BSN225 Exam 2 Actual Exam Style V2 |
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is caring for a patient who has been diagnosed with tuberculosis. Which type of
isolation precautions should the nurse implement?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions only
Answer: C
Rationale: Tuberculosis is caused by Mycobacterium tuberculosis which is transmitted
through small droplets that remain suspended in the air. Airborne precautions require the
use of an N95 respirator and a private room with negative pressure airflow. These
measures are essential to prevent the spread of the pathogen to healthcare workers and
other patients.
2. When assessing a patient’s radial pulse, the nurse finds it to be irregular. What is the most
appropriate next action for the nurse to take?
A. Document the finding as normal for an adult
B. Wait 15 minutes and reassess the radial pulse
,C. Notify the healthcare provider immediately
D. Assess the apical pulse for one full minute
Answer: D
Rationale: An irregular radial pulse requires a more accurate assessment of the heart’s
true rhythm. Assessing the apical pulse for a full 60 seconds provides the most reliable
measurement of heart rate and rhythm. This helps the nurse identify if a pulse deficit exists
between the peripheral and central pulses.
3. A nurse is preparing to administer an intramuscular injection to an infant. Which site is
most appropriate for this age group?
A. Vastus lateralis
B. Deltoid
C. Dorsogluteal
D. Ventrogluteal
Answer: A
Rationale: The vastus lateralis is the preferred site for intramuscular injections in infants
because it is the most developed muscle in that age group. Using this site avoids potential
injury to the sciatic nerve or major blood vessels found in the gluteal areas. Proper
technique involves injecting into the middle third of the muscle on the anterior lateral
aspect of the thigh.
, 4. Which ethical principle is the nurse practicing when they advocate for a patient’s right to
refuse a recommended medical treatment?
A. Beneficence
B. Autonomy
C. Non-maleficence
D. Justice
Answer: B
Rationale: Autonomy refers to the patient’s right to make their own healthcare decisions
without outside control. By advocating for the patient’s choice, the nurse respects the
individual’s self-determination and personal values. This principle is fundamental to
informed consent and patient-centered care in modern nursing practice.
5. A patient has an order for 0.9% Sodium Chloride to be infused intravenously. Which type of
solution is this considered?
A. Hypotonic
B. Isotonic
C. Hypertonic
D. Colloid
Answer: B
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is caring for a patient who has been diagnosed with tuberculosis. Which type of
isolation precautions should the nurse implement?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions only
Answer: C
Rationale: Tuberculosis is caused by Mycobacterium tuberculosis which is transmitted
through small droplets that remain suspended in the air. Airborne precautions require the
use of an N95 respirator and a private room with negative pressure airflow. These
measures are essential to prevent the spread of the pathogen to healthcare workers and
other patients.
2. When assessing a patient’s radial pulse, the nurse finds it to be irregular. What is the most
appropriate next action for the nurse to take?
A. Document the finding as normal for an adult
B. Wait 15 minutes and reassess the radial pulse
,C. Notify the healthcare provider immediately
D. Assess the apical pulse for one full minute
Answer: D
Rationale: An irregular radial pulse requires a more accurate assessment of the heart’s
true rhythm. Assessing the apical pulse for a full 60 seconds provides the most reliable
measurement of heart rate and rhythm. This helps the nurse identify if a pulse deficit exists
between the peripheral and central pulses.
3. A nurse is preparing to administer an intramuscular injection to an infant. Which site is
most appropriate for this age group?
A. Vastus lateralis
B. Deltoid
C. Dorsogluteal
D. Ventrogluteal
Answer: A
Rationale: The vastus lateralis is the preferred site for intramuscular injections in infants
because it is the most developed muscle in that age group. Using this site avoids potential
injury to the sciatic nerve or major blood vessels found in the gluteal areas. Proper
technique involves injecting into the middle third of the muscle on the anterior lateral
aspect of the thigh.
, 4. Which ethical principle is the nurse practicing when they advocate for a patient’s right to
refuse a recommended medical treatment?
A. Beneficence
B. Autonomy
C. Non-maleficence
D. Justice
Answer: B
Rationale: Autonomy refers to the patient’s right to make their own healthcare decisions
without outside control. By advocating for the patient’s choice, the nurse respects the
individual’s self-determination and personal values. This principle is fundamental to
informed consent and patient-centered care in modern nursing practice.
5. A patient has an order for 0.9% Sodium Chloride to be infused intravenously. Which type of
solution is this considered?
A. Hypotonic
B. Isotonic
C. Hypertonic
D. Colloid
Answer: B
