rather than staying in the subcutaneous layer. Using a
gauge that is too small or a needle that is too short can lead to ineffective delivery and
localized irritation.
2. When administering an anticoagulant medication subcutaneously, which action should the
nurse perform to minimize bruising?
A. Massage the site vigorously after injection
,B. Aspirate for blood return before injecting
C. Apply pressure with a gauze pad for 1-2 minutes
D. Inject the medication into the deltoid muscle
Answer: C
Rationale: Applying gentle pressure after a subcutaneous anticoagulant injection helps
prevent hematoma formation by facilitating clotting at the needle track. Massaging the site
is contraindicated because it causes tissue trauma and increases the risk of bleeding and
bruising. Aspiration is no longer recommended for subcutaneous injections as it increases
the risk of hematoma and does not guarantee placement.
3. A nurse is monitoring an IV site and notes that the area is cool to the touch, swollen, and
the infusion has slowed. Which complication should the nurse suspect?
A. Phlebitis
B. Cellulitis
C. Extravasation
D. Infiltration
Answer: D
Rationale: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
subcutaneous tissue, causing coolness, edema, and pallor. Phlebitis would present with
, warmth and redness along the vein track, rather than coolness. The nurse should
immediately stop the infusion and remove the catheter to prevent further tissue damage.
4. The nurse is reviewing the rights of medication administration. Which of the following is
considered one of the ‘six rights’?
A. Right diagnosis
B. Right room number
C. Right documentation
D. Right physician
Answer: C
Rationale: The six rights of medication administration include right patient, right
medication, right dose, right route, right time, and right documentation. Proper
documentation ensures that the administration is recorded accurately to prevent double
dosing and maintain a legal record. Failure to adhere to these rights is a primary cause of
medication errors in clinical practice.
5. A patient is diagnosed with a stage 3 pressure injury. How should the nurse describe this
wound in the medical record?
A. Full-thickness skin loss with visible subcutaneous fat
B. Partial-thickness skin loss with exposed dermis
C. Non-blanchable erythema of intact skin
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is preparing to administer an intramuscular (IM) injection to an adult patient.
Which needle gauge and length are most appropriate for a ventrogluteal injection?
A. 25-gauge, 5/8 inch
B. 22-gauge, 1.5 inch
C. 18-gauge, 1.5 inch
D. 27-gauge, 0.5 inch
Answer: B
Rationale: For an adult intramuscular injection in the ventrogluteal site, a 20- to 25-gauge
needle that is 1.5 inches long is typically recommended. This ensures the medication
reaches the deep muscle tissue rather than staying in the subcutaneous layer. Using a
gauge that is too small or a needle that is too short can lead to ineffective delivery and
localized irritation.
2. When administering an anticoagulant medication subcutaneously, which action should the
nurse perform to minimize bruising?
A. Massage the site vigorously after injection
,B. Aspirate for blood return before injecting
C. Apply pressure with a gauze pad for 1-2 minutes
D. Inject the medication into the deltoid muscle
Answer: C
Rationale: Applying gentle pressure after a subcutaneous anticoagulant injection helps
prevent hematoma formation by facilitating clotting at the needle track. Massaging the site
is contraindicated because it causes tissue trauma and increases the risk of bleeding and
bruising. Aspiration is no longer recommended for subcutaneous injections as it increases
the risk of hematoma and does not guarantee placement.
3. A nurse is monitoring an IV site and notes that the area is cool to the touch, swollen, and
the infusion has slowed. Which complication should the nurse suspect?
A. Phlebitis
B. Cellulitis
C. Extravasation
D. Infiltration
Answer: D
Rationale: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
subcutaneous tissue, causing coolness, edema, and pallor. Phlebitis would present with
, warmth and redness along the vein track, rather than coolness. The nurse should
immediately stop the infusion and remove the catheter to prevent further tissue damage.
4. The nurse is reviewing the rights of medication administration. Which of the following is
considered one of the ‘six rights’?
A. Right diagnosis
B. Right room number
C. Right documentation
D. Right physician
Answer: C
Rationale: The six rights of medication administration include right patient, right
medication, right dose, right route, right time, and right documentation. Proper
documentation ensures that the administration is recorded accurately to prevent double
dosing and maintain a legal record. Failure to adhere to these rights is a primary cause of
medication errors in clinical practice.
5. A patient is diagnosed with a stage 3 pressure injury. How should the nurse describe this
wound in the medical record?
A. Full-thickness skin loss with visible subcutaneous fat
B. Partial-thickness skin loss with exposed dermis
C. Non-blanchable erythema of intact skin
