BSN 206 Hallmark Exam Complete
Question Bank | Foundations of
Nursing Fundamentals | Nightingale
College | 200+ Verified Questions
with Answers & Rationales |
2026/2027 Edition
1. The nurse is performing a morning assessment and notes the
client to be experiencing dyspnea. Which client assessment findings
would most indicate this respiratory condition? (Select all that
apply.)
• A. Occasional productive cough
• B. Temperature 100.1 °F
• C. Pulse oximetry 89%
• D. Respirations 26 & shallow
• E. Patient in orthopneic position
Correct Answer: C, D, E
Rationale: Dyspnea is characterized by subjective difficulty breathing.
Objective signs include tachypnea (rapid respirations), shallow breathing,
hypoxia (SpO2 < 92%), and orthopnea (difficulty breathing when lying
flat). Fever and a productive cough may be present but are not specific
indicators of dyspnea .
2. A nurse notes a client has abnormal vital signs. What action by
the nurse is best?
• A. Notify the provider immediately.
• B. Compare with prior readings.
• C. Document the findings.
, • D. Retake the vital signs in 15 minutes.
Correct Answer: B. Compare with prior readings.
Rationale: When abnormal vital signs are noted, the nurse should first
compare them with the patient's baseline and prior readings to
determine if this is a significant change. This assessment step guides the
next action, such as retaking the vital signs or notifying the healthcare
provider .
3. Which of the following is the most effective way to prevent the
spread of infection in a healthcare setting?
• A. Wearing gloves for all patient contact.
• B. Performing hand hygiene before and after patient contact.
• C. Isolating all patients with infections.
• D. Administering prophylactic antibiotics to all patients.
Correct Answer: B. Performing hand hygiene before and after patient
contact.
Rationale: Hand hygiene is the single most important and effective
practice to prevent the transmission of microorganisms and healthcare-
associated infections. While other measures like gloves and isolation are
important, hand hygiene is the foundational practice .
4. The client reports an allergy to latex. What alterations should be
made in the client's care? (Select all that apply.)
• A. Use latex-free or synthetic gloves when gloves are necessary.
• B. Avoid wearing gloves unless absolutely necessary and only for
short periods.
• C. Avoid use of alcohol-based hand rubs.
• D. Remove items that contain latex in the care of the client.
• E. Determine whether syringes, IV tubing, and catheters contain
latex.
Correct Answer: A, D, E
Rationale: For a patient with a latex allergy, the plan of care should
eliminate or minimize exposure. This includes using latex-free gloves,
removing all latex-containing items from the patient's environment, and
verifying that equipment like syringes and IV tubing is latex-free.
,Alcohol-based hand rubs are safe for use with patients who have a latex
allergy .
5. What is the best indicator of a patient's long-term nutritional
status regarding wound healing?
• A. Prealbumin
• B. Serum Albumin
• C. White Blood Cell Count
• D. Hemoglobin
Correct Answer: B. Serum Albumin
Rationale: Serum albumin is a marker for long-term nutritional status
because it has a half-life of about 20 days. Prealbumin is a better
indicator of acute or short-term nutritional changes due to its shorter
half-life of 2 days .
6. A patient has a peripheral IV infusion that develops swelling,
coolness, and pallor at the insertion site. What is the most likely
complication?
• A. Phlebitis
• B. Infiltration
• C. Infection
• D. Air embolism
Correct Answer: B. Infiltration
Rationale: Infiltration occurs when IV fluid leaks into the surrounding
tissue, causing swelling, coolness, and pallor at the site. Phlebitis is
characterized by redness, warmth, and a palpable cord along the vein.
Infection presents with redness, warmth, and purulent drainage .
Mobility & Safety
7. When preparing to safely transfer a patient from a bed to a
wheelchair using a transfer belt, the nurse would do what first?
• A. Coordinate extra help.
• B. Assess the patient's vital signs.
• C. Assess the patient's physiological capacity to transfer.
, • D. Determine whether to transfer the patient to a wheelchair or
chair.
Correct Answer: C. Assess the patient's physiological capacity to
transfer.
Rationale: The nurse must first assess the patient's strength, ability to
bear weight, and overall physiological status to determine the safest
transfer method and whether assistance is needed .
8. Which instruction would the nurse give a patient who is able to
assist with transfer from a bed to a wheelchair using a transfer belt?
• A. "Please tell me how I can best help you get up off the bed and
stand up."
• B. "Please push down onto the mattress with both hands and
stand when I count to three."
• C. "When I count to three, please rock yourself into a standing
position."
• D. "Please hold on to my waist while I help you stand."
Correct Answer: B. "Please push down onto the mattress with both
hands and stand when I count to three."
Rationale: This instruction provides clear, specific guidance for the
patient to push up from the bed using their arms, which uses major
muscle groups and facilitates a safe and coordinated transfer. The nurse
provides stability via the transfer belt .
9. A patient has been transferred to a wheelchair with a transfer
belt. What is one action the nurse would take to position the patient
safely in the chair?
• A. Ask the patient to rate his or her pain level.
• B. Lower the foot rests, and place the patient's feet on them.
• C. Remove the wheelchair leg rests.
• D. Remove the transfer belt.
Correct Answer: B. Lower the foot rests, and place the patient's feet on
them.
Rationale: This action ensures the patient's feet are supported, which
promotes safety, comfort, and proper positioning in the wheelchair .
Question Bank | Foundations of
Nursing Fundamentals | Nightingale
College | 200+ Verified Questions
with Answers & Rationales |
2026/2027 Edition
1. The nurse is performing a morning assessment and notes the
client to be experiencing dyspnea. Which client assessment findings
would most indicate this respiratory condition? (Select all that
apply.)
• A. Occasional productive cough
• B. Temperature 100.1 °F
• C. Pulse oximetry 89%
• D. Respirations 26 & shallow
• E. Patient in orthopneic position
Correct Answer: C, D, E
Rationale: Dyspnea is characterized by subjective difficulty breathing.
Objective signs include tachypnea (rapid respirations), shallow breathing,
hypoxia (SpO2 < 92%), and orthopnea (difficulty breathing when lying
flat). Fever and a productive cough may be present but are not specific
indicators of dyspnea .
2. A nurse notes a client has abnormal vital signs. What action by
the nurse is best?
• A. Notify the provider immediately.
• B. Compare with prior readings.
• C. Document the findings.
, • D. Retake the vital signs in 15 minutes.
Correct Answer: B. Compare with prior readings.
Rationale: When abnormal vital signs are noted, the nurse should first
compare them with the patient's baseline and prior readings to
determine if this is a significant change. This assessment step guides the
next action, such as retaking the vital signs or notifying the healthcare
provider .
3. Which of the following is the most effective way to prevent the
spread of infection in a healthcare setting?
• A. Wearing gloves for all patient contact.
• B. Performing hand hygiene before and after patient contact.
• C. Isolating all patients with infections.
• D. Administering prophylactic antibiotics to all patients.
Correct Answer: B. Performing hand hygiene before and after patient
contact.
Rationale: Hand hygiene is the single most important and effective
practice to prevent the transmission of microorganisms and healthcare-
associated infections. While other measures like gloves and isolation are
important, hand hygiene is the foundational practice .
4. The client reports an allergy to latex. What alterations should be
made in the client's care? (Select all that apply.)
• A. Use latex-free or synthetic gloves when gloves are necessary.
• B. Avoid wearing gloves unless absolutely necessary and only for
short periods.
• C. Avoid use of alcohol-based hand rubs.
• D. Remove items that contain latex in the care of the client.
• E. Determine whether syringes, IV tubing, and catheters contain
latex.
Correct Answer: A, D, E
Rationale: For a patient with a latex allergy, the plan of care should
eliminate or minimize exposure. This includes using latex-free gloves,
removing all latex-containing items from the patient's environment, and
verifying that equipment like syringes and IV tubing is latex-free.
,Alcohol-based hand rubs are safe for use with patients who have a latex
allergy .
5. What is the best indicator of a patient's long-term nutritional
status regarding wound healing?
• A. Prealbumin
• B. Serum Albumin
• C. White Blood Cell Count
• D. Hemoglobin
Correct Answer: B. Serum Albumin
Rationale: Serum albumin is a marker for long-term nutritional status
because it has a half-life of about 20 days. Prealbumin is a better
indicator of acute or short-term nutritional changes due to its shorter
half-life of 2 days .
6. A patient has a peripheral IV infusion that develops swelling,
coolness, and pallor at the insertion site. What is the most likely
complication?
• A. Phlebitis
• B. Infiltration
• C. Infection
• D. Air embolism
Correct Answer: B. Infiltration
Rationale: Infiltration occurs when IV fluid leaks into the surrounding
tissue, causing swelling, coolness, and pallor at the site. Phlebitis is
characterized by redness, warmth, and a palpable cord along the vein.
Infection presents with redness, warmth, and purulent drainage .
Mobility & Safety
7. When preparing to safely transfer a patient from a bed to a
wheelchair using a transfer belt, the nurse would do what first?
• A. Coordinate extra help.
• B. Assess the patient's vital signs.
• C. Assess the patient's physiological capacity to transfer.
, • D. Determine whether to transfer the patient to a wheelchair or
chair.
Correct Answer: C. Assess the patient's physiological capacity to
transfer.
Rationale: The nurse must first assess the patient's strength, ability to
bear weight, and overall physiological status to determine the safest
transfer method and whether assistance is needed .
8. Which instruction would the nurse give a patient who is able to
assist with transfer from a bed to a wheelchair using a transfer belt?
• A. "Please tell me how I can best help you get up off the bed and
stand up."
• B. "Please push down onto the mattress with both hands and
stand when I count to three."
• C. "When I count to three, please rock yourself into a standing
position."
• D. "Please hold on to my waist while I help you stand."
Correct Answer: B. "Please push down onto the mattress with both
hands and stand when I count to three."
Rationale: This instruction provides clear, specific guidance for the
patient to push up from the bed using their arms, which uses major
muscle groups and facilitates a safe and coordinated transfer. The nurse
provides stability via the transfer belt .
9. A patient has been transferred to a wheelchair with a transfer
belt. What is one action the nurse would take to position the patient
safely in the chair?
• A. Ask the patient to rate his or her pain level.
• B. Lower the foot rests, and place the patient's feet on them.
• C. Remove the wheelchair leg rests.
• D. Remove the transfer belt.
Correct Answer: B. Lower the foot rests, and place the patient's feet on
them.
Rationale: This action ensures the patient's feet are supported, which
promotes safety, comfort, and proper positioning in the wheelchair .
