BSN 225 HESI RN Specialty Fundamentals of Nursing Exam V1
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1. A nurse is preparing to administer a medication to a client. Which of the following actions should
the nurse take to verify the client's identity?
A) Ask the client to state their name and date of birth.
B) Check the client's room number against the MAR.
C) Verify the client's identification band matches the MAR.
D) Both A and C.
Answer: D – Both A and C.
Rationale: The two-identifier method includes asking the client to state their name and DOB and
comparing the ID band to the MAR. Room number is not a reliable identifier as clients can be moved.
2. A nurse is caring for a client with a new diagnosis of Clostridium difficile. Which of the following
infection control precautions should the nurse implement?
A) Airborne precautions
B) Droplet precautions
C) Contact precautions
D) Standard precautions only
Answer: C – Contact precautions
,Rationale: C. difficile is transmitted via spores on contaminated surfaces. Contact precautions (gown,
gloves, dedicated equipment) are required. Alcohol hand sanitizer is ineffective against C. diff spores;
soap and water must be used.
3. A nurse is preparing to insert an indwelling urinary catheter. Which of the following actions
demonstrates proper sterile technique?
A) Opening the outer package on the bedside table
B) Placing the sterile field at the edge of the table
C) Holding the catheter with sterile gloves and maintaining it within the sterile field
D) Using clean gloves to open the catheter package
Answer: C – Holding the catheter with sterile gloves and maintaining it within the sterile field
Rationale: Sterile items must remain within the sterile field. The outer package is opened onto a clean
surface, but the inner wrap creates the sterile field. The edge of the table is considered unsterile.
4. A client is receiving continuous enteral feedings through a nasogastric tube. Which of the following
actions should the nurse take to reduce the risk of aspiration?
A) Elevate the head of the bed to 30–45 degrees.
B) Check gastric residual volume every 8 hours.
C) Flush the tube with 30 mL of water before and after feeding.
D) Both A and C.
Answer: D – Both A and C.
Rationale: Head elevation reduces aspiration risk; flushing maintains patency. Residual volumes
should be checked every 4–6 hours, not every 8.
,5. A nurse is caring for a client who has a new tracheostomy. Which action should the nurse take to
maintain a patent airway?
A) Suction the tracheostomy tube every 2 hours routinely.
B) Hyperoxygenate with 100% oxygen before suctioning.
C) Apply suction while inserting the catheter.
D) Use clean technique for suctioning.
Answer: B – Hyperoxygenate with 100% oxygen before suctioning.
Rationale: Hyperoxygenation prevents hypoxia during suctioning. Suction should only be applied
during withdrawal, not insertion. Suctioning should be done PRN, not routinely. Sterile technique is
required.
6. The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a
cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What
action is most important for the nurse to implement?
A) Tell the UAP to use a larger cuff at the next scheduled assessment.
B) Reassess the client's blood pressure using a larger cuff.
C) Have the unit educator review this procedure with the UAPs.
D) Teach the UAP the correct technique for assessing blood pressure.
Answer: B – Reassess the client's blood pressure using a larger cuff.
Rationale: The most important action is to ensure that an accurate BP reading is obtained. A cuff that
is too small can give a falsely elevated reading. Reassessment should not be postponed.
7. A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months
ago. Which assessment measure best determines if the intended outcome of the policy is being
achieved?
, A) Number of staff induced injuries
B) Client satisfaction survey
C) Health care-associated infection rate
D) Rate of needle-stick injuries by nurse
Answer: C – Health care-associated infection rate
Rationale: Acrylic nails are known to carry bacteria and increase the risk of healthcare-associated
infections. Therefore, by banning acrylic nails, you would expect the prevalence of healthcare-
associated infections to decrease.
8. A client with a new tracheostomy is being discharged. Which statement indicates the client needs
further teaching about tracheostomy care?
A) "I will clean the inner cannula with hydrogen peroxide."
B) "I will keep extra tracheostomy tubes at home."
C) "I can use tap water to clean the outer cannula."
D) "I will suction the tracheostomy whenever I feel short of breath."
Answer: C – "I can use tap water to clean the outer cannula."
Rationale: Sterile technique and sterile water should be used for tracheostomy care. Tap water
contains microorganisms that could infect the stoma.
9. The nurse is caring for a client who has MRSA in a surgical wound. Which precaution should the
nurse implement?
A) Airborne precautions
B) Contact precautions
C) Droplet precautions
EXAM GAURANTEED PASS WITH 100+ TEST BANK QUESTIONS
2026 CARRICULUM BASSED VERRIFIED TEST INSTANT PDF
DOWNLOAD
1. A nurse is preparing to administer a medication to a client. Which of the following actions should
the nurse take to verify the client's identity?
A) Ask the client to state their name and date of birth.
B) Check the client's room number against the MAR.
C) Verify the client's identification band matches the MAR.
D) Both A and C.
Answer: D – Both A and C.
Rationale: The two-identifier method includes asking the client to state their name and DOB and
comparing the ID band to the MAR. Room number is not a reliable identifier as clients can be moved.
2. A nurse is caring for a client with a new diagnosis of Clostridium difficile. Which of the following
infection control precautions should the nurse implement?
A) Airborne precautions
B) Droplet precautions
C) Contact precautions
D) Standard precautions only
Answer: C – Contact precautions
,Rationale: C. difficile is transmitted via spores on contaminated surfaces. Contact precautions (gown,
gloves, dedicated equipment) are required. Alcohol hand sanitizer is ineffective against C. diff spores;
soap and water must be used.
3. A nurse is preparing to insert an indwelling urinary catheter. Which of the following actions
demonstrates proper sterile technique?
A) Opening the outer package on the bedside table
B) Placing the sterile field at the edge of the table
C) Holding the catheter with sterile gloves and maintaining it within the sterile field
D) Using clean gloves to open the catheter package
Answer: C – Holding the catheter with sterile gloves and maintaining it within the sterile field
Rationale: Sterile items must remain within the sterile field. The outer package is opened onto a clean
surface, but the inner wrap creates the sterile field. The edge of the table is considered unsterile.
4. A client is receiving continuous enteral feedings through a nasogastric tube. Which of the following
actions should the nurse take to reduce the risk of aspiration?
A) Elevate the head of the bed to 30–45 degrees.
B) Check gastric residual volume every 8 hours.
C) Flush the tube with 30 mL of water before and after feeding.
D) Both A and C.
Answer: D – Both A and C.
Rationale: Head elevation reduces aspiration risk; flushing maintains patency. Residual volumes
should be checked every 4–6 hours, not every 8.
,5. A nurse is caring for a client who has a new tracheostomy. Which action should the nurse take to
maintain a patent airway?
A) Suction the tracheostomy tube every 2 hours routinely.
B) Hyperoxygenate with 100% oxygen before suctioning.
C) Apply suction while inserting the catheter.
D) Use clean technique for suctioning.
Answer: B – Hyperoxygenate with 100% oxygen before suctioning.
Rationale: Hyperoxygenation prevents hypoxia during suctioning. Suction should only be applied
during withdrawal, not insertion. Suctioning should be done PRN, not routinely. Sterile technique is
required.
6. The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a
cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What
action is most important for the nurse to implement?
A) Tell the UAP to use a larger cuff at the next scheduled assessment.
B) Reassess the client's blood pressure using a larger cuff.
C) Have the unit educator review this procedure with the UAPs.
D) Teach the UAP the correct technique for assessing blood pressure.
Answer: B – Reassess the client's blood pressure using a larger cuff.
Rationale: The most important action is to ensure that an accurate BP reading is obtained. A cuff that
is too small can give a falsely elevated reading. Reassessment should not be postponed.
7. A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months
ago. Which assessment measure best determines if the intended outcome of the policy is being
achieved?
, A) Number of staff induced injuries
B) Client satisfaction survey
C) Health care-associated infection rate
D) Rate of needle-stick injuries by nurse
Answer: C – Health care-associated infection rate
Rationale: Acrylic nails are known to carry bacteria and increase the risk of healthcare-associated
infections. Therefore, by banning acrylic nails, you would expect the prevalence of healthcare-
associated infections to decrease.
8. A client with a new tracheostomy is being discharged. Which statement indicates the client needs
further teaching about tracheostomy care?
A) "I will clean the inner cannula with hydrogen peroxide."
B) "I will keep extra tracheostomy tubes at home."
C) "I can use tap water to clean the outer cannula."
D) "I will suction the tracheostomy whenever I feel short of breath."
Answer: C – "I can use tap water to clean the outer cannula."
Rationale: Sterile technique and sterile water should be used for tracheostomy care. Tap water
contains microorganisms that could infect the stoma.
9. The nurse is caring for a client who has MRSA in a surgical wound. Which precaution should the
nurse implement?
A) Airborne precautions
B) Contact precautions
C) Droplet precautions
