BSN225 Final Exam Actual Exam Style V2
| BSN 225 HESI RN Specialty
Fundamentals of Nursing Exam |
Nightingale
1. A nurse is caring for a client who is scheduled for surgery. The client expresses concern
about the procedure. Which of the following responses by the nurse demonstrates the use of
therapeutic communication?
A. Do not worry, you have the best surgeon in the hospital.
B. I will call your doctor to come and explain the procedure again.
C. Everything will turn out fine once the surgery is over.
D. Tell me more about what is specifically concerning you.
Answer: D
Rationale: Open-ended statements encourage the client to explore and express their
feelings in more detail. This approach helps the nurse understand the specific source of the
client’s anxiety. Offering false reassurance or passing responsibility to the doctor does not
address the client’s immediate emotional needs.
2. A nurse is preparing to administer an intramuscular injection to an adult client. Which of
the following sites is the safest for this type of injection?
A. Dorsogluteal
,B. Ventrogluteal
C. Deltoid
D. Vastus lateralis
Answer: B
Rationale: The ventrogluteal site is considered the safest for intramuscular injections
because it is away from major nerves and blood vessels. It provides a large muscle mass
that is well-developed in adults. The dorsogluteal site is no longer recommended due to the
proximity of the sciatic nerve.
3. Which of the following interventions should a nurse implement to prevent the
development of a pressure injury in an immobile client?
A. Massage reddened bony prominences every shift.
B. Limit fluid intake to reduce the frequency of urination.
C. Keep the head of the bed elevated at 45 degrees.
D. Reposition the client every 2 hours.
Answer: D
Rationale: Frequent repositioning is the primary method to relieve pressure on bony
prominences and improve circulation. Massaging reddened areas can cause further tissue
damage and is contraindicated. Keeping the head of the bed high can increase shear force,
so a lower angle is generally preferred unless medically contraindicated.
, 4. A nurse is assessing a client’s pulse and notes it is irregular. What is the most appropriate
action for the nurse to take next?
A. Check the radial pulse for 30 seconds.
B. Auscultate the apical pulse for a full minute.
C. Document the finding and check again in 4 hours.
D. Notify the physician immediately.
Answer: B
Rationale: Auscultating the apical pulse for 60 seconds is the gold standard for evaluating
an irregular heart rhythm. This allows the nurse to count the actual heartbeats and identify
the pattern of the irregularity. Radial pulses can be inaccurate when the rhythm is not
regular due to pulse deficits.
5. A nurse is caring for a client who is on a clear liquid diet. Which of the following food items
can the nurse provide to the client?
A. Vanilla pudding
B. Apple juice
C. Orange juice with pulp
D. Low-fat yogurt
Answer: B
| BSN 225 HESI RN Specialty
Fundamentals of Nursing Exam |
Nightingale
1. A nurse is caring for a client who is scheduled for surgery. The client expresses concern
about the procedure. Which of the following responses by the nurse demonstrates the use of
therapeutic communication?
A. Do not worry, you have the best surgeon in the hospital.
B. I will call your doctor to come and explain the procedure again.
C. Everything will turn out fine once the surgery is over.
D. Tell me more about what is specifically concerning you.
Answer: D
Rationale: Open-ended statements encourage the client to explore and express their
feelings in more detail. This approach helps the nurse understand the specific source of the
client’s anxiety. Offering false reassurance or passing responsibility to the doctor does not
address the client’s immediate emotional needs.
2. A nurse is preparing to administer an intramuscular injection to an adult client. Which of
the following sites is the safest for this type of injection?
A. Dorsogluteal
,B. Ventrogluteal
C. Deltoid
D. Vastus lateralis
Answer: B
Rationale: The ventrogluteal site is considered the safest for intramuscular injections
because it is away from major nerves and blood vessels. It provides a large muscle mass
that is well-developed in adults. The dorsogluteal site is no longer recommended due to the
proximity of the sciatic nerve.
3. Which of the following interventions should a nurse implement to prevent the
development of a pressure injury in an immobile client?
A. Massage reddened bony prominences every shift.
B. Limit fluid intake to reduce the frequency of urination.
C. Keep the head of the bed elevated at 45 degrees.
D. Reposition the client every 2 hours.
Answer: D
Rationale: Frequent repositioning is the primary method to relieve pressure on bony
prominences and improve circulation. Massaging reddened areas can cause further tissue
damage and is contraindicated. Keeping the head of the bed high can increase shear force,
so a lower angle is generally preferred unless medically contraindicated.
, 4. A nurse is assessing a client’s pulse and notes it is irregular. What is the most appropriate
action for the nurse to take next?
A. Check the radial pulse for 30 seconds.
B. Auscultate the apical pulse for a full minute.
C. Document the finding and check again in 4 hours.
D. Notify the physician immediately.
Answer: B
Rationale: Auscultating the apical pulse for 60 seconds is the gold standard for evaluating
an irregular heart rhythm. This allows the nurse to count the actual heartbeats and identify
the pattern of the irregularity. Radial pulses can be inaccurate when the rhythm is not
regular due to pulse deficits.
5. A nurse is caring for a client who is on a clear liquid diet. Which of the following food items
can the nurse provide to the client?
A. Vanilla pudding
B. Apple juice
C. Orange juice with pulp
D. Low-fat yogurt
Answer: B
