BSN206 Exam 1 Actual Exam Style V2 |
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is preparing to perform hand hygiene. Which action is the most important for the
nurse to take to prevent the spread of microorganisms?
A. Applying friction for at least 20 seconds during washing
B. Using hot water to kill bacteria on the skin
C. Drying hands from the elbows down to the fingertips
D. Shaking hands vigorously over the sink to remove water
Answer: A
Rationale: Hand hygiene is the most effective way to prevent the spread of
microorganisms in clinical settings. The nurse should rub all surfaces of the hands with
soap and water for at least 20 seconds to create mechanical friction. This friction is
essential for removing transient flora and pathogens from the skin surfaces effectively.
2. When assessing a patient’s blood pressure, the nurse notes the cuff is too small for the
patient’s arm. What impact will this have on the reading?
A. The blood pressure reading will be falsely low
B. The blood pressure reading will be falsely high
,C. The diastolic pressure will be accurate but systolic will be low
D. The reading will be unaffected by the cuff size
Answer: B
Rationale: Using a blood pressure cuff that is too small or too narrow for the patient’s arm
circumference will result in a falsely high reading. This occurs because the small bladder
does not evenly distribute pressure, requiring more inflation to occlude the artery. Nurses
must always ensure the cuff width is approximately 40% of the arm circumference for
accuracy.
3. A nurse is caring for a patient on contact precautions. Which of the following is the correct
sequence for donning personal protective equipment (PPE)?
A. Gloves, Goggles, Mask, Gown
B. Mask, Gown, Gloves, Goggles
C. Gown, Mask, Goggles, Gloves
D. Goggles, Gloves, Mask, Gown
Answer: C
Rationale: The correct order for donning PPE ensures that the nurse is fully protected
before entering the patient’s environment. The sequence begins with the gown, followed by
the mask or respirator, then goggles or face shield, and finally gloves. This specific order
minimizes the risk of contaminating the nurse’s clothing or skin during the process.
, 4. During the assessment phase of the nursing process, which of the following is considered
subjective data?
A. The patient’s blood pressure is 140/90 mmHg
B. The patient states, ‘I feel like my heart is racing’
C. The patient’s surgical incision is red and swollen
D. The patient’s weight is 185 pounds
Answer: B
Rationale: Subjective data consists of information provided by the patient that cannot be
measured or observed directly by the nurse. Examples include feelings, perceptions, and
self-reported symptoms like pain or anxiety. In contrast, objective data includes
measurable signs like vital signs and physical observations.
5. A nurse is assisting a patient with limited mobility to move up in bed. Which principle of
body mechanics should the nurse apply?
A. Keep the feet close together to provide a narrow base of support
B. Bend at the waist to use the back muscles for lifting
C. Push the patient toward the head of the bed alone
D. Adjust the bed to a comfortable working height at the waist level
Answer: D
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is preparing to perform hand hygiene. Which action is the most important for the
nurse to take to prevent the spread of microorganisms?
A. Applying friction for at least 20 seconds during washing
B. Using hot water to kill bacteria on the skin
C. Drying hands from the elbows down to the fingertips
D. Shaking hands vigorously over the sink to remove water
Answer: A
Rationale: Hand hygiene is the most effective way to prevent the spread of
microorganisms in clinical settings. The nurse should rub all surfaces of the hands with
soap and water for at least 20 seconds to create mechanical friction. This friction is
essential for removing transient flora and pathogens from the skin surfaces effectively.
2. When assessing a patient’s blood pressure, the nurse notes the cuff is too small for the
patient’s arm. What impact will this have on the reading?
A. The blood pressure reading will be falsely low
B. The blood pressure reading will be falsely high
,C. The diastolic pressure will be accurate but systolic will be low
D. The reading will be unaffected by the cuff size
Answer: B
Rationale: Using a blood pressure cuff that is too small or too narrow for the patient’s arm
circumference will result in a falsely high reading. This occurs because the small bladder
does not evenly distribute pressure, requiring more inflation to occlude the artery. Nurses
must always ensure the cuff width is approximately 40% of the arm circumference for
accuracy.
3. A nurse is caring for a patient on contact precautions. Which of the following is the correct
sequence for donning personal protective equipment (PPE)?
A. Gloves, Goggles, Mask, Gown
B. Mask, Gown, Gloves, Goggles
C. Gown, Mask, Goggles, Gloves
D. Goggles, Gloves, Mask, Gown
Answer: C
Rationale: The correct order for donning PPE ensures that the nurse is fully protected
before entering the patient’s environment. The sequence begins with the gown, followed by
the mask or respirator, then goggles or face shield, and finally gloves. This specific order
minimizes the risk of contaminating the nurse’s clothing or skin during the process.
, 4. During the assessment phase of the nursing process, which of the following is considered
subjective data?
A. The patient’s blood pressure is 140/90 mmHg
B. The patient states, ‘I feel like my heart is racing’
C. The patient’s surgical incision is red and swollen
D. The patient’s weight is 185 pounds
Answer: B
Rationale: Subjective data consists of information provided by the patient that cannot be
measured or observed directly by the nurse. Examples include feelings, perceptions, and
self-reported symptoms like pain or anxiety. In contrast, objective data includes
measurable signs like vital signs and physical observations.
5. A nurse is assisting a patient with limited mobility to move up in bed. Which principle of
body mechanics should the nurse apply?
A. Keep the feet close together to provide a narrow base of support
B. Bend at the waist to use the back muscles for lifting
C. Push the patient toward the head of the bed alone
D. Adjust the bed to a comfortable working height at the waist level
Answer: D
