BSN225 Exam 4 Actual Exam Style V1 |
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is preparing to administer an intramuscular injection to an adult client. Which of
the following sites is the safest and most preferred for this procedure?
A. Dorsogluteal site
B. Vastus lateralis site
C. Deltoid site
D. Ventrogluteal site
Answer: D
Rationale: The ventrogluteal site is the preferred location for intramuscular injections
because it is situated away from major nerves and blood vessels. It provides a large muscle
mass that can accommodate larger volumes of medication safely. Using this site reduces the
risk of injury compared to the dorsogluteal site, which is no longer recommended due to its
proximity to the sciatic nerve.
2. When assessing a patient with a fluid volume deficit, which of the following clinical
manifestations should the nurse expect to find?
A. Jugular venous distension
B. Orthostatic hypotension
,C. Bounding pulses
D. Dependent edema
Answer: B
Rationale: Orthostatic hypotension is a common sign of fluid volume deficit as there is less
circulating volume to maintain blood pressure when changing positions. Other signs
include dry mucous membranes, poor skin turgor, and tachycardia. Bounding pulses and
jugular venous distension are typically associated with fluid volume excess rather than
deficit.
3. A nurse is caring for a client who is on airborne precautions. Which of the following pieces
of personal protective equipment (PPE) is essential when entering the room?
A. Surgical mask
B. N95 respirator
C. Goggles
D. Gown
Answer: B
Rationale: An N95 respirator is required for airborne precautions to filter out small
droplets that remain suspended in the air. This type of protection is necessary for diseases
such as tuberculosis, varicella, and measles. Surgical masks are insufficient as they only
provide protection against larger droplets used in droplet precautions.
, 4. Which of the following interventions is most effective in preventing the development of
pressure injuries in a bedbound client?
A. Massaging bony prominences every 2 hours
B. Repositioning the client at least every 2 hours
C. Using a ring-shaped cushion to relieve pressure
D. Keeping the head of the bed elevated at 45 degrees at all times
Answer: B
Rationale: Repositioning the client frequently is the gold standard for preventing pressure
injuries by ensuring that no single area is subjected to prolonged pressure. Massaging bony
prominences is actually contraindicated as it can cause deep tissue damage. Keeping the
head of the bed too high increases shearing forces, which can lead to skin breakdown.
5. A patient has a serum potassium level of 6.2 mEq/L. Which of the following actions should
the nurse prioritize?
A. Encourage the intake of bananas and orange juice
B. Administer a potassium-sparing diuretic
C. Obtain an electrocardiogram (ECG)
D. Check for signs of hypocalcemia
Answer: C
BSN 225 HESI RN Specialty Fundamentals
of Nursing Exam | Nightingale
1. A nurse is preparing to administer an intramuscular injection to an adult client. Which of
the following sites is the safest and most preferred for this procedure?
A. Dorsogluteal site
B. Vastus lateralis site
C. Deltoid site
D. Ventrogluteal site
Answer: D
Rationale: The ventrogluteal site is the preferred location for intramuscular injections
because it is situated away from major nerves and blood vessels. It provides a large muscle
mass that can accommodate larger volumes of medication safely. Using this site reduces the
risk of injury compared to the dorsogluteal site, which is no longer recommended due to its
proximity to the sciatic nerve.
2. When assessing a patient with a fluid volume deficit, which of the following clinical
manifestations should the nurse expect to find?
A. Jugular venous distension
B. Orthostatic hypotension
,C. Bounding pulses
D. Dependent edema
Answer: B
Rationale: Orthostatic hypotension is a common sign of fluid volume deficit as there is less
circulating volume to maintain blood pressure when changing positions. Other signs
include dry mucous membranes, poor skin turgor, and tachycardia. Bounding pulses and
jugular venous distension are typically associated with fluid volume excess rather than
deficit.
3. A nurse is caring for a client who is on airborne precautions. Which of the following pieces
of personal protective equipment (PPE) is essential when entering the room?
A. Surgical mask
B. N95 respirator
C. Goggles
D. Gown
Answer: B
Rationale: An N95 respirator is required for airborne precautions to filter out small
droplets that remain suspended in the air. This type of protection is necessary for diseases
such as tuberculosis, varicella, and measles. Surgical masks are insufficient as they only
provide protection against larger droplets used in droplet precautions.
, 4. Which of the following interventions is most effective in preventing the development of
pressure injuries in a bedbound client?
A. Massaging bony prominences every 2 hours
B. Repositioning the client at least every 2 hours
C. Using a ring-shaped cushion to relieve pressure
D. Keeping the head of the bed elevated at 45 degrees at all times
Answer: B
Rationale: Repositioning the client frequently is the gold standard for preventing pressure
injuries by ensuring that no single area is subjected to prolonged pressure. Massaging bony
prominences is actually contraindicated as it can cause deep tissue damage. Keeping the
head of the bed too high increases shearing forces, which can lead to skin breakdown.
5. A patient has a serum potassium level of 6.2 mEq/L. Which of the following actions should
the nurse prioritize?
A. Encourage the intake of bananas and orange juice
B. Administer a potassium-sparing diuretic
C. Obtain an electrocardiogram (ECG)
D. Check for signs of hypocalcemia
Answer: C
