BSN225 Exam 4 Actual Exam Style V2 |
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is verifying the placement of a nasogastric (NG) tube after the initial X-ray
confirmation. Which bedside method is most appropriate for checking placement before
administering a feeding?
A. Auscultating air injected into the tube
B. Checking the tube’s markings at the nare
C. Observing the color of the aspirate
D. Testing the pH of the aspirated gastric contents
Answer: D
Rationale: Testing the pH of gastric aspirate is the most reliable bedside method to
confirm placement after initial X-ray. A pH of less than 5.5 typically indicates that the tube
is correctly positioned in the stomach. This practice significantly reduces the risk of
accidental pulmonary aspiration of feedings.
2. When caring for a patient with a confirmed Clostridioides difficile (C. diff) infection, which
hand hygiene practice is mandatory?
A. Using alcohol-based hand sanitizer
B. Changing gloves without washing hands
,C. Washing with water only
D. Washing hands with soap and water
Answer: D
Rationale: Handwashing with soap and water is the required method for hygiene when
dealing with C. diff because alcohol-based sanitizers do not kill the spores. Mechanical
friction during washing helps physically remove the spores from the skin. This protocol is
essential to prevent the cross-contamination of other patients in the facility.
3. The nurse discovers a small fire in a trash can in a patient’s room. What is the priority
action according to the RACE acronym?
A. Rescue the patient from the room
B. Activate the fire alarm system
C. Extinguish the fire using a fire extinguisher
D. Close the doors to contain the fire
Answer: A
Rationale: The RACE acronym stands for Rescue, Alarm, Contain, and
Extinguish/Evacuate. The nurse’s first priority is always to rescue and remove patients
from immediate danger. After the patient is safe, the nurse can then proceed to activate the
alarm and contain the smoke.
, 4. A nurse is caring for a patient who requires wrist restraints. Which action must the nurse
prioritize regarding the restraint order?
A. Ensure the physician performs a face-to-face assessment within 1 hour
B. Obtain a verbal order and get it signed within 48 hours
C. Tie the restraints using a square knot for security
D. Apply restraints to the side rails of the bed
Answer: A
Rationale: Federal and state regulations require a face-to-face assessment by a provider
within one hour of restraint application. This ensures that the patient’s safety and the
necessity of the restraints are properly evaluated. Restraints must always be tied to the bed
frame using a quick-release knot, never the side rails.
5. During a sterile procedure, the nurse notices that the edge of the sterile field has been
touched by a non-sterile object. How much of the sterile field border is considered
contaminated?
A. The outer 0.5 inch (1.27 cm)
B. None, as long as the center remains untouched
C. The outer 2 inches (5.08 cm)
D. The outer 1 inch (2.54 cm)
Answer: D
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is verifying the placement of a nasogastric (NG) tube after the initial X-ray
confirmation. Which bedside method is most appropriate for checking placement before
administering a feeding?
A. Auscultating air injected into the tube
B. Checking the tube’s markings at the nare
C. Observing the color of the aspirate
D. Testing the pH of the aspirated gastric contents
Answer: D
Rationale: Testing the pH of gastric aspirate is the most reliable bedside method to
confirm placement after initial X-ray. A pH of less than 5.5 typically indicates that the tube
is correctly positioned in the stomach. This practice significantly reduces the risk of
accidental pulmonary aspiration of feedings.
2. When caring for a patient with a confirmed Clostridioides difficile (C. diff) infection, which
hand hygiene practice is mandatory?
A. Using alcohol-based hand sanitizer
B. Changing gloves without washing hands
,C. Washing with water only
D. Washing hands with soap and water
Answer: D
Rationale: Handwashing with soap and water is the required method for hygiene when
dealing with C. diff because alcohol-based sanitizers do not kill the spores. Mechanical
friction during washing helps physically remove the spores from the skin. This protocol is
essential to prevent the cross-contamination of other patients in the facility.
3. The nurse discovers a small fire in a trash can in a patient’s room. What is the priority
action according to the RACE acronym?
A. Rescue the patient from the room
B. Activate the fire alarm system
C. Extinguish the fire using a fire extinguisher
D. Close the doors to contain the fire
Answer: A
Rationale: The RACE acronym stands for Rescue, Alarm, Contain, and
Extinguish/Evacuate. The nurse’s first priority is always to rescue and remove patients
from immediate danger. After the patient is safe, the nurse can then proceed to activate the
alarm and contain the smoke.
, 4. A nurse is caring for a patient who requires wrist restraints. Which action must the nurse
prioritize regarding the restraint order?
A. Ensure the physician performs a face-to-face assessment within 1 hour
B. Obtain a verbal order and get it signed within 48 hours
C. Tie the restraints using a square knot for security
D. Apply restraints to the side rails of the bed
Answer: A
Rationale: Federal and state regulations require a face-to-face assessment by a provider
within one hour of restraint application. This ensures that the patient’s safety and the
necessity of the restraints are properly evaluated. Restraints must always be tied to the bed
frame using a quick-release knot, never the side rails.
5. During a sterile procedure, the nurse notices that the edge of the sterile field has been
touched by a non-sterile object. How much of the sterile field border is considered
contaminated?
A. The outer 0.5 inch (1.27 cm)
B. None, as long as the center remains untouched
C. The outer 2 inches (5.08 cm)
D. The outer 1 inch (2.54 cm)
Answer: D
