BSN225 Exam 3 Actual Exam Style V1 |
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is caring for a client who is post-operative and reports difficulty breathing. What is
the nurse’s priority action?
A. Administer the PRN pain medication as ordered.
B. Elevate the head of the bed to a high-Fowler’s position.
C. Contact the healthcare provider immediately.
D. Check the client’s oxygen saturation levels.
Answer: B
Rationale: The first action for a client experiencing respiratory distress should be to
improve chest expansion and lung aeration. Elevating the head of the bed utilizes gravity to
drop the diaphragm, providing immediate relief. While assessing oxygen levels is
important, physical positioning is a quick and effective nursing intervention that takes
priority.
2. When performing a physical assessment, the nurse notes a client’s pulse is irregular. Which
action should the nurse take next?
A. Document the finding and reassess in four hours.
B. Notify the rapid response team immediately.
,C. Measure the blood pressure in both arms.
D. Auscultate the apical pulse for one full minute.
Answer: D
Rationale: When a peripheral pulse is found to be irregular, the nurse must obtain a more
accurate assessment of the heart rate. Auscultating the apical pulse for a full 60 seconds
allows the nurse to identify the true heart rate and note any specific rhythm abnormalities.
Documentation should only occur after a thorough assessment is completed.
3. A nurse is preparing to administer an intramuscular injection to an obese client. Which site
is the preferred choice for this patient population to ensure safety and medication
absorption?
A. Dorsogluteal
B. Vastus lateralis
C. Deltoid
D. Ventrogluteal
Answer: D
Rationale: The ventrogluteal site is the preferred injection site for adults because it is
located away from major nerves and blood vessels. In obese patients, this site has a thinner
layer of subcutaneous fat compared to other gluteal areas, ensuring the medication reaches
the muscle. The dorsogluteal site is no longer recommended due to the risk of sciatic nerve
injury.
, 4. The nurse is assessing a client with a stage 2 pressure injury. Which characteristic should
the nurse expect to observe?
A. Partial-thickness skin loss with a pink or red wound bed.
B. Visible subcutaneous fat and granulation tissue.
C. Non-blanchable erythema of intact skin.
D. Full-thickness skin loss with exposed bone or tendon.
Answer: A
Rationale: A stage 2 pressure injury involves partial-thickness loss of the dermis and
presents as a shallow open ulcer with a red-pink wound bed. It may also present as an
intact or open/ruptured serum-filled blister. Stage 1 involves non-blanchable redness,
while stages 3 and 4 involve deeper tissue layers.
5. A nurse is providing discharge teaching to a client with a new prescription for a cane.
Which instruction should the nurse include?
A. Move the cane forward about 6 to 10 inches with each step.
B. Advance the stronger leg forward first when walking.
C. Hold the cane on the side of the affected (weaker) leg.
D. Ensure the cane handle is at the level of the waist.
Answer: A
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is caring for a client who is post-operative and reports difficulty breathing. What is
the nurse’s priority action?
A. Administer the PRN pain medication as ordered.
B. Elevate the head of the bed to a high-Fowler’s position.
C. Contact the healthcare provider immediately.
D. Check the client’s oxygen saturation levels.
Answer: B
Rationale: The first action for a client experiencing respiratory distress should be to
improve chest expansion and lung aeration. Elevating the head of the bed utilizes gravity to
drop the diaphragm, providing immediate relief. While assessing oxygen levels is
important, physical positioning is a quick and effective nursing intervention that takes
priority.
2. When performing a physical assessment, the nurse notes a client’s pulse is irregular. Which
action should the nurse take next?
A. Document the finding and reassess in four hours.
B. Notify the rapid response team immediately.
,C. Measure the blood pressure in both arms.
D. Auscultate the apical pulse for one full minute.
Answer: D
Rationale: When a peripheral pulse is found to be irregular, the nurse must obtain a more
accurate assessment of the heart rate. Auscultating the apical pulse for a full 60 seconds
allows the nurse to identify the true heart rate and note any specific rhythm abnormalities.
Documentation should only occur after a thorough assessment is completed.
3. A nurse is preparing to administer an intramuscular injection to an obese client. Which site
is the preferred choice for this patient population to ensure safety and medication
absorption?
A. Dorsogluteal
B. Vastus lateralis
C. Deltoid
D. Ventrogluteal
Answer: D
Rationale: The ventrogluteal site is the preferred injection site for adults because it is
located away from major nerves and blood vessels. In obese patients, this site has a thinner
layer of subcutaneous fat compared to other gluteal areas, ensuring the medication reaches
the muscle. The dorsogluteal site is no longer recommended due to the risk of sciatic nerve
injury.
, 4. The nurse is assessing a client with a stage 2 pressure injury. Which characteristic should
the nurse expect to observe?
A. Partial-thickness skin loss with a pink or red wound bed.
B. Visible subcutaneous fat and granulation tissue.
C. Non-blanchable erythema of intact skin.
D. Full-thickness skin loss with exposed bone or tendon.
Answer: A
Rationale: A stage 2 pressure injury involves partial-thickness loss of the dermis and
presents as a shallow open ulcer with a red-pink wound bed. It may also present as an
intact or open/ruptured serum-filled blister. Stage 1 involves non-blanchable redness,
while stages 3 and 4 involve deeper tissue layers.
5. A nurse is providing discharge teaching to a client with a new prescription for a cane.
Which instruction should the nurse include?
A. Move the cane forward about 6 to 10 inches with each step.
B. Advance the stronger leg forward first when walking.
C. Hold the cane on the side of the affected (weaker) leg.
D. Ensure the cane handle is at the level of the waist.
Answer: A
