BSN225 Exam 1 Actual Exam Style V3 |
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is caring for a client who is at risk for falls. Which of the following is the priority
nursing action?
A. Place the call light within the client’s reach.
B. Perform a fall risk assessment using a validated tool.
C. Keep the client’s bed in the lowest position.
D. Apply physical restraints to the client’s wrists.
Answer: B
Rationale: Assessment is the first step of the nursing process and must be completed to
identify specific risks. Once the risk is identified, appropriate interventions such as
lowering the bed can be implemented. Validated tools like the Morse Fall Scale provide a
standardized approach to safety.
2. Which action should the nurse take first when discovering a fire in a client’s room?
A. Activate the fire alarm system.
B. Rescue the client from the room.
C. Close the doors to the room.
D. Extinguish the fire with a portable extinguisher.
,Answer: B
Rationale: The RACE acronym guides fire safety, where ‘R’ stands for rescue. Saving the life
of the client is always the absolute priority before addressing the fire itself. After rescue,
the nurse should alarm, contain, and then extinguish or evacuate.
3. A nurse is preparing to administer an intramuscular injection to an adult client. Which of
the following sites is the safest for this procedure?
A. Dorsogluteal
B. Deltoid
C. Ventrogluteal
D. Vastus lateralis
Answer: C
Rationale: The ventrogluteal site is considered the safest for intramuscular injections
because it is away from major nerves and blood vessels. It provides a large muscle mass
that can accommodate various volumes of medication. The dorsogluteal site is no longer
recommended due to the proximity of the sciatic nerve.
4. When performing hand hygiene with soap and water, how long should the nurse rub their
hands together?
A. At least 5 seconds
10 seconds. 10 seconds
, C. At least 60 seconds
D. At least 20 seconds
Answer: D
Rationale: Handwashing with soap and water requires at least 20 seconds of vigorous
friction to effectively remove transient flora. Friction is the most important component of
the handwashing process for mechanical debridement. This practice is essential to prevent
healthcare-associated infections.
5. A nurse is assessing a client’s blood pressure for the first time. What is the most common
error that results in a falsely high reading?
A. Using a cuff that is too wide.
B. Positioning the arm above the level of the heart.
C. Deflating the cuff too quickly.
D. Using a cuff that is too narrow.
Answer: D
Rationale: A blood pressure cuff that is too narrow or small will result in a falsely high
reading because it requires more pressure to occlude the artery. Conversely, a cuff that is
too wide will result in a falsely low reading. Proper cuff sizing is critical for obtaining
accurate hemodynamic data.
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is caring for a client who is at risk for falls. Which of the following is the priority
nursing action?
A. Place the call light within the client’s reach.
B. Perform a fall risk assessment using a validated tool.
C. Keep the client’s bed in the lowest position.
D. Apply physical restraints to the client’s wrists.
Answer: B
Rationale: Assessment is the first step of the nursing process and must be completed to
identify specific risks. Once the risk is identified, appropriate interventions such as
lowering the bed can be implemented. Validated tools like the Morse Fall Scale provide a
standardized approach to safety.
2. Which action should the nurse take first when discovering a fire in a client’s room?
A. Activate the fire alarm system.
B. Rescue the client from the room.
C. Close the doors to the room.
D. Extinguish the fire with a portable extinguisher.
,Answer: B
Rationale: The RACE acronym guides fire safety, where ‘R’ stands for rescue. Saving the life
of the client is always the absolute priority before addressing the fire itself. After rescue,
the nurse should alarm, contain, and then extinguish or evacuate.
3. A nurse is preparing to administer an intramuscular injection to an adult client. Which of
the following sites is the safest for this procedure?
A. Dorsogluteal
B. Deltoid
C. Ventrogluteal
D. Vastus lateralis
Answer: C
Rationale: The ventrogluteal site is considered the safest for intramuscular injections
because it is away from major nerves and blood vessels. It provides a large muscle mass
that can accommodate various volumes of medication. The dorsogluteal site is no longer
recommended due to the proximity of the sciatic nerve.
4. When performing hand hygiene with soap and water, how long should the nurse rub their
hands together?
A. At least 5 seconds
10 seconds. 10 seconds
, C. At least 60 seconds
D. At least 20 seconds
Answer: D
Rationale: Handwashing with soap and water requires at least 20 seconds of vigorous
friction to effectively remove transient flora. Friction is the most important component of
the handwashing process for mechanical debridement. This practice is essential to prevent
healthcare-associated infections.
5. A nurse is assessing a client’s blood pressure for the first time. What is the most common
error that results in a falsely high reading?
A. Using a cuff that is too wide.
B. Positioning the arm above the level of the heart.
C. Deflating the cuff too quickly.
D. Using a cuff that is too narrow.
Answer: D
Rationale: A blood pressure cuff that is too narrow or small will result in a falsely high
reading because it requires more pressure to occlude the artery. Conversely, a cuff that is
too wide will result in a falsely low reading. Proper cuff sizing is critical for obtaining
accurate hemodynamic data.
