BSN206 Final Exam Actual Exam Style V3
| BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is assessing a patient who reports a pain level of 9 on a scale of 0 to 10. Which part
of the nursing process is the nurse performing?
A. Implementation
B. Diagnosis
C. Assessment
D. Evaluation
Answer: C
Rationale: Assessment is the first step of the nursing process and involves collecting
subjective and objective data. In this scenario, the nurse is gathering information about the
patient’s pain level. This data collection is essential before any nursing diagnosis or
intervention can be determined.
2. Which action should a nurse take first when a fire is discovered in a patient’s room?
A. Activate the fire alarm system.
B. Extinguish the fire using a portable extinguisher.
C. Rescue the patient from immediate danger.
,D. Close all doors and windows in the area.
Answer: C
Rationale: According to the RACE acronym, the first step in fire safety is ‘Rescue’ anyone in
immediate danger. This ensures the safety of the individual before addressing the fire itself.
Only after the patient is safe should the nurse proceed to ‘Alarm’ and ‘Confine’ the fire.
3. A nurse is preparing to perform hand hygiene. According to the CDC, how long should the
nurse scrub their hands with soap and water?
A. At least 20 seconds
B. At least 10 seconds
C. At least 60 seconds
D. At least 5 seconds
Answer: A
Rationale: The Centers for Disease Control and Prevention recommends scrubbing hands
for at least 20 seconds to effectively remove pathogens. This duration allows for the
mechanical action of soap and friction to break down microorganisms. Proper hand
hygiene is the most effective way to prevent the spread of healthcare-associated infections.
4. A patient is diagnosed with Tuberculosis (TB). Which type of isolation precautions should
the nurse implement?
A. Contact precautions
, B. Airborne precautions
C. Droplet precautions
D. Protective environment
Answer: B
Rationale: Tuberculosis is caused by microorganisms that are transmitted through very
small droplets that remain suspended in the air. Therefore, airborne precautions are
required, which include the use of a private room with negative pressure. Healthcare
providers must also wear an N95 respirator mask when entering the room.
5. When assessing an older adult patient, the nurse notes a blood pressure of 150/95 mmHg.
How should the nurse categorize this reading?
A. Normal blood pressure
B. Elevated blood pressure
C. Hypotension
D. Stage 2 hypertension
Answer: D
Rationale: A systolic blood pressure of 140 mmHg or higher or a diastolic of 90 mmHg or
higher is classified as Stage 2 hypertension. While blood pressure can naturally increase
with age, these specific numbers indicate a need for clinical follow-up. The nurse should
confirm this finding with subsequent measurements to ensure accuracy.
| BSN 206 Foundations of Nursing
Fundamentals Exam | Nightingale
Hallmark ISB
1. A nurse is assessing a patient who reports a pain level of 9 on a scale of 0 to 10. Which part
of the nursing process is the nurse performing?
A. Implementation
B. Diagnosis
C. Assessment
D. Evaluation
Answer: C
Rationale: Assessment is the first step of the nursing process and involves collecting
subjective and objective data. In this scenario, the nurse is gathering information about the
patient’s pain level. This data collection is essential before any nursing diagnosis or
intervention can be determined.
2. Which action should a nurse take first when a fire is discovered in a patient’s room?
A. Activate the fire alarm system.
B. Extinguish the fire using a portable extinguisher.
C. Rescue the patient from immediate danger.
,D. Close all doors and windows in the area.
Answer: C
Rationale: According to the RACE acronym, the first step in fire safety is ‘Rescue’ anyone in
immediate danger. This ensures the safety of the individual before addressing the fire itself.
Only after the patient is safe should the nurse proceed to ‘Alarm’ and ‘Confine’ the fire.
3. A nurse is preparing to perform hand hygiene. According to the CDC, how long should the
nurse scrub their hands with soap and water?
A. At least 20 seconds
B. At least 10 seconds
C. At least 60 seconds
D. At least 5 seconds
Answer: A
Rationale: The Centers for Disease Control and Prevention recommends scrubbing hands
for at least 20 seconds to effectively remove pathogens. This duration allows for the
mechanical action of soap and friction to break down microorganisms. Proper hand
hygiene is the most effective way to prevent the spread of healthcare-associated infections.
4. A patient is diagnosed with Tuberculosis (TB). Which type of isolation precautions should
the nurse implement?
A. Contact precautions
, B. Airborne precautions
C. Droplet precautions
D. Protective environment
Answer: B
Rationale: Tuberculosis is caused by microorganisms that are transmitted through very
small droplets that remain suspended in the air. Therefore, airborne precautions are
required, which include the use of a private room with negative pressure. Healthcare
providers must also wear an N95 respirator mask when entering the room.
5. When assessing an older adult patient, the nurse notes a blood pressure of 150/95 mmHg.
How should the nurse categorize this reading?
A. Normal blood pressure
B. Elevated blood pressure
C. Hypotension
D. Stage 2 hypertension
Answer: D
Rationale: A systolic blood pressure of 140 mmHg or higher or a diastolic of 90 mmHg or
higher is classified as Stage 2 hypertension. While blood pressure can naturally increase
with age, these specific numbers indicate a need for clinical follow-up. The nurse should
confirm this finding with subsequent measurements to ensure accuracy.
