BSN225 Exam 1 Actual Exam Style V2 |
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is preparing to perform hand hygiene. Which action is considered the most
important factor in removing microorganisms?
A. Using hot water
B. Applying antibacterial soap
C. Friction during rubbing
D. Drying with a cloth towel
Answer: C
Rationale: Friction is the most effective way to physically remove microorganisms and
debris from the surface of the skin. The mechanical action of rubbing the hands together for
at least 20 seconds is essential for breaking down biofilms. While soap helps emulsify oils,
it is the friction that ensures the pathogens are actually washed away.
2. When assessing a patient’s blood pressure, the nurse uses a cuff that is too narrow for the
patient’s arm. What result should the nurse expect?
A. A false high reading
B. A false low reading
C. An accurate systolic but low diastolic
,D. An accurate diastolic but low systolic
Answer: A
Rationale: Using a blood pressure cuff that is too small or narrow for the limb will result in
a false high reading because it requires more pressure to occlude the artery. Conversely, a
cuff that is too large will result in a false low reading. Nurses must ensure the bladder of the
cuff encircles at least 80% of the arm to maintain accuracy.
3. The nurse is caring for a patient on contact precautions. Which of the following PPE
combinations is required before entering the room?
A. Gloves and gown
B. Mask and goggles
C. N95 respirator and gloves
D. Gown and surgical mask
Answer: A
Rationale: Contact precautions are designed to prevent the transmission of infectious
agents through direct or indirect contact with the patient or the patient’s environment. The
minimum requirement for PPE in this scenario includes gloves and a gown. This ensures
that the nurse’s clothing and skin are protected from contamination while providing care.
4. A patient who is non-ambulatory needs to be repositioned in bed. Which principle of body
mechanics should the nurse implement?
A. Keep the knees locked while lifting
, B. Bend at the waist to reach the patient
C. Twist the torso to shift the weight
D. Maintain a wide base of support with feet
Answer: D
Rationale: Maintaining a wide base of support by keeping the feet shoulder-width apart
increases stability and balance. Nurses should also bend at the knees rather than the waist
to utilize the large muscles of the legs. Proper body mechanics are essential for preventing
musculoskeletal injuries and ensuring patient safety during transfers.
5. Which phase of the nursing process involves the nurse prioritizing nursing diagnoses and
identifying patient-centered goals?
A. Planning
B. Diagnosis
C. Assessment
D. Implementation
Answer: A
Rationale: The planning phase of the nursing process is where the nurse sets priorities
and establishes measurable outcomes. During this time, the nurse works with the patient to
develop a plan of care that addresses the identified nursing diagnoses. This phase is critical
because it provides the roadmap for the interventions that will follow.
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is preparing to perform hand hygiene. Which action is considered the most
important factor in removing microorganisms?
A. Using hot water
B. Applying antibacterial soap
C. Friction during rubbing
D. Drying with a cloth towel
Answer: C
Rationale: Friction is the most effective way to physically remove microorganisms and
debris from the surface of the skin. The mechanical action of rubbing the hands together for
at least 20 seconds is essential for breaking down biofilms. While soap helps emulsify oils,
it is the friction that ensures the pathogens are actually washed away.
2. When assessing a patient’s blood pressure, the nurse uses a cuff that is too narrow for the
patient’s arm. What result should the nurse expect?
A. A false high reading
B. A false low reading
C. An accurate systolic but low diastolic
,D. An accurate diastolic but low systolic
Answer: A
Rationale: Using a blood pressure cuff that is too small or narrow for the limb will result in
a false high reading because it requires more pressure to occlude the artery. Conversely, a
cuff that is too large will result in a false low reading. Nurses must ensure the bladder of the
cuff encircles at least 80% of the arm to maintain accuracy.
3. The nurse is caring for a patient on contact precautions. Which of the following PPE
combinations is required before entering the room?
A. Gloves and gown
B. Mask and goggles
C. N95 respirator and gloves
D. Gown and surgical mask
Answer: A
Rationale: Contact precautions are designed to prevent the transmission of infectious
agents through direct or indirect contact with the patient or the patient’s environment. The
minimum requirement for PPE in this scenario includes gloves and a gown. This ensures
that the nurse’s clothing and skin are protected from contamination while providing care.
4. A patient who is non-ambulatory needs to be repositioned in bed. Which principle of body
mechanics should the nurse implement?
A. Keep the knees locked while lifting
, B. Bend at the waist to reach the patient
C. Twist the torso to shift the weight
D. Maintain a wide base of support with feet
Answer: D
Rationale: Maintaining a wide base of support by keeping the feet shoulder-width apart
increases stability and balance. Nurses should also bend at the knees rather than the waist
to utilize the large muscles of the legs. Proper body mechanics are essential for preventing
musculoskeletal injuries and ensuring patient safety during transfers.
5. Which phase of the nursing process involves the nurse prioritizing nursing diagnoses and
identifying patient-centered goals?
A. Planning
B. Diagnosis
C. Assessment
D. Implementation
Answer: A
Rationale: The planning phase of the nursing process is where the nurse sets priorities
and establishes measurable outcomes. During this time, the nurse works with the patient to
develop a plan of care that addresses the identified nursing diagnoses. This phase is critical
because it provides the roadmap for the interventions that will follow.
