BSN225 Exam 3 Actual Exam Style V2 | BSN 225 HESI RN Specialty Fundamentals of Nursing
Exam | Nightingale
1. A nurse is preparing to administer an intramuscular injection to an adult patient. Which
site is considered the safest and most preferred for large volume injections in adults?
A. Dorsogluteal
B. Ventrogluteal
C. Deltoid
D. Vastus Lateralis
Answer: B
Rationale: The ventrogluteal site is the preferred and safest site for all adults, children, and
infants because it is located away from major blood vessels and nerves. It provides a large
muscle mass that can accommodate larger volumes of medication. This site is also less
likely to have subcutaneous fat compared to the dorsogluteal site.
2. While assessing a patient’s wound, the nurse notes thick, yellow-green drainage. How
should the nurse document this finding?
A. Purulent drainage
B. Sanguineous drainage
C. Serosanguineous drainage
D. Serous drainage
,Answer: A
Rationale: Purulent drainage is thick and indicates infection, often appearing yellow,
green, or brown. This type of exudate consists of white blood cells, dead tissue debris, and
bacteria. Proper documentation of wound drainage is essential for monitoring healing
progress and identifying complications early.
3. A patient is being treated for a Clostridium difficile (C. diff) infection. Which infection
control precaution is mandatory for the nurse to implement?
A. Airborne Precautions
B. Droplet Precautions
C. Contact Precautions
D. Standard Precautions only
Answer: C
Rationale: C. difficile requires contact precautions because the spores are spread through
direct and indirect contact. The nurse must wear gloves and a gown when entering the
room to prevent cross-contamination. Additionally, hand hygiene must be performed with
soap and water as alcohol-based rubs are ineffective against C. diff spores.
4. The nurse is teaching a patient about using an incentive spirometer. Which instruction is
correct?
A. Exhale forcefully into the device.
B. Inhale slowly and deeply through the mouthpiece.
, C. Hold your breath for 30 seconds after inhalation.
D. Use the device once every 4 hours while awake.
Answer: B
Rationale: Incentive spirometry is designed to promote lung expansion and prevent
atelectasis by encouraging slow, deep inhalations. The patient should place the mouthpiece
in their mouth and breathe in deeply to lift the piston to the target level. It is typically
recommended to use the device 5 to 10 times every hour while awake.
5. A nurse discovers a fire in a patient’s room. According to the RACE acronym, what is the
first action the nurse should take?
A. Rescue the patient.
B. Extinguish the fire.
C. Activate the fire alarm.
D. Confine the fire by closing doors.
Answer: A
Rationale: The RACE acronym stands for Rescue, Alarm, Confine, and Extinguish/Evacuate.
The immediate priority is always the safety of the patient by removing them from the area
of danger. Once the patient is safe, the nurse should then pull the alarm and proceed with
the remaining steps.
Exam | Nightingale
1. A nurse is preparing to administer an intramuscular injection to an adult patient. Which
site is considered the safest and most preferred for large volume injections in adults?
A. Dorsogluteal
B. Ventrogluteal
C. Deltoid
D. Vastus Lateralis
Answer: B
Rationale: The ventrogluteal site is the preferred and safest site for all adults, children, and
infants because it is located away from major blood vessels and nerves. It provides a large
muscle mass that can accommodate larger volumes of medication. This site is also less
likely to have subcutaneous fat compared to the dorsogluteal site.
2. While assessing a patient’s wound, the nurse notes thick, yellow-green drainage. How
should the nurse document this finding?
A. Purulent drainage
B. Sanguineous drainage
C. Serosanguineous drainage
D. Serous drainage
,Answer: A
Rationale: Purulent drainage is thick and indicates infection, often appearing yellow,
green, or brown. This type of exudate consists of white blood cells, dead tissue debris, and
bacteria. Proper documentation of wound drainage is essential for monitoring healing
progress and identifying complications early.
3. A patient is being treated for a Clostridium difficile (C. diff) infection. Which infection
control precaution is mandatory for the nurse to implement?
A. Airborne Precautions
B. Droplet Precautions
C. Contact Precautions
D. Standard Precautions only
Answer: C
Rationale: C. difficile requires contact precautions because the spores are spread through
direct and indirect contact. The nurse must wear gloves and a gown when entering the
room to prevent cross-contamination. Additionally, hand hygiene must be performed with
soap and water as alcohol-based rubs are ineffective against C. diff spores.
4. The nurse is teaching a patient about using an incentive spirometer. Which instruction is
correct?
A. Exhale forcefully into the device.
B. Inhale slowly and deeply through the mouthpiece.
, C. Hold your breath for 30 seconds after inhalation.
D. Use the device once every 4 hours while awake.
Answer: B
Rationale: Incentive spirometry is designed to promote lung expansion and prevent
atelectasis by encouraging slow, deep inhalations. The patient should place the mouthpiece
in their mouth and breathe in deeply to lift the piston to the target level. It is typically
recommended to use the device 5 to 10 times every hour while awake.
5. A nurse discovers a fire in a patient’s room. According to the RACE acronym, what is the
first action the nurse should take?
A. Rescue the patient.
B. Extinguish the fire.
C. Activate the fire alarm.
D. Confine the fire by closing doors.
Answer: A
Rationale: The RACE acronym stands for Rescue, Alarm, Confine, and Extinguish/Evacuate.
The immediate priority is always the safety of the patient by removing them from the area
of danger. Once the patient is safe, the nurse should then pull the alarm and proceed with
the remaining steps.
