BSN225 Exam 1 Actual Exam Style V1 |
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is performing an admission assessment on a client. Which of the following is
considered objective data?
A. The client reports feeling nauseated.
B. The client states they have a headache.
C. The client says they are feeling anxious.
D. The client’s blood pressure is 140/90 mmHg.
Answer: D
Rationale: Objective data are observable and measurable signs that can be seen, heard, or
felt by the nurse. Blood pressure is a clinical measurement that provides factual
information about the client’s status. Subjective data, such as nausea or pain, consist of the
client’s own perceptions and feelings.
2. Which phase of the nursing process involves setting priorities and identifying measurable
goals?
A. Assessment
B. Evaluation
C. Implementation
,D. Planning
Answer: D
Rationale: The planning phase is the stage where the nurse develops a care plan based on
the nursing diagnoses. During this phase, the nurse collaborates with the client to set
SMART goals that are specific and measurable. It acts as a roadmap for the nursing
interventions that will follow.
3. A nurse is caring for a client with a history of falls. Which action should the nurse take first?
A. Apply physical restraints to keep the client in bed.
B. Place the client in a room far from the nurse’s station.
C. Request a prescription for a sedative medication.
D. Complete a fall risk assessment using a standardized tool.
Answer: D
Rationale: The first step in the nursing process is assessment, which provides the baseline
for safety interventions. Using a tool like the Morse Fall Scale helps identify specific risks
unique to the client. Interventions can only be appropriately planned once the level of risk
is established.
4. Which technique should the nurse use to assess the client’s abdomen?
A. Palpation, Percussion, Auscultation, Inspection
B. Inspection, Auscultation, Percussion, Palpation
, C. Auscultation, Inspection, Palpation, Percussion
D. Inspection, Palpation, Auscultation, Percussion
Answer: B
Rationale: The order of abdominal assessment is unique because palpation and percussion
can alter bowel sounds. By inspecting and then auscultating first, the nurse ensures a more
accurate assessment of the gastrointestinal activity. Palpation and percussion are
performed last to avoid stimulating the bowel unnecessarily.
5. A nurse is preparing to administer an intramuscular injection. Which of the following is the
most important action for safety?
A. Verify the client’s identity using two identifiers.
B. Recap the needle immediately after use.
C. Aspirate for blood return before injecting.
D. Select a 1-inch needle for a client with high BMI.
Answer: A
Rationale: Verifying the client’s identity is one of the ‘six rights’ of medication
administration and is crucial for preventing errors. Using two identifiers ensures that the
correct medication is given to the correct individual. This step is a fundamental safety
standard mandated by healthcare accrediting bodies.
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is performing an admission assessment on a client. Which of the following is
considered objective data?
A. The client reports feeling nauseated.
B. The client states they have a headache.
C. The client says they are feeling anxious.
D. The client’s blood pressure is 140/90 mmHg.
Answer: D
Rationale: Objective data are observable and measurable signs that can be seen, heard, or
felt by the nurse. Blood pressure is a clinical measurement that provides factual
information about the client’s status. Subjective data, such as nausea or pain, consist of the
client’s own perceptions and feelings.
2. Which phase of the nursing process involves setting priorities and identifying measurable
goals?
A. Assessment
B. Evaluation
C. Implementation
,D. Planning
Answer: D
Rationale: The planning phase is the stage where the nurse develops a care plan based on
the nursing diagnoses. During this phase, the nurse collaborates with the client to set
SMART goals that are specific and measurable. It acts as a roadmap for the nursing
interventions that will follow.
3. A nurse is caring for a client with a history of falls. Which action should the nurse take first?
A. Apply physical restraints to keep the client in bed.
B. Place the client in a room far from the nurse’s station.
C. Request a prescription for a sedative medication.
D. Complete a fall risk assessment using a standardized tool.
Answer: D
Rationale: The first step in the nursing process is assessment, which provides the baseline
for safety interventions. Using a tool like the Morse Fall Scale helps identify specific risks
unique to the client. Interventions can only be appropriately planned once the level of risk
is established.
4. Which technique should the nurse use to assess the client’s abdomen?
A. Palpation, Percussion, Auscultation, Inspection
B. Inspection, Auscultation, Percussion, Palpation
, C. Auscultation, Inspection, Palpation, Percussion
D. Inspection, Palpation, Auscultation, Percussion
Answer: B
Rationale: The order of abdominal assessment is unique because palpation and percussion
can alter bowel sounds. By inspecting and then auscultating first, the nurse ensures a more
accurate assessment of the gastrointestinal activity. Palpation and percussion are
performed last to avoid stimulating the bowel unnecessarily.
5. A nurse is preparing to administer an intramuscular injection. Which of the following is the
most important action for safety?
A. Verify the client’s identity using two identifiers.
B. Recap the needle immediately after use.
C. Aspirate for blood return before injecting.
D. Select a 1-inch needle for a client with high BMI.
Answer: A
Rationale: Verifying the client’s identity is one of the ‘six rights’ of medication
administration and is crucial for preventing errors. Using two identifiers ensures that the
correct medication is given to the correct individual. This step is a fundamental safety
standard mandated by healthcare accrediting bodies.
