BSN206 Exam 3 Actual Exam Style V1 |
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is educating a client about an upcoming procedure and ensures the client
understands the risks and benefits before they sign the consent form. Which ethical principle
is being demonstrated?
A. Justice
B. Autonomy
C. Fidelity
D. Nonmaleficence
Answer: B
Rationale: Autonomy refers to the right of the individual to make their own healthcare
decisions. By providing necessary information for informed consent, the nurse supports
the client’s self-determination. This principle is fundamental to patient-centered care and
legal nursing practice.
2. A nurse fails to raise the side rails on the bed of a confused elderly patient, resulting in the
patient falling and sustaining a hip fracture. What legal term describes this action?
A. Assault
,B. Battery
C. Negligence
D. Defamation
Answer: C
Rationale: Negligence is the failure to provide the standard of care that a reasonably
prudent person would provide in a similar situation. In this case, the nurse failed to
implement safety measures, leading to injury. This falls under the category of unintentional
torts in nursing law.
3. While walking down the hallway, a nurse smells smoke and sees flames coming from a
trash can in a patient’s room. Using the RACE acronym, what is the nurse’s first action?
A. Activate the fire alarm.
B. Confine the fire by closing the door.
C. Rescue the patient from the room.
D. Extinguish the fire with a portable extinguisher.
Answer: C
Rationale: The RACE acronym stands for Rescue, Alarm, Confine, and Extinguish. The
priority is always the safety of the patient currently in immediate danger. Once the patient
is moved to safety, the nurse should proceed to activate the alarm system.
, 4. A nurse is preparing to administer a liquid medication to a patient. Which action ensures
the correct dose is measured?
A. Hold the medication cup at eye level when pouring.
B. Measure the dose at the top of the meniscus.
C. Pour the medication with the label facing away from the palm.
D. Place the cup on a high shelf to view the lines.
Answer: A
Rationale: Holding the medication cup at eye level allows the nurse to accurately read the
calibration lines. The nurse should measure the dose at the bottom of the meniscus for
liquid medications. This practice is part of the ‘Right Dose’ medication safety check.
5. Which assessment finding should the nurse prioritize as the most urgent for a patient with
a respiratory infection?
A. Productive cough with yellow sputum
B. Oral temperature of 101.2°F (38.4°C)
C. Fine crackles heard at the lung bases
D. Restlessness and confusion
Answer: D
Rationale: Restlessness and confusion are early signs of hypoxia or inadequate
oxygenation. These neurological changes often precede significant drops in oxygen
BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is educating a client about an upcoming procedure and ensures the client
understands the risks and benefits before they sign the consent form. Which ethical principle
is being demonstrated?
A. Justice
B. Autonomy
C. Fidelity
D. Nonmaleficence
Answer: B
Rationale: Autonomy refers to the right of the individual to make their own healthcare
decisions. By providing necessary information for informed consent, the nurse supports
the client’s self-determination. This principle is fundamental to patient-centered care and
legal nursing practice.
2. A nurse fails to raise the side rails on the bed of a confused elderly patient, resulting in the
patient falling and sustaining a hip fracture. What legal term describes this action?
A. Assault
,B. Battery
C. Negligence
D. Defamation
Answer: C
Rationale: Negligence is the failure to provide the standard of care that a reasonably
prudent person would provide in a similar situation. In this case, the nurse failed to
implement safety measures, leading to injury. This falls under the category of unintentional
torts in nursing law.
3. While walking down the hallway, a nurse smells smoke and sees flames coming from a
trash can in a patient’s room. Using the RACE acronym, what is the nurse’s first action?
A. Activate the fire alarm.
B. Confine the fire by closing the door.
C. Rescue the patient from the room.
D. Extinguish the fire with a portable extinguisher.
Answer: C
Rationale: The RACE acronym stands for Rescue, Alarm, Confine, and Extinguish. The
priority is always the safety of the patient currently in immediate danger. Once the patient
is moved to safety, the nurse should proceed to activate the alarm system.
, 4. A nurse is preparing to administer a liquid medication to a patient. Which action ensures
the correct dose is measured?
A. Hold the medication cup at eye level when pouring.
B. Measure the dose at the top of the meniscus.
C. Pour the medication with the label facing away from the palm.
D. Place the cup on a high shelf to view the lines.
Answer: A
Rationale: Holding the medication cup at eye level allows the nurse to accurately read the
calibration lines. The nurse should measure the dose at the bottom of the meniscus for
liquid medications. This practice is part of the ‘Right Dose’ medication safety check.
5. Which assessment finding should the nurse prioritize as the most urgent for a patient with
a respiratory infection?
A. Productive cough with yellow sputum
B. Oral temperature of 101.2°F (38.4°C)
C. Fine crackles heard at the lung bases
D. Restlessness and confusion
Answer: D
Rationale: Restlessness and confusion are early signs of hypoxia or inadequate
oxygenation. These neurological changes often precede significant drops in oxygen
