BSN225 Exam 4 Actual Exam Style V3 |
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is caring for a patient who has a serum potassium level of 2.8 mEq/L. Which of the
following assessment findings should the nurse expect?
A. Peaked T-waves on ECG
B. Hyperactive bowel sounds
C. Muscle weakness and leg cramps
D. Positive Chvostek sign
Answer: C
Rationale: Hypokalemia is characterized by a potassium level lower than 3.5 mEq/L.
Common clinical manifestations include muscle weakness, cardiac dysrhythmias, and
decreased gastrointestinal motility. The nurse should prioritize monitoring the respiratory
and cardiac systems to prevent life-threatening complications.
2. Which clinical manifestation is a hallmark sign of fluid volume excess?
A. Tented skin turgor
B. Distended neck veins
C. Dark amber urine
D. Dry mucous membranes
,Answer: B
Rationale: Fluid volume excess occurs when there is too much fluid in the extracellular
compartment. Distended neck veins are caused by increased venous pressure from the
excess volume. The nurse should also assess for crackles in the lungs and peripheral edema
in these patients.
3. A nurse is preparing to administer an intramuscular injection into the ventrogluteal site.
Which action should the nurse take to locate the site?
A. Place the heel of the hand on the greater trochanter
B. Measure two fingerbreadths below the acromion process
C. Locate the middle third of the anterior thigh
D. Identify the posterior superior iliac spine
Answer: A
Rationale: The ventrogluteal site is the preferred location for IM injections in adults
because it is away from major nerves and blood vessels. To locate it, the nurse places the
palm over the greater trochanter and points the index finger toward the anterior superior
iliac spine. This creates a V-shaped area where the injection is safely administered into the
muscle.
4. Which of the following describes a Stage III pressure injury?
A. Full-thickness skin loss with visible adipose tissue
B. Partial-thickness loss of dermis
, C. Non-blanchable erythema of intact skin
D. Full-thickness tissue loss with exposed bone or tendon
Answer: A
Rationale: A Stage III pressure injury involves full-thickness skin loss where subcutaneous
fat may be visible, but bone, tendon, or muscle are not exposed. Slough or eschar may be
present but does not obscure the depth of tissue loss. This stage represents significant
damage to the integumentary layers and requires specialized wound care.
5. A patient is diagnosed with Clostridium difficile (C. diff). Which infection control precaution
is required?
A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Standard precautions only
Answer: C
Rationale: C. diff requires contact precautions because the spores are transmitted through
direct or indirect contact with contaminated surfaces. Nurses must wear gowns and gloves
when entering the room to prevent cross-contamination. Additionally, hand hygiene must
be performed with soap and water rather than alcohol-based rubs because sanitizer is
ineffective against C. diff spores.
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is caring for a patient who has a serum potassium level of 2.8 mEq/L. Which of the
following assessment findings should the nurse expect?
A. Peaked T-waves on ECG
B. Hyperactive bowel sounds
C. Muscle weakness and leg cramps
D. Positive Chvostek sign
Answer: C
Rationale: Hypokalemia is characterized by a potassium level lower than 3.5 mEq/L.
Common clinical manifestations include muscle weakness, cardiac dysrhythmias, and
decreased gastrointestinal motility. The nurse should prioritize monitoring the respiratory
and cardiac systems to prevent life-threatening complications.
2. Which clinical manifestation is a hallmark sign of fluid volume excess?
A. Tented skin turgor
B. Distended neck veins
C. Dark amber urine
D. Dry mucous membranes
,Answer: B
Rationale: Fluid volume excess occurs when there is too much fluid in the extracellular
compartment. Distended neck veins are caused by increased venous pressure from the
excess volume. The nurse should also assess for crackles in the lungs and peripheral edema
in these patients.
3. A nurse is preparing to administer an intramuscular injection into the ventrogluteal site.
Which action should the nurse take to locate the site?
A. Place the heel of the hand on the greater trochanter
B. Measure two fingerbreadths below the acromion process
C. Locate the middle third of the anterior thigh
D. Identify the posterior superior iliac spine
Answer: A
Rationale: The ventrogluteal site is the preferred location for IM injections in adults
because it is away from major nerves and blood vessels. To locate it, the nurse places the
palm over the greater trochanter and points the index finger toward the anterior superior
iliac spine. This creates a V-shaped area where the injection is safely administered into the
muscle.
4. Which of the following describes a Stage III pressure injury?
A. Full-thickness skin loss with visible adipose tissue
B. Partial-thickness loss of dermis
, C. Non-blanchable erythema of intact skin
D. Full-thickness tissue loss with exposed bone or tendon
Answer: A
Rationale: A Stage III pressure injury involves full-thickness skin loss where subcutaneous
fat may be visible, but bone, tendon, or muscle are not exposed. Slough or eschar may be
present but does not obscure the depth of tissue loss. This stage represents significant
damage to the integumentary layers and requires specialized wound care.
5. A patient is diagnosed with Clostridium difficile (C. diff). Which infection control precaution
is required?
A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Standard precautions only
Answer: C
Rationale: C. diff requires contact precautions because the spores are transmitted through
direct or indirect contact with contaminated surfaces. Nurses must wear gowns and gloves
when entering the room to prevent cross-contamination. Additionally, hand hygiene must
be performed with soap and water rather than alcohol-based rubs because sanitizer is
ineffective against C. diff spores.
