BSN206 Exam 2 Actual Exam Style V1 |
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is preparing to perform a physical assessment on a newly admitted patient. Which
of the following should be the first step in the nursing process?
A. Formulating a nursing diagnosis
B. Implementation of nursing interventions
C. Evaluation of patient outcomes
D. Assessment and data collection
Answer: D
Rationale: Assessment is the first and most critical step of the nursing process where data
is gathered. This information forms the foundation for all subsequent nursing decisions and
care planning. Without a thorough assessment, the nurse cannot accurately identify patient
needs or develop effective interventions.
2. Which of the following is considered subjective data during a patient interview?
A. The patient reports feeling nauseated.
B. The patient’s temperature is 101.2°F.
C. The nurse observes the patient grimacing.
,D. The patient’s blood pressure is 140/90 mmHg.
Answer: A
Rationale: Subjective data consists of information that only the patient can experience and
describe, such as feelings or symptoms. Objective data, conversely, are measurable signs
like vital signs or lab results that can be observed by others. In this scenario, nausea is a
personal sensation reported by the patient and cannot be directly measured by the nurse.
3. A nurse is caring for a patient who has a prescription for ‘Contact Precautions.’ Which
personal protective equipment (PPE) is required?
A. N95 respirator and gloves
B. Gown and gloves
C. Mask and eye protection
D. Gloves only
Answer: B
Rationale: Contact precautions are used to prevent the spread of pathogens through direct
or indirect contact with the patient or their environment. The minimum requirement for
PPE in contact precautions includes a gown and gloves. These barriers protect the nurse’s
skin and clothing from contamination while providing care.
4. When assessing a patient’s radial pulse, the nurse notes it is irregular. What is the most
appropriate action for the nurse to take next?
A. Document the pulse as ‘normal.’
, B. Auscultate the apical pulse for one full minute.
C. Check the pulse for 15 seconds and multiply by 4.
D. Wait 30 minutes and re-check the radial pulse.
Answer: B
Rationale: If a radial pulse is irregular, the nurse should assess the apical pulse to get a
more accurate heart rate reading. Auscultating the apical pulse for one full minute is the
standard procedure for identifying the true heart rate and rhythm. This action ensures that
the nurse does not miss any beats that might not be palpable at the radial site.
5. Which of the following vital sign changes would the nurse expect to see in a patient
experiencing acute pain?
A. Decreased heart rate
B. Decreased respiratory rate
C. Increased blood pressure
D. Increased body temperature
Answer: C
Rationale: Acute pain typically triggers the sympathetic nervous system, leading to the
‘fight or flight’ response. This physiological reaction often results in elevated blood
pressure, increased heart rate, and rapid breathing. Monitoring these changes helps the
nurse objectively validate the patient’s subjective report of pain.
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is preparing to perform a physical assessment on a newly admitted patient. Which
of the following should be the first step in the nursing process?
A. Formulating a nursing diagnosis
B. Implementation of nursing interventions
C. Evaluation of patient outcomes
D. Assessment and data collection
Answer: D
Rationale: Assessment is the first and most critical step of the nursing process where data
is gathered. This information forms the foundation for all subsequent nursing decisions and
care planning. Without a thorough assessment, the nurse cannot accurately identify patient
needs or develop effective interventions.
2. Which of the following is considered subjective data during a patient interview?
A. The patient reports feeling nauseated.
B. The patient’s temperature is 101.2°F.
C. The nurse observes the patient grimacing.
,D. The patient’s blood pressure is 140/90 mmHg.
Answer: A
Rationale: Subjective data consists of information that only the patient can experience and
describe, such as feelings or symptoms. Objective data, conversely, are measurable signs
like vital signs or lab results that can be observed by others. In this scenario, nausea is a
personal sensation reported by the patient and cannot be directly measured by the nurse.
3. A nurse is caring for a patient who has a prescription for ‘Contact Precautions.’ Which
personal protective equipment (PPE) is required?
A. N95 respirator and gloves
B. Gown and gloves
C. Mask and eye protection
D. Gloves only
Answer: B
Rationale: Contact precautions are used to prevent the spread of pathogens through direct
or indirect contact with the patient or their environment. The minimum requirement for
PPE in contact precautions includes a gown and gloves. These barriers protect the nurse’s
skin and clothing from contamination while providing care.
4. When assessing a patient’s radial pulse, the nurse notes it is irregular. What is the most
appropriate action for the nurse to take next?
A. Document the pulse as ‘normal.’
, B. Auscultate the apical pulse for one full minute.
C. Check the pulse for 15 seconds and multiply by 4.
D. Wait 30 minutes and re-check the radial pulse.
Answer: B
Rationale: If a radial pulse is irregular, the nurse should assess the apical pulse to get a
more accurate heart rate reading. Auscultating the apical pulse for one full minute is the
standard procedure for identifying the true heart rate and rhythm. This action ensures that
the nurse does not miss any beats that might not be palpable at the radial site.
5. Which of the following vital sign changes would the nurse expect to see in a patient
experiencing acute pain?
A. Decreased heart rate
B. Decreased respiratory rate
C. Increased blood pressure
D. Increased body temperature
Answer: C
Rationale: Acute pain typically triggers the sympathetic nervous system, leading to the
‘fight or flight’ response. This physiological reaction often results in elevated blood
pressure, increased heart rate, and rapid breathing. Monitoring these changes helps the
nurse objectively validate the patient’s subjective report of pain.
