BSN206 Exam 4 Actual Exam Style V1 |
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is assessing a patient with a stage 2 pressure injury on the heel. Which of the
following findings should the nurse expect?
A. Exposed bone and muscle tissue
B. Non-blanchable redness of intact skin
C. Partial-thickness skin loss with a pink wound bed
D. Full-thickness tissue loss with visible adipose tissue
Answer: C
Rationale: A stage 2 pressure injury involves partial-thickness loss of the dermis and
presents as a shallow, open ulcer with a red or pink wound bed. It may also present as an
intact or open/ruptured serum-filled blister. This stage does not involve visible fat, muscle,
or bone, which are characteristics of deeper stages.
2. A nurse is caring for a client who is receiving oxygen at 2 L/min via a nasal cannula. What is
the approximate oxygen concentration (FiO2) the client is receiving?
A. 24%
B. 28%
,C. 32%
D. 36%
Answer: B
Rationale: Oxygen concentration via nasal cannula starts at approximately 24% for 1
L/min and increases by roughly 4% for every additional liter per minute. Therefore, at 2
L/min, the FiO2 is approximately 28%. This method is suitable for patients requiring low
concentrations of supplemental oxygen.
3. A nurse is preparing to administer a cleansing enema to a client. Which position should the
nurse place the client in?
A. Orthopneic position
B. Prone position
C. Left-sided Sims’ position
D. Right-sided Fowler’s position
Answer: C
Rationale: The left-sided Sims’ position allows the enema solution to flow by gravity into
the sigmoid colon and rectum. This position involves the client lying on the left side with
the right knee flexed toward the chest. Proper positioning ensures the effectiveness of the
procedure and decreases the risk of discomfort.
, 4. A client has a surgical wound that is healing by secondary intention. Which of the following
should the nurse expect to observe?
A. Edges are closely approximated
B. Wound edges are widely separated
C. Minimal scar tissue formation
D. Rapid healing with no risk of infection
Answer: B
Rationale: Secondary intention healing occurs when wound edges are not approximated,
usually due to significant tissue loss or infection. The wound fills with granulation tissue
and takes longer to heal than primary intention. This process results in a larger scar and
requires careful monitoring for infection.
5. A nurse is teaching a client about using a cane. Which of the following instructions should
the nurse include?
A. Hold the cane on the stronger side of the body
B. Move the stronger leg forward first
C. Hold the cane on the weaker side of the body
D. Advance the cane 15 inches with each step
Answer: A
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is assessing a patient with a stage 2 pressure injury on the heel. Which of the
following findings should the nurse expect?
A. Exposed bone and muscle tissue
B. Non-blanchable redness of intact skin
C. Partial-thickness skin loss with a pink wound bed
D. Full-thickness tissue loss with visible adipose tissue
Answer: C
Rationale: A stage 2 pressure injury involves partial-thickness loss of the dermis and
presents as a shallow, open ulcer with a red or pink wound bed. It may also present as an
intact or open/ruptured serum-filled blister. This stage does not involve visible fat, muscle,
or bone, which are characteristics of deeper stages.
2. A nurse is caring for a client who is receiving oxygen at 2 L/min via a nasal cannula. What is
the approximate oxygen concentration (FiO2) the client is receiving?
A. 24%
B. 28%
,C. 32%
D. 36%
Answer: B
Rationale: Oxygen concentration via nasal cannula starts at approximately 24% for 1
L/min and increases by roughly 4% for every additional liter per minute. Therefore, at 2
L/min, the FiO2 is approximately 28%. This method is suitable for patients requiring low
concentrations of supplemental oxygen.
3. A nurse is preparing to administer a cleansing enema to a client. Which position should the
nurse place the client in?
A. Orthopneic position
B. Prone position
C. Left-sided Sims’ position
D. Right-sided Fowler’s position
Answer: C
Rationale: The left-sided Sims’ position allows the enema solution to flow by gravity into
the sigmoid colon and rectum. This position involves the client lying on the left side with
the right knee flexed toward the chest. Proper positioning ensures the effectiveness of the
procedure and decreases the risk of discomfort.
, 4. A client has a surgical wound that is healing by secondary intention. Which of the following
should the nurse expect to observe?
A. Edges are closely approximated
B. Wound edges are widely separated
C. Minimal scar tissue formation
D. Rapid healing with no risk of infection
Answer: B
Rationale: Secondary intention healing occurs when wound edges are not approximated,
usually due to significant tissue loss or infection. The wound fills with granulation tissue
and takes longer to heal than primary intention. This process results in a larger scar and
requires careful monitoring for infection.
5. A nurse is teaching a client about using a cane. Which of the following instructions should
the nurse include?
A. Hold the cane on the stronger side of the body
B. Move the stronger leg forward first
C. Hold the cane on the weaker side of the body
D. Advance the cane 15 inches with each step
Answer: A
