BSN225 Exam 2 Actual Exam Style V3 |
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is performing hand hygiene after caring for a patient. What is the most important
reason for using friction while washing hands?
A. To remove transient flora from the skin surface
B. To increase blood flow to the skin
C. To ensure the soap creates a thick lather
D. To soften the cuticles of the fingernails
Answer: A
Rationale: Friction is the most effective component of handwashing because it
mechanically loosens and removes microorganisms. The CDC recommends scrubbing for at
least 20 seconds to effectively eliminate transient flora. This process significantly reduces
the risk of healthcare-associated infections between patients.
2. When assessing a client’s blood pressure, the nurse notes the cuff is too small for the
client’s arm. Which result should the nurse expect?
A. A falsely low systolic reading
B. A falsely high reading
C. An accurate reading if the client is sitting
,D. A reading that only affects the diastolic pressure
Answer: B
Rationale: Using a blood pressure cuff that is too narrow or small will result in a reading
that is falsely elevated. The bladder should ideally encircle 80% of the adult’s arm
circumference to provide accurate pressure. Conversely, a cuff that is too large would
result in a falsely low reading.
3. A nurse is preparing a sterile field for a dressing change. Which action by the nurse would
contaminate the sterile field?
A. Opening the sterile pack away from the body
B. Keeping sterile objects within the field of vision
C. Dropping a sterile gauze onto the one-inch border
D. Holding sterile items above the waist level
Answer: C
Rationale: The outer one-inch border of a sterile field is considered contaminated and
non-sterile. Any sterile object that touches this border is no longer considered sterile and
must be discarded. Nurses must ensure that all sterile items are placed well within the
center of the field to maintain aseptic technique.
4. Which phase of the nursing process involves the nurse collecting objective and subjective
data?
A. Diagnosis
, B. Planning
C. Assessment
D. Evaluation
Answer: C
Rationale: Assessment is the first step of the nursing process and involves the systematic
collection of data. This includes gathering subjective data from the patient’s statements and
objective data through physical examination. A thorough assessment is necessary to
develop an accurate plan of care.
5. A client is diagnosed with influenza and placed on droplet precautions. What PPE must the
nurse wear when entering the room?
A. Surgical mask
B. N95 respirator mask
C. Gown and goggles only
D. Gloves and shoe covers
Answer: A
Rationale: Droplet precautions are used for pathogens transmitted by large-particle
droplets, such as the influenza virus. The primary requirement for droplet precautions is
the use of a surgical mask when working within three feet of the patient. Unlike airborne
precautions, a specialized N95 respirator is not required for influenza.
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is performing hand hygiene after caring for a patient. What is the most important
reason for using friction while washing hands?
A. To remove transient flora from the skin surface
B. To increase blood flow to the skin
C. To ensure the soap creates a thick lather
D. To soften the cuticles of the fingernails
Answer: A
Rationale: Friction is the most effective component of handwashing because it
mechanically loosens and removes microorganisms. The CDC recommends scrubbing for at
least 20 seconds to effectively eliminate transient flora. This process significantly reduces
the risk of healthcare-associated infections between patients.
2. When assessing a client’s blood pressure, the nurse notes the cuff is too small for the
client’s arm. Which result should the nurse expect?
A. A falsely low systolic reading
B. A falsely high reading
C. An accurate reading if the client is sitting
,D. A reading that only affects the diastolic pressure
Answer: B
Rationale: Using a blood pressure cuff that is too narrow or small will result in a reading
that is falsely elevated. The bladder should ideally encircle 80% of the adult’s arm
circumference to provide accurate pressure. Conversely, a cuff that is too large would
result in a falsely low reading.
3. A nurse is preparing a sterile field for a dressing change. Which action by the nurse would
contaminate the sterile field?
A. Opening the sterile pack away from the body
B. Keeping sterile objects within the field of vision
C. Dropping a sterile gauze onto the one-inch border
D. Holding sterile items above the waist level
Answer: C
Rationale: The outer one-inch border of a sterile field is considered contaminated and
non-sterile. Any sterile object that touches this border is no longer considered sterile and
must be discarded. Nurses must ensure that all sterile items are placed well within the
center of the field to maintain aseptic technique.
4. Which phase of the nursing process involves the nurse collecting objective and subjective
data?
A. Diagnosis
, B. Planning
C. Assessment
D. Evaluation
Answer: C
Rationale: Assessment is the first step of the nursing process and involves the systematic
collection of data. This includes gathering subjective data from the patient’s statements and
objective data through physical examination. A thorough assessment is necessary to
develop an accurate plan of care.
5. A client is diagnosed with influenza and placed on droplet precautions. What PPE must the
nurse wear when entering the room?
A. Surgical mask
B. N95 respirator mask
C. Gown and goggles only
D. Gloves and shoe covers
Answer: A
Rationale: Droplet precautions are used for pathogens transmitted by large-particle
droplets, such as the influenza virus. The primary requirement for droplet precautions is
the use of a surgical mask when working within three feet of the patient. Unlike airborne
precautions, a specialized N95 respirator is not required for influenza.
