BSN225 Exam 2 Actual Exam Style V1 |
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the
following food items should the nurse offer?
A. Vanilla pudding
B. Orange juice with pulp
C. Apple juice
D. Cream of chicken soup
Answer: C
Rationale: A clear liquid diet consists of liquids that are transparent to light and liquid at
room temperature. Apple juice fits these criteria because it does not contain pulp or dairy.
Other choices like vanilla pudding or cream soup are considered full liquids.
2. When transferring a client from a bed to a chair, which action should the nurse take first to
ensure safety?
A. Place the chair at a 90-degree angle to the bed.
B. Lock the wheels on the bed and the chair.
C. Instruct the client to reach for the chair arms.
,D. Assess the client’s ability to assist with the transfer.
Answer: D
Rationale: The nursing process dictates that assessment is the priority action before any
intervention. Determining the client’s strength and balance helps the nurse decide if
additional help or equipment is needed. This step prevents injury to both the client and the
healthcare provider.
3. A nurse is documenting in a client’s medical record. Which of the following entries is an
example of objective data?
A. The client reports feeling nauseous after lunch.
B. The client states, ‘I am worried about my surgery.’
C. The client complains of sharp pain in the right hip.
D. The client’s skin is warm and dry to the touch.
Answer: D
Rationale: Objective data is observable and measurable information obtained through
physical examination or diagnostic tests. Subjective data consists of the client’s personal
perceptions or feelings, such as pain or nausea. By noting that the skin is warm and dry, the
nurse is documenting a physical finding that can be verified by others.
4. A nurse is preparing to administer an intramuscular injection to an obese client. Which of
the following needle lengths should the nurse select?
A. 5/8 inch
, B. 1/2 inch
C. 1 inch
D. 1.5 inches
Answer: D
Rationale: Obese clients require longer needles to ensure the medication reaches the
muscle tissue rather than staying in the subcutaneous layer. A 1.5-inch needle is typically
appropriate for an adult of higher body mass index depending on the site. Shorter needles
like 5/8 inch are usually reserved for pediatric patients or very thin adults.
5. Which of the following is the most effective way for a nurse to prevent the spread of
healthcare-associated infections?
A. Administering prophylactic antibiotics to all clients.
B. Wearing gloves for all client interactions.
C. Performing hand hygiene before and after client contact.
D. Keeping the client’s door closed at all times.
Answer: C
Rationale: Hand hygiene is recognized as the single most important practice to reduce the
transmission of infectious agents. It should be performed before touching a patient and
after touching blood, body fluids, or contaminated surfaces. Following this protocol strictly
protects both the healthcare worker and the patient population.
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the
following food items should the nurse offer?
A. Vanilla pudding
B. Orange juice with pulp
C. Apple juice
D. Cream of chicken soup
Answer: C
Rationale: A clear liquid diet consists of liquids that are transparent to light and liquid at
room temperature. Apple juice fits these criteria because it does not contain pulp or dairy.
Other choices like vanilla pudding or cream soup are considered full liquids.
2. When transferring a client from a bed to a chair, which action should the nurse take first to
ensure safety?
A. Place the chair at a 90-degree angle to the bed.
B. Lock the wheels on the bed and the chair.
C. Instruct the client to reach for the chair arms.
,D. Assess the client’s ability to assist with the transfer.
Answer: D
Rationale: The nursing process dictates that assessment is the priority action before any
intervention. Determining the client’s strength and balance helps the nurse decide if
additional help or equipment is needed. This step prevents injury to both the client and the
healthcare provider.
3. A nurse is documenting in a client’s medical record. Which of the following entries is an
example of objective data?
A. The client reports feeling nauseous after lunch.
B. The client states, ‘I am worried about my surgery.’
C. The client complains of sharp pain in the right hip.
D. The client’s skin is warm and dry to the touch.
Answer: D
Rationale: Objective data is observable and measurable information obtained through
physical examination or diagnostic tests. Subjective data consists of the client’s personal
perceptions or feelings, such as pain or nausea. By noting that the skin is warm and dry, the
nurse is documenting a physical finding that can be verified by others.
4. A nurse is preparing to administer an intramuscular injection to an obese client. Which of
the following needle lengths should the nurse select?
A. 5/8 inch
, B. 1/2 inch
C. 1 inch
D. 1.5 inches
Answer: D
Rationale: Obese clients require longer needles to ensure the medication reaches the
muscle tissue rather than staying in the subcutaneous layer. A 1.5-inch needle is typically
appropriate for an adult of higher body mass index depending on the site. Shorter needles
like 5/8 inch are usually reserved for pediatric patients or very thin adults.
5. Which of the following is the most effective way for a nurse to prevent the spread of
healthcare-associated infections?
A. Administering prophylactic antibiotics to all clients.
B. Wearing gloves for all client interactions.
C. Performing hand hygiene before and after client contact.
D. Keeping the client’s door closed at all times.
Answer: C
Rationale: Hand hygiene is recognized as the single most important practice to reduce the
transmission of infectious agents. It should be performed before touching a patient and
after touching blood, body fluids, or contaminated surfaces. Following this protocol strictly
protects both the healthcare worker and the patient population.
