BSN 206 Hallmark Exam Actual
Exam 2026/2027 | Foundations of
Nursing Fundamentals |
Nightingale | Questions with
Verified Answers | 100% Correct |
Pass Guaranteed GRADED A+
SECTION 1: URINARY CATHETERIZATION & CATHETER CARE
Q: When performing catheter care, how many inches of the catheter
will you cleanse after it exits the urinary meatus?
1 inch (2.5 cm)
2 inches (5 cm)
3 inches (7.5 cm)
4 inches (10 cm) ✓
Rationale: This is the optimum distance to reduce the presence of secretions
or drainage on the exterior catheter surface.
Q: When providing indwelling catheter care, you should clean around
the anchor tapes to prevent the catheter from slipping out of the
urethra. True or False?
False ✓
, Rationale: Anchor tapes must be changed daily and the skin inspected
carefully. The balloon in the bladder prevents the catheter from falling out.
Q: At least 10 cm (4 inches) of an indwelling urinary catheter that exits
the meatus should be wiped with a clean washcloth during routine
care. True or False?
True ✓
Rationale: Moving away from the body in a circular motion is the correct
procedure for cleaning the catheter.
Q: The nurse is reviewing urinary catheter care with a newly hired
nursing assistive personnel (NAP). Which statement made by the NAP
indicates further instruction is needed?
"Urinary catheter care is a clean procedure; sterile gloves are unnecessary."
"The bedside drainage bag should only be emptied when it is full." ✓
"The securement device that anchors the catheter should be reapplied."
"Catheter care can be delegated to nursing assistive personnel."
Rationale: The drainage bag should be emptied when it is approximately half
full to maintain proper drainage and prevent backflow.
Q: A patient had an indwelling catheter for 3 weeks. The patient had
the catheter removed 3 hours ago and now complains of having to go
to the bathroom frequently and that it is painful to void. Which
instruction is appropriate for the nurse to give the patient?
"This is a normal occurrence after having a catheter in place for more
than several days." ✓
"It sounds like you have a UTI. I will notify your health care provider."
"I will need to inspect your perineal area and wash and dry the area."
"If these symptoms continue, I will notify your health care provider to see if
we can reinsert the catheter."
, Rationale: If the catheter was in place for more than several days, the patient
may experience dysuria (painful voiding) resulting from inflammation of the
urethral canal. Because of decreased bladder muscle tone, the patient may
urinate frequently. These symptoms should subside with time.
Q: If a patient's indwelling catheter is removed at 0900, the patient
should be due to void by:
1900 to 2100 (7:00 PM to 9:00 PM)
1100 to 1200 (11:00 AM to 12:00 PM)
1500 to 1700 (3:00 PM to 5:00 PM) ✓
0930 (9:30 AM)
Rationale: The patient should be due to void in 6-8 hours. If the patient fails
to void, nursing measures should be taken (assess for bladder fullness,
provide privacy, assist to normal voiding position, run water).
Q: Identify the indicators of a UTI: (Select all that apply.)
✓ Fever
Urinary drainage
✓ Complaints of pain with urination (dysuria)
Hypothermia
✓ Lower abdominal pain
✓ Cloudiness of the urine
SECTION 2: VITAL SIGNS ASSESSMENT
Q: The nurse documents vital signs on a newly admitted patient as:
"blood pressure is 148/94 mm Hg, the pulse is 80 beats/min, and the
respirations are 16 breaths/min." The nurse would record the pulse
pressure as:
14 mm Hg
, 54 mm Hg ✓
64 mm Hg
80 mm Hg
Rationale: Pulse pressure = systolic - diastolic (148 - 94 = 54 mm Hg).
Q: A nurse performs orthostatic blood pressure readings on a client
with the following results: lying 148/76 mm Hg, standing 110/60 mm
Hg. What action by the nurse is best?
Reassess the blood pressures in 1 hour.
Reassure the client that these findings are normal.
Instruct the client not to get up without help. ✓
Document the findings and continue to monitor.
Rationale: A drop of more than 20 mmHg systolic or 10 mmHg diastolic
indicates orthostatic hypotension, placing the patient at risk for falls.
Q: The nurse caring for a 30-year-old post-surgical client would assess
that they are in pain as indicated by:
A temperature of 102° F
A pulse rate of 120 beats/min ✓
Respirations of 16 breaths/min
Blood pressure of 128/86 mm Hg
Rationale: Tachycardia is a common physiological response to pain.
Q: A nurse assesses a client's radial pulse rate to be 110 beats/min and
regular. What action by the nurse is best?
Assess the client for causes of tachycardia. ✓
Document the findings in the client's chart.
Take an apical heart rate and compare the two.
Notify the client's health care provider.
Rationale: The nurse should first assess for potential causes before notifying
the provider.
Exam 2026/2027 | Foundations of
Nursing Fundamentals |
Nightingale | Questions with
Verified Answers | 100% Correct |
Pass Guaranteed GRADED A+
SECTION 1: URINARY CATHETERIZATION & CATHETER CARE
Q: When performing catheter care, how many inches of the catheter
will you cleanse after it exits the urinary meatus?
1 inch (2.5 cm)
2 inches (5 cm)
3 inches (7.5 cm)
4 inches (10 cm) ✓
Rationale: This is the optimum distance to reduce the presence of secretions
or drainage on the exterior catheter surface.
Q: When providing indwelling catheter care, you should clean around
the anchor tapes to prevent the catheter from slipping out of the
urethra. True or False?
False ✓
, Rationale: Anchor tapes must be changed daily and the skin inspected
carefully. The balloon in the bladder prevents the catheter from falling out.
Q: At least 10 cm (4 inches) of an indwelling urinary catheter that exits
the meatus should be wiped with a clean washcloth during routine
care. True or False?
True ✓
Rationale: Moving away from the body in a circular motion is the correct
procedure for cleaning the catheter.
Q: The nurse is reviewing urinary catheter care with a newly hired
nursing assistive personnel (NAP). Which statement made by the NAP
indicates further instruction is needed?
"Urinary catheter care is a clean procedure; sterile gloves are unnecessary."
"The bedside drainage bag should only be emptied when it is full." ✓
"The securement device that anchors the catheter should be reapplied."
"Catheter care can be delegated to nursing assistive personnel."
Rationale: The drainage bag should be emptied when it is approximately half
full to maintain proper drainage and prevent backflow.
Q: A patient had an indwelling catheter for 3 weeks. The patient had
the catheter removed 3 hours ago and now complains of having to go
to the bathroom frequently and that it is painful to void. Which
instruction is appropriate for the nurse to give the patient?
"This is a normal occurrence after having a catheter in place for more
than several days." ✓
"It sounds like you have a UTI. I will notify your health care provider."
"I will need to inspect your perineal area and wash and dry the area."
"If these symptoms continue, I will notify your health care provider to see if
we can reinsert the catheter."
, Rationale: If the catheter was in place for more than several days, the patient
may experience dysuria (painful voiding) resulting from inflammation of the
urethral canal. Because of decreased bladder muscle tone, the patient may
urinate frequently. These symptoms should subside with time.
Q: If a patient's indwelling catheter is removed at 0900, the patient
should be due to void by:
1900 to 2100 (7:00 PM to 9:00 PM)
1100 to 1200 (11:00 AM to 12:00 PM)
1500 to 1700 (3:00 PM to 5:00 PM) ✓
0930 (9:30 AM)
Rationale: The patient should be due to void in 6-8 hours. If the patient fails
to void, nursing measures should be taken (assess for bladder fullness,
provide privacy, assist to normal voiding position, run water).
Q: Identify the indicators of a UTI: (Select all that apply.)
✓ Fever
Urinary drainage
✓ Complaints of pain with urination (dysuria)
Hypothermia
✓ Lower abdominal pain
✓ Cloudiness of the urine
SECTION 2: VITAL SIGNS ASSESSMENT
Q: The nurse documents vital signs on a newly admitted patient as:
"blood pressure is 148/94 mm Hg, the pulse is 80 beats/min, and the
respirations are 16 breaths/min." The nurse would record the pulse
pressure as:
14 mm Hg
, 54 mm Hg ✓
64 mm Hg
80 mm Hg
Rationale: Pulse pressure = systolic - diastolic (148 - 94 = 54 mm Hg).
Q: A nurse performs orthostatic blood pressure readings on a client
with the following results: lying 148/76 mm Hg, standing 110/60 mm
Hg. What action by the nurse is best?
Reassess the blood pressures in 1 hour.
Reassure the client that these findings are normal.
Instruct the client not to get up without help. ✓
Document the findings and continue to monitor.
Rationale: A drop of more than 20 mmHg systolic or 10 mmHg diastolic
indicates orthostatic hypotension, placing the patient at risk for falls.
Q: The nurse caring for a 30-year-old post-surgical client would assess
that they are in pain as indicated by:
A temperature of 102° F
A pulse rate of 120 beats/min ✓
Respirations of 16 breaths/min
Blood pressure of 128/86 mm Hg
Rationale: Tachycardia is a common physiological response to pain.
Q: A nurse assesses a client's radial pulse rate to be 110 beats/min and
regular. What action by the nurse is best?
Assess the client for causes of tachycardia. ✓
Document the findings in the client's chart.
Take an apical heart rate and compare the two.
Notify the client's health care provider.
Rationale: The nurse should first assess for potential causes before notifying
the provider.
